Jim Ducharme, MD

Following up on Neal Little, MD

On Dec 20, 2009, Neal wrote that in Canada, “not all bugs need drugs” was a campaign to decrease antibiotic usage. I think the C. Difficile scare with high mortality rates in Ontario and Quebec might also have played a role. Throughout my career, I have always wondered why we prescribe so many antibiotics. In the 1950’s we treated otitis media with antibiotics to prevent the severe suppurative complications that could arise – and not to treat the self limited ear infection. We have demonstrated convincingly since then that mastoiditis and brain abscess arose due to poor public health, inadequate nutrition and lack of vaccines – none of which exist in most of North America today. European and North American studies have shown that analgesics work as well as antibiotics for the symptoms of otitis media. We treated strep throat in the 1950’s and 1960’s because of the real threat of rheumatic fever – again, not for the limited local infection. In more than 98% of North America there is now zero risk of rheumatic fever. So I have to ask: why the antibiotics?

Do not hide behind the old argument that it is because the patients want a prescription: more than 20 studies show that being given a prescription yields the lowest amount of patient satisfaction, and being given a proper explanation provides the highest. Do not say the patients cannot be taught any better: when asked the number one reason why they come to the clinic for a prescription, their answer is that is what the doctor did last time they had those same symptoms. In other words we taught them just fine!

What is even more appalling is the number of prescriptions supposedly intelligent educated doctors prescribe for known viral illnesses: URI, rhino-sinusitis, acute bronchitis. Across the world anywhere up to 80% of prescriptions are for infections that cannot possibly respond to their action. Given the cost of these (useless) medications to the patients, the number needed to harm and the growing rate of resistance, one has to ask how we as physicians can justify this behavior any longer. We know they are not of value, we know it provides little satisfaction to the patient, we know it can harm the patient and we all know about drug resistance and cMRSA. I am not sure that the next time a patient gets C. Difficile from an antibiotic for which there was no indication, the doctor should not be held accountable.

And yet….I met a young patient with an acute cough just last week….who had been prescribed imipenem  just one week earlier…and who now was back as her mom said she was coughing just as much. Will we ever get it?