Antibiotic Prescriptions Add Up to Overuse

U.S. doctors write enough prescriptions each year to provide antibiotics to 4 out of 5 Americans, a new study shows. That's so many that the drugs probably are being overused, experts told the Associated Press (AP). Excess use helps bacteria to become resistant to the drugs. The new study used a national drug database. Numbers come from 2010. In that year, health care professionals wrote 258 million prescriptions for antibiotics. The population was about 309 million. That's about 833 prescriptions for every 1,000 people. But the numbers varied greatly from state to state. West Virginia, Kentucky and Tennessee had the highest rates. About 1,200 prescriptions were written for every 1,000 people in those states. In Alaska, Oregon and California, the numbers were 600 or below. Experts said Southern states may have more infections than other states. They do have the highest rates of diabetes. Diabetics tend to have more infections than others. The New England Journal of Medicine published the study. AP wrote about it April 10.

By Mary Pickett, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

How many antibiotic prescriptions does a typical family practice doctor write in a day? Two or three, according to data from the National Prescription Drug Database. This count leaves out IV antibiotics that are used for severe infections. It also leaves out skin ointments and creams.

Family practice doctors, pediatricians, internal medicine doctors and dentists combined hand out two-thirds of the oral antibiotic prescriptions in America. In total, doctors are prescribing enough antibiotics to give them to 4 out of 5 Americans each year.

This is too much. Antibiotics are wonderful friends when we need them. But we don't always need them. The problem with prescriptions we don't need is that antibiotics can do harm.

I don't think most of my patients believe this about the harm. "Doc," they ask me time and again, "do you think I should take an antibiotic -- you know, to be on the safe side?"

I do my best to help my patients know when taking an antibiotic is less safe than not taking one. But truly, I don't have time to go through all of the details. Some of my patients are frustrated when I choose not to use one of these drugs.

Antibiotics can harm us in three ways:

1. Drug reactions -- These include side effects, allergies or bad reactions. In unlucky patients, some antibiotics can cause:
   • Kidney damage
   • Permanent hearing loss
   • Very bad rashes
2. Resistant bacteria -- Widespread use of antibiotics is to blame for "super-bugs." When you take antibiotics, you kill the easy targets. A small fraction of bacteria may be protected by a special gene, and these remain. Even if you recover from the active infection, your next infection might be "resistant."
3. Lost "normal flora" -- Many kinds of bacteria live on your skin and in your mouth, gut and respiratory tract. They are your normal flora or "microbiome." Here are some problems that happen when normal flora are lost or changed by antibiotics:
   • Poor digestion -- Bacteria in your intestine help you to break down carbohydrates. After antibiotics, some carbohydrates stay undigested. This results in diarrhea.
   • Nutrition issues -- Bacteria produce vitamin K in your body.
   • Colitis -- It is common to have spores from the bacteria Clostridium difficile in the intestine. The death of normal flora can allow C. diff to change from spores into more active bacteria. During this change, it makes a toxin that can cause life-threatening inflammation of the colon.
   • Vaginitis (yeast infection) -- It is normal for women to have yeast spores in the vagina. Bacteria determine the chemistry of the mucus in the vagina. After subtle adjustments in this chemistry, yeast multiply and change shape. They make glue-like proteins that allow them to attach to the vagina surface and form clumps. Yeast in this changed form are very irritating.
   • Allergic asthma -- If babies get antibiotics, they are more likely to develop asthma as kids. Exposure to harmless bacteria and proteins in your early life allows your immune system to recognize them as harmless. Without this exposure, your immune system is more likely to react later against harmless proteins and create allergy symptoms.
   • Inflammatory bowel disease and other autoimmune problems -- Mice that are raised "germ free" have unusual immune-system activity. Similar activity is seen in autoimmune diseases such as inflammatory bowel disease. Some of these diseases are more likely to occur in people who have had many courses of antibiotics.
   • Upper respiratory infections -- Pills and creams used for acne have been linked to more frequent head colds. Changes in normal flora of the nose, throat and mouth apparently can make it easier for a virus to begin an infection.

What Changes Can I Make Now?

The U.S. Centers for Disease Control and Prevention says that up to half of antibiotic prescriptions may not be needed.

Guidelines advise doctors to avoid antibiotics for the following:

• Acute (short-term) bronchitis
• Sinusitis that has lasted for less than a week
• Ear infections without fever in children over age 2

These infections can clear themselves without antibiotics. Viruses cause about 90% of respiratory and cold symptoms, such as runny nose and sore throat. They do not require (or benefit from) treatment with antibiotics.

We are learning about ways to help normal flora to come back after antibiotic treatment. "Probiotics" help only a little. The best thing you can do is to take antibiotics only when you need them.

What Can I Expect Looking to the Future?

Some doctors are not wary enough of antibiotics. Even when they are, doctors don't have enough appointment time to explain all the risks of unneeded antibiotics.

What we need for this problem is a public information campaign. You are being asked to choose wisely in all sorts of ways as customers of the health care system. Choosing wisely is also important when you talk with your doctor about whether to start antibiotics for any illness, particularly when you have sinus and respiratory tract symptoms.