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.
Oversimplification is great as everyone needs to read and understand it. Great post, Doc :)
ReplyDeleteThanks Coral..i recognize a kindred spirit here....
Deletebtw, welcome to my blog....hoping to see you more here