Almost 3 million antibiotic-resistant infections occur in the United States annually, with 35,000 people dying from those infections. Antibiotic-resistant bacteria were first seen in healthcare settings, but they’re increasingly seen in community settings as well. Think MRSA staph infection outbreaks and antibiotic-resistant UTIs.
“Any antibiotic use pushes us toward the emergence of antibiotic-resistant infections,” says Dr. David Hyun, director of the Antibiotic Resistance Project at the Pew Charitable Trusts. “We need to minimize and reduce wherever possible, and the best way to do that is to eliminate unnecessary use.”
Antibiotic overuse is an issue across all healthcare, but it’s of particular concern in outpatient settings and urgent-care clinics. Antibiotic-resistant bacteria and fungi endanger the most vulnerable — specifically, older populations and those with immune deficiencies due to chemotherapy and organ transplants. Although many illnesses don’t require antibiotic prescriptions, one 2020 study found that in urgent care centers, 46 percent of patients were prescribed antibiotics inappropriately. That number outranks emergency departments, office-based clinics and retail health clinics.
All the dire data begs us to ask the question: Why do urgent care physicians struggle with overprescription, and is there anything patients can do to help?
Why and how overprescription happens
Antibiotics are almost always recommended for some stubborn issues, such as urinary tract infections and pneumonia. But antibiotics aren’t the only or even the correct fix for viral upper respiratory tract infections, bronchitis, flu, viral pneumonia and some ear infections. Physicians tend to prescribe unnecessarily for acute respiratory conditions, Hyun says. Not so coincidentally, many patients go to urgent care when respiratory symptoms get bad.
For physicians, factors influencing antibiotic overprescription in outpatient settings include decision fatigue, time management, habit, concerns about serious future complications and, notably, a belief that patients want antibiotics.
Studies have shown that if a patient expects antibiotics, the doctor feels pressured to provide, even if the physician suspects antibiotics won’t help. In one survey of 1,550 primary care physicians, 47 percent of physicians noted “moderate pressure” from patients or caregivers to prescribe antibiotics, and 37 percent reported “high or very high” pressure. Only 1 percent reported feeling no pressure at all.
Urgent care can amplify that pressure, Hyun says. If a patient comes in with a very sore throat or chest congestion that could turn serious, an urgent care physician may be concerned about lack of follow-up care, delayed test results or an inability to contact the patient. Under those circumstances, antibiotics seem like a fair “just-in-case” measure. In contrast, a primary care physician could feel more confident delaying antibiotics for 48 hours and following up.
As a nation, we prescribe more than twice the rate of some of the lowest-prescribing European countries, Hyun says. That said, there has been a modest, slow decline in the seven to eight years leading up to the COVID-19 pandemic, particularly among children in pediatric settings. The West Coast also prescribes at lower rates than the rest of the US.
Interestingly, antibiotic prescription rates can vary widely by provider. One study looked at prescribing rates in the large urgent care network Intermountain Healthcare in Salt Lake City. Rates ranged from 3 percent to 94 percent for respiratory conditions, although the physicians were essentially working with the same population. Studies and data like this help physicians see where their prescribing rates are amiss. More clinics are also engaging in “antibiotic stewardship” programs to reduce misuse and overuse.
Dr. Park Willis is one of Intermountain Healthcare’s urgent care physicians prescribing the fewest antibiotics within the system. Willis says his approach stems from a generational difference to some degree; he graduated medical school in 2011 and says he benefited from more recent antibiotic-related research. Although Willis estimates around 40 percent to 50 percent of his patients come in with respiratory conditions, he says few need antibiotics to recover.
“Medicine created this problem,” Willis says. He notes that the oldest patients have antibiotics for decades for various ailments: “There’s a presumption that you need antibiotics to get better.” Many patients have experienced visiting a physician, taking antibiotics, and soon recovering. Willis believes that probably had more to do with the virus running its course than medication.
What patients can do
While misinformation circles COVID-19, antibiotics are infused with misunderstandings. “Even in the basic concept that antibiotics don’t work against viral infections, there’s room for improved patient understanding and ways for the general public to be part of the effort against misuse and overprescription,” Hyun says.
Patients under age 40 tend to be more receptive to discussions about viruses versus bacteria, Willis says. He takes time to explain the potential risks, especially to older patients who see antibiotics as a cure-all. Some antibiotics can cause rare but severe side effects, such as Achilles tendon rupture. Antibiotics can also cause allergic reactions and even infections with the bacteria C. difficile, which caused the deaths of at least 12,800 people in 2017, according to the CDC.
Willis says that science is just starting to understand how antibiotics affect the microbiome and our gut bacteria. For example, antibiotic interaction with the microbiome may contribute to obesity, allergies and type 2 diabetes.
Patients can assist in decreasing antibiotic misuse, overuse and resistance. Most physicians will likely assume you want antibiotics, Willis says. He offers a script for patients: “I’m not here to get antibiotics unless they’re necessary. But I’d like to better understand my symptoms, if there’s anything I can use to help, or something I need to worry about.”
“It’s important to advocate for yourself,” Willis says. “It can be helpful to let the doctor know what your expectations are for the visit, in the event they do not ask you directly.”
If a physician hands you a prescription for an antibiotic and you don’t understand why, ask if they can explain why you need an antibiotic. Ask about potential benefits and side effects, Hyun suggests.
“There are many cases where the benefits of antibiotics outweigh the risk,” Willis says. “But they are not a panacea every time you feel unwell.”