It’s been one full week since I decided to start recording my treatment decisions for nonspecific upper respiratory infections in an attempt to keep myself honest about (and motivate me to improve) my antibiotic prescribing. I know it’s not as exciting as trash cake, but I’ve decided I’m going to try to stick with it for a bit here, since I think it ACTUALLY MIGHT BE WORKING. (With my N of 1. N=me.)
Now, I’m fully aware it’s only been a week. And that week included, um, a four day weekend. Maybe not the most auspicious time to start? But whatevers, after 4 days of tracking my daily #AbxScore, here’s how I fared:
Day 1: The day I decide to start tracking. Because I’m all fired up, my AbxScore=3/3. YES.
Day 2: I’m embarrassed to say I only saw two patients the ENTIRE DAY, and neither of them had a URI. College campus + Thanksgiving eve = ghost town.
Day 3: AbxScore=3/4. Patient #1 had asthma and seriously funky sounding lungs, all the way to the bases. I just couldn’t convince myself that he didn’t have early CAP, despite normal vitals. Z-Pak given. But I rallied, and the following 3 URIs were given heaps of reassurance and symptom management advice.
Day 4, yesterday: AbxScore=6/6. KILLING IT. This was the day where I realized that even if my N remains 1 (ME) this is still worth doing. Because I saw a total of 6 URIs in patients with varying lengths of illness and varying pre-visit levels of commitment to the idea of leaving with antibiotics, and I did it. I DID IT. Even the patient who tearfully told me about the time when she came in with a cold and we “DID NOTHING” and she was sick for months and months until finally she was given antibiotics at home and just like that she was CURED – even SHE left without an antibiotic prescription for 3 days of nasal congestion and sinus pressure.
In a perfect world, obviously, the appropriate number of antibiotic prescriptions of dubious necessity given would be zero. But the reality is that the majority of visits for “bronchitis” (=nearly always viral) continue to end with an antibiotic prescription, so IMHO any reduction in this number whatsoever is an improvement.
Now, I will fully admit that I was already a bit of a striver; all those guilt-inducing missives to prescribers and patients alike over the years about conscientious prescribing were already getting to me, so it’s not like every single one of these URI patients would have left with antibiotics in my halcyon pre-AbxScore days. But if I’m being honest with myself: the girl with the tears, another girl with an asthma history, and a guy with an annoyingly persistent cough probably would have been given a script yesterday.
And now, since I knew I’d have to add them to my total for the day, I found myself that much more willing to a) commit to my diagnosis (is there evidence here of a bacterial infection, really and truly, or isn’t there?) and b) take the extra time to talk to patients about why exactly they don’t need antibiotics, so that we all leave the visit on the same page. Because if they believe me when I tell them that I’m confident antibiotics won’t make them any better, any faster, why would they want to take one?
Most of the time, I think we tend to assume that all patients want are antibiotics, so we “cave” with a prescription. Now, we all know that sometimes, they do. I’m sure I’ll be seeing one later this afternoon, or tomorrow. But often, more often than we think, our patients just want someone to listen to them, explain why they feel the way they do, and let them know what they can do to get better. Because whether or not they “need antibiotics”, viral infections suck big time. Really. And we can acknowledge that reality without writing a prescription that won’t actually make our patients’ mucousy misery go away any faster.
It even worked with the girl with the tears. Believe me, as soon as the crying began, I began to mentally subtract this visit from AbxScore numerator for the day. But after we spent some time talking about the whens and the whys of viral infections and sinusitis and antibiotics and all that, she’d agreed to go with sinus rinses, some guaifenesin, rest, and time.
So there it is. Week 1 down. Progress observed. And if you’d like to add to my N of 1, spread the word.
Love and LadyBits 
WOOHOOOO!! -High five!-
Here are a few of my strategies in case they may be helpful to you or others:
I find patients are quite amenable to these, or if they are not, will become so eventually (after they hear me say them over and over again)
1. explaining that the far majority of URIs start as viral, and then, if we don’t get them better enough soon enough, can develop into secondary bacterial infections.
(to the curious I would explain further that we actually typically infect ourselves with our own normal bacteria, that then have a hay day in or already inflamed sinuses / lungs)
2. the NIH lists “common cold” sx that typically last 7-10 days (there’s a patient handout on this that I’ve given out a bajillion or so times).
3. the treatments of viral infections (which may be common, but are much meaner than they used to be, and typically take the average healthy person out for a few days at least) include:
– TONS OF REST
– TONS OF LIQUIDS
– TONS OF REST
– TONS OF LIQUIDS
– symptom management to enable the two above (decongestants, OTC pain meds, antitussives, expectorants)
– nasal or inhaled medications for those prone to sinusitis or bronchitis, or a prophylactic increase in asthma medication a the onset of symptoms (all above unless contraindicated, of course)
4. explaining that in a young, healthy person, if they are getting enough rest, fluids, and their upper respiratory tract is not swollen (see steroid nasal sprays and inhalers), even if they did develop a degree of bacterial infection, their bodies should be able to fight it off itself without needing an antibiotic (and that their bodies are very well built for this, in fact).
5. antibiotics are not actually as benign as we’d thought (see c.diff and abx resistance and more- there’s actually a JAMA patient handout on inappropriate use of abx too-)
6. at times I even tell them that my treatment recommendations for them are the ways I treat my own URIs (even with an asthmatic tendency myself), and my family’s, and how I try very hard to avoid taking antibiotics if I can. I tell them to stay home, both for their own benefit and the benefit of those around them (so they don’t get them sick – especially for anyone that has serious lung disease- these bugs can mean serious trouble)
Of course always it depends on clinical judgement, and the patient. I’ve seen a severe COPD that goes so fast into respiratory failure (requiring intubation) that I am just not willing to risk waiting with the abx. Her pulmonologist can take that risk if he’s comfortable; being a general practitioner, I’m not.
I figure with a typical URI onset: starts with sore / scratchy throat, rhinitis, thickening congestion over 2-3d and into cough, another day or two of feeling flat out miserable, then sx should be improving gradually over the remaining days- typically takes a couple days to get local corticosteroids (fluticasone nasal or something) up and running- depending on how devoted the pt is to recovering (getting required rest and fluids), we actually have several days to get symptom control going in time to prevent secondary bacterial infection, or minimize body requiring medication assistance to fight off a bacterial infection.
Oh, and, the other awesome part, is that as much time as I might spend telling patients all this the first time, they know the drill thereafter, and in fact, often become champions of avoiding antibiotics if possible (esp if they know someone who’s dealt with c.diff, which, it is also worth noting, has failed treatment with metronidazole in several cases I know, requiring then it be treated with vanco. YIKES).
p.s. thank you for the great posts!!
Fantastic advice! I love it! We all need to be doing more of this, please.
And I totes agree, there are plenty o times where antibiotics are indicated for URIs. Just not nearly as often as they end up being prescribed.
if anyone else has other explanations / approaches, I’d love to hear them too- need good strategies and many-mind contributions
🙂
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