The sore throat menace

The IDSA's report on infectious disease IVDs is out now, and it is squarely focused on the need for tests that will enhance antibiotic stewardship efforts. In particular, a test that would distinguish viral from bacterial infections is needed. Tens of millions of patients seek medical aid for upper respiratory infections each year in the US. About 10% of them have bacterial infections, but 60% or more go home with a prescription for antibiotics. Worse, the fraction of these prescriptions that are for broad-spectrum antibiotics is steadily increasing.

This is pure folly in so many different ways. Antibiotic susceptibility is a finite resource. Of the few sore throats that are bacterial infections, nearly all are due to Strep pyogenes, and nearly all strains are susceptible to penicillin. How many patients who went home with Cipro later ended up with C. difficile diarrhea or became infected by some cephalosporin-resistant bug?

A place where the report's authors did not go is to advocate restrictions on the ability of physicians to prescribe antibiotics as promiscuously as they have become accustomed to doing. Guidelines and education are all that is advocated. But this approach has been in place for decades and has stalled out: antibiotic prescriptions for upper respiratory infections went from 80% of patients in the 90's to 60% in the 00's, and has stayed there ever since.

 

From Barnett and Lindner 2013

Two developments are needed to have an impact. The technological fix would be a point of care test that distinguishes viral from bacterial infections, and this is certainly near the top of the IDSA's wish list. But availability of a test that will improve prescribing practices is not enough to ensure its adoption. We developed such a test at MicroPhage, and it sank like a rock in the clinical marketplace. There also needs to be some form of coercion, or if you like, encouragement, to do the right thing rather than the expedient thing. The growth of electronic medical record keeping means that it should be possible to track MDs who prescribe excessive amounts of antibiotics. A letter from the state medical board, or the FDA, might be a good way of gaining the attention of these miscreants. Or just knowing that someone is watching is often sufficient to improve behavior.

If this seems heavy-handed, consider that these physicians are creating a public health hazard, while providing minimal clinical benefit to their patients and exposing them to an increased risk of adverse events. I think that is sufficient rationale for impinging on physician autonomy.

 

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