'Wait and see' gains ground

Antibiotic prescriptions are being written less frequently for patients with respiratory tract infections, which include ear infections, sinus infections and bronchitis, as well as colds and flu.

The finding, published earlier this month, has been received positively by doctors and public health officials who are worried about the increasing problem of "superbugs," disease-causing bacteria that are resistant to antibiotic drugs. "It's a very encouraging finding," says Dr. Stuart Levy, a professor at Tufts University School of Medicine in Boston and and author of a 2001 book on the topic, "The Antibiotic Paradox."

Antibiotics must be used judiciously or they'll start to lose their effectiveness. Bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and penicillin-resistant Streptococcus pneumoniae are a growing problem as they've become resistant to entire classes of antibiotic drugs. This means many bacterial illnesses are harder to treat. Further, antibiotics that are developed to combat resistant bacteria are generally more expensive and often more toxic.

The most egregious misuse of antibiotics is when they're used to treat a viral illness such as the common cold. Antibiotics are effective against bacteria, not viruses. However, ear infections, sinus infections and bronchitis may be viral, bacterial or both, so sometimes antibiotics are prescribed just in case there's a bacterial component.

A prescription also may be written when a doctor feels pressure from a patient or sleep-deprived parent of a sick child. By acquiescing, the doctor might get better patient-satisfaction scores, says Dr. Carlos Lerner, medical director of the children's health center at Mattel Children's Hospital at UCLA. "Also it's much quicker to write a prescription than to explain to families why an alternative approach is more desirable."

The study, published Aug. 19 in the Journal of the American Medical Assn., examined national survey data from the years 1995-2006. In children younger than 5, rates of antibiotic prescription decreased by 27% overall, and by 36% in patients with respiratory tract infections. In children 5 and older and adults, overall rates of antibiotic prescription didn't change over the study period, but an 18% decrease was found for people with respiratory tract infections.

For ear infections -- the most frequent reason for prescribing antibiotics to young children -- researchers found antibiotic use didn't change during the study period. Antibiotics were prescribed about 80% of the time an ear infection was diagnosed in kids less than 5 years old.

However, 33% fewer ear infections were diagnosed in 2005-06 as compared to 1995-96, which the authors say is a result of vaccinating U.S. babies against the main cause of ear infection, pneumococcus bacteria. (The vaccine has been routine since 2000.) This means fewer antibiotics will be used for this condition.

New guidelines for doctors may have played a role in the decrease in antibiotic use, the study authors write.

Diagnostic criteria for certain respiratory tract infections have been tightened so that only more severe cases warrant antibiotics.

The American Academy of Pediatrics revised its treatment guidelines for ear infections in 2004 and included an "observation" option -- meaning waiting a day or two before resorting to antibiotics in the case of a child with a mild ear infection to see if the illness gets better. However, this practice has not been as widely adopted in the U.S. as it has in many European countries.

Levy credits public education campaigns for much of the decrease in antibiotic use. One such effort is "Get Smart: Know When Antibiotics Work," launched by Centers for Disease Control and Prevention in 2003. It focuses on the conditions that result in the most inappropriate antibiotic prescriptions, typically upper respiratory tract infections such as colds, sinusitis, bronchitis and laryngitis, says Dr. Lauri Hicks, the campaign's medical director.

"Much more is being said, read, printed in the newspapers to explain to patients, family members and parents, that an antibiotic is not a cure-all," Levy says.

The new study extends previous research by the CDC, which showed decreased antibiotic use in the 1990s. This sustained pattern of reduced antibiotic use in outpatient settings is a marked turnaround from the 1980s, when antibiotic use increased by 48% over the decade. "We've made more progress than many of us expected," Lerner says. "But there's still many thousands of inappropriate antibiotic prescriptions that continue to be written. There's plenty of room for improvement."

Though the link between antibiotic overuse and resistant bacteria is well accepted, parents may be less concerned with that than the well-being of their child. But they may be wrong in that assumption, Lerner says. "We're learning now that even for an individual patient, if that patient receives inappropriate antibiotics, they themselves are at risk of harboring more resistant bacteria. So it's not just bad for the community, but also a risk for the child."



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