Monday, April 11, 2016

What we say when we don't give an antibiotic matters

- Jennifer Middleton, MD, MPH

Most patients with upper respiratory infections (URIs) and/or sinusitis don't need an antibiotic, but many physicians still receive requests for one. Physicians may use language to describe the viral nature of the infection, stating perhaps that it's "only a virus" or otherwise implying that the illness is not serious enough to mandate an antibiotic. This type of wording may, paradoxically, increase some patients' belief in the utility of antibiotics, as demonstrated by a recent qualitative study published in the Annals of Family Medicine.

Cabral et al video-recorded 60 encounters of children, ages 3 months to 12 years, seen in primary care offices in the United Kingdom with URI symptoms. They then interviewed some of the children's parents after the visit to learn more about their beliefs regarding antibiotics and URIs. They found that parent belief regarding the lack of utility of antibiotics for viral infections was overall high, but this belief did not always translate into reassurance when one was not provided. Parents who felt that their child's illness was minor were reassured, but parents who felt that their child was significantly ill (which typically correlated with disrupted sleep and/or length of illness) felt oppositely, that their physician was trivializing their child's illness by not deeming it "serious enough" to justify an antibiotic.

Interestingly, physicians in this study used different language with parents to describe the child's illness according to their decision to prescribe antibiotics. If not prescribing antibiotics, they would often describe concrete physical exam findings and observations that they felt were reassuring about a lack of a bacterial cause; if prescribing antibiotics, they would instead describe more subjective concerns about worrisome symptoms, especially if these symptoms were worsening. The researchers deduced that this symptom-driven language further reinforced the parents' beliefs that antibiotics are needed for more serious illness, as most parents found the descriptions of concrete physical exam findings in children not receiving antibiotics reassuring.

This study will change the way I speak with parents - and adult patients - about my decision not to prescribe antibiotics. I will make sure not to trivialize their concerns or refer to an illness as "just" a virus, and I will aim to use objective language to describe my rationale either way. Despite rigorous evidence showing that antibiotics insignificantly aid recovery and can cause adverse effects, as many as 80% of patients who present with an URI and/or sinusitis are prescribed one.  The Choosing Wisely campaign reminds us to avoid prescribing antibiotics for URIs in adults and in children. Besides recommending supportive care, nasal corticosteroids are a treatment option in adults with acute sinusitis as well. This 2012 AFP article reviews other treatment options for URIs in adults and children.

You can find AFP's Choosing Wisely search tool here, and there's also an AFP By Topic on Upper Respiratory Tract Infections if you'd like to read more. Family Practice Management featured an article last year, co-authored by Dr. Lin, on implementing the Choosing Wisely recommendations in your office, and they also published this handy resource on coding URIs using ICD-10.

How are you responding to requests for antibiotics from patients with URIs?