Tuesday, August 13, 2013

Shoot First, Ask Later Policy – Of Giving Antibiotics

Shoot First, Ask Later Policy – Of Giving Antibiotics

(Disclaimer : I have tried to avoid medical jargon and simplify this as much as possible for everyone to read and understand- some of my fellow medicos might call it oversimplification- but I want people to understand the issues and form their own opinions. As always I would love to answer your comments and questions related to this post)

This morning I saw a patient in her early twenties who had undergone a open heart surgery for valve replacement in the heart a couple of years ago and the patient shared the story of how she had suffered from frequent knee pains in her younger years and how it developed into a heart disease without being diagnosed. Joint pains followed by valvular disease of the heart is known as rheumatic heart disease- a misleading name - since it is caused by a bacterial infection from a bacteria called Streptococcus (Strep Pyogenes)- the same one responsible for sore throat disease- cough and cold and sniffling nose, anyone?.

Streptococcal sore throat is often mistakenly diagnosed as a common cold -which is caused by a virus and is self limiting and is automatically cured after a week or so. But if the strep infection is not diagnosed and treated by giving antibiotics at the initial stage itself then the heart and its valves are damaged resulting in uneven pumping of blood by the heart and hence by the time the disease is finally confirmed the only treatment left is open heart surgery for replacement of the diseased heart valve by a new artificial valve. And to think that it could have been easily prevented - if someone had diagnosed it early and prescribed the correct antibiotics to kill those bacteria in the throat itself. Makes you wonder doesn’t it?

Which brings to mind an interesting online conversation I had a few days ago based on one of my recent blog posts- with a couple of fellow medicos (Sai Sriram and Sulaiman)- on antibiotic abuse. I want to share the same here on the blog as there were several interesting points made which would be of use to everyone. And I hope, would also offer you an insight on the thought processes of doctors and how and why certain prescriptions contain antibiotics and others don’t.

Every single doctor when he/she undergoes the basic course and during residency training is taught about the inviolability of evidence based medicine- that is treating diseases based on best practices developed by research and published in journals. There are clearly defined protocols for each and every disease treatment- developed internationally and standardized for treatment all over the globe and doctors are expected to follow it in all countries and circumstances. But practical realities differ from country to country and play a major role in actual prescription writing.

For example, a doctor practicing in a country like the United states of America with a robust and well developed emergency medicine facilities can often adopt a wait and watch approach when it comes to certain diseases like infections -to see if it really develops into a major disease (life threatening) or if the persons normal immune system can deal with the infection on its own without need of taking any medicines. But in a country like India where emergency facilities are more often swamped by accident cases, suicide patients etc and there are very few infection specialists and many more general practitioners -the treatment of infections is radically different on the ground. Here doctors prefer the prevention is the best cure formula rather than patience is a virtue formula practiced abroad. Let me explain my point with examples.

When a patient, let’s say a child is brought to the doctor with a sore throat, cold and fever -it is clinically difficult to differentiate whether the sore throat is caused by a virus or by a bacteria and investigation like culture method to diagnose the organism responsible takes a few days at least to come out with the results. In such cases some doctors prescribe antibiotics immediately -just to cover the bases but other doctors don’t- for they reason that if it’s a viral infection, it is soon going to go away on its own, so why should we give something of no use -for antibiotics don’t work on viruses.

And there are so many evidence based medicine guidelines which scream that easy availability of antibiotics- pill popping even when unnecessary -is causing widespread antibiotic resistance and require stronger and stronger antibiotics in future for even simple infections. So following international guidelines and out of best intentions - the doctors don’t prescribe any antibiotics and nine times out of ten the infection is viral and heals quietly. But rarely, in the rarest of rare cases-the infection spreads throughout the body and attacks the heart and other important organs. And that’s when the doctors start second guessing themselves about whether they should have given antibiotics - just to play safe. And believe me it is as traumatic for the doctor who could have done something but didn’t do it -as it is for patients themselves.

In India most practitioners prefer not to take this risk and by routinely prescribing antibiotics make sure that the  rare case does not happen to their patients- antibiotic over use protocols be damned. Most doctors are either not trained to communicate all the reasons for not giving antibiotics or they just don’t have the time to confront an  anxious parent of a sick child and try to convince them to wait and watch before taking any concrete step to cure the child -masterly inactivity technique of treatment (with apologies to Warren Hastings).

Besides more often we see that the most popular doctors are the "take immediate action" types and the average patient prefers a doctor who prescribes antibiotics rather than just give advice. And we cannot find fault with them for it’s easier to trust a doctor who give medicines than the doctor who shows you reams of statistics and dozens of scientific evidence about antibiotic abuse but does nothing else. Every patient prefers to go home with some medicine or the other- even if it’s just for mental satisfaction.

And don’t mistake me, not for a moment am I suggesting that we give drugs based on the whims and fancies of the patients. No we don’t and we shouldn't. We should as far as possible follow the best practices of evidence based medicine and give only the treatment actually required. But we should also remember that we are treating people and not just diseases. And it’s up to us to reconcile the dilemmas involved by listening to our patients- spoken and unspoken complaints.

Medical diagnosis is not often cut and dried- it involves a degree of subjectivity and guess-work. No doctor intentionally plans to give unwanted drugs (at least most don’t-exceptions are always there) to any patient. The simplest and most obvious reason for giving antibiotics is   they assume they are treating a bacterial infection and not a viral infection. If it’s a bacterial infection the patient gets well immediately. And even if it is a viral infection the patient is going to get well anyway. And so unless we are absolutely sure that the benefits of giving prophylactic antibiotics is outweighed by the risks involved I vote that we continue to prescribe antibiotics where necessary.

So to get back to my original premise of the title - should we shoot antibiotics first and then decide later? Or should we not? In my view- there are no clear cut solutions for this problem- it is complicated, confusing and most of the time it requires a bit of compromise to suit the particular patients condition. Horses for courses is the only solution I would recommend. Rather than follow a guideline based medicine I would suggest an individualized medicine paradigm where patients are at the center of everything and not rule books framed in a distant laboratory.

So I rest my case by saying that -"If the shoe fits wear it. If not- don’t cut off the foot trying to cram it into the shoe."

P.s. The introduction of the American model of Defensive medicine where doctors have to keep justifying every single clinical decision of theirs to insurance companies which are the paymasters is ill-suited to Indian conditions. What we are seeing now is just the crest of the wave- the tsunami will soon be here.


  1. Oversimplification is great as everyone needs to read and understand it. Great post, Doc :)

    1. Thanks Coral..i recognize a kindred spirit here....

      btw, welcome to my blog....hoping to see you more here