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I was scrolling through my email this morning, and just before clicking delete on what looked like junk, I noticed an interesting headline titled: Doctors May Play Big Role in Antibiotic Overuse: Study.1 The bottom line of the report was that physicians and other healthcare providers at the VA system prescribed antibiotics for an excessively large number of patients for upper respiratory tract infections, most of which are viral in origin. The article attributed differences in practice patterns to habitual differences of providers.2
There’s nothing strikingly new about healthcare providers overprescribing antibiotics. We’ve known about this problem for many years. I even recall debating one of my doctors about this very issue when I was in college. I had an upper respiratory tract infection and he immediately began writing a prescription for an antibiotic. As a microbiology major at the time, my brain was chock full of information about the risks of antibiotic overuse and the potential for the creation of "superbugs" that would destroy our ability to fight bacterial infections.
Incidentally, I love that term: "superbugs." It’s so hyperbolic, isn’t it? I just love how it equates bacteria with insects, conjuring that hatred many of us have for those hard-shelled critters.  I think of cockroaches immediately and the absolutely disgusting sound their shells make when they’re squished underfoot. Yuck.
Layered on top of that is the idea that these “bugs” somehow have superpowers. Can you picture it? There’s a little E. coli rod in a Superman outfit, undies on the outside of its tights and all, with cape fluttering in the breeze, flagella wriggling, as it leaps tall buildings in a single bound only to end up jumping into your throat and causing some comic book-sized infection. Now it’s just poor little mortal you versus the horrible superbug. Scares the living poop out of you, right? Even more so since we’re talking about E. coli! Your gastrointestinal tract just became the setting of an epic battlefield unlike any other in history. Marvel Entertainment should be all over this!
I digress. Sorry. Got lost in the battle. We all know that this entire phenomenon is simply due to Darwinian evolution. We create a selective pressure on the bacterial fauna of our bodies when prescribing antimicrobials, and some of those bacteria have what it takes to survive to breed another day. They have the genetic wherewithal to resist certain antimicrobial medications. It is true that this is a problem, but I wonder if the medical community leadership really takes it seriously?
I’m one of those people who generally do not prescribe antibiotics to patients unless there is clinical evidence to support an infection. For example, I commonly see patients referred to me for ingrown toenails that have been on at least one and sometimes more than one course of antibiotics. This is completely unnecessary and a waste of that precious store of Kryptonite to fight those superbugs (sorry, couldn’t resist the metaphor).
In fact, this has long been proven to be unnecessary in the medical literature by members of our own profession. Reyzelman and colleagues prospectively enrolled 154 patients with infected ingrown nails and randomized them to either one week of antibiotics plus chemical matrixectomy, antibiotics and then matrixectomy, or matrixectomy alone. Fifty-four (54) healthy patients were actually studied (after exclusion criteria). These researchers concluded that the antibiotics did not improve the outcomes of treatment of infected ingrown nails.3
We podiatrists know an ingrown toenail is essentially a foreign body reaction that will only resolve with removal of the offending nail. It does not require antibiotics. I’ll go so far as to say that I almost never prescribe antibiotics for this condition, even when purulence is noted. I need to see frank cellulitis of the digit before I prescribe. Nail avulsion and matrixectomy is the optimal treatment. Unfortunately, we podiatrists have done a poor job educating our general practice colleagues about this and indirectly contribute to the over-prescribing problem.
The other place that I’ve recently noted a problem is in the operating room. In the past, I would order preoperative antibiotics only under certain circumstances (for example, a long case). I generally did not prescribe any antimicrobials unless the patient had a postoperative infection. Today, due to the SCIP program (Surgical Care Improvement Project), my local hospitals are really leaning on me to give an antibiotic preop. Take a look at the figure below (abstracted from Surgical Care Improvement Project) and note that the first three measures have to do with antibiotics.
There has never been (or likely ever will be) a study that demonstrates that simply doing surgery using today’s sterile technique increases the risk of postoperative foot infection. We know that there are certain situations where it is likely to occur (immunocompromised patients, long procedures, break in sterility, etc.), but in the otherwise healthy patient undergoing elective podiatric surgery, there really is no need for antibiotics. It would greatly improve the situation if physicians and surgeons could simply practice medicine according to our training and the current research evidence, rather than have to worry about initiatives like the SCIP program, which tries to treat every surgery as if it fit into a box.
Though I agree that healthcare providers overprescribe antibiotics, we really should keep the whole thing in perspective. Watch out friends. We don’t want to turn Clark Klebsiella into the evil superbug Super Coli. If our national initiatives don’t match the science, then how can we providers be expected to change our overprescribing ways?
Best wishes,
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
References
- Doctors May Play Big Role in Antibiotic Overuse: Study
University of Utah news release, 7/20/15.
- Jones BE, Sauer B, Jones MM, Campo J, Damal K, He T, et al. Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Infections in the Veteran Population: A Cross-sectional Study.
Ann Int Med. 2015;163(2):73-80.
- Reyzelman AM, Trombello KA, Vayser DJ, Armstrong DG, Harkless LB. Are antibiotics necessary in the treatment of locally infected ingrown toenails? Arch Fam Med. 2000 Sep-Oct;9(9):930-932.
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