Case 15: Bug Drugs

The Fast Track area of our Emergency Department is like a walk-in clinic; one cubicle after another – most with curtains too short for problems below the waist. It’s where easier patients are seen as we wind down our shifts – cuts, broken bones, mild infections. I’m seeing a fifty-something with knee pain who’s telling me that the Toronto Blue Jays have just won their eleventh consecutive game. Just as I start taking his history, I feel the curtain behind me erupt open.

It’s Roland, a twenty-five year who’s refusing to leave the E.R. “Why are you being so difficult?” he says, his breath at my neck. “Why can’t you just give me the prescription?”

The Blue Jays fan sits frozen, shoulders stiff, eyes bulged. I turn around and wave my hand over Roland’s head. “Call security.” In medical school, I was taught to find common ground with patients. I tried. Roland and I are at an impasse. He wants a prescription, and I’m not caving. He’s swearing again, and I can hear security’s racing footsteps as a Code White is called. “I have nothing more to say to you,” I tell him. “You don’t need a prescription.”

Roland sounds like an escaped inmate as he’s hauled out of the department, hands held behind his back.

Ten minutes earlier, I’d read his triage note – sore throat, fever, cough, history of strep – before hearing his story. “I’ve had a bad throat for a couple of  days,” he told me. “It happens every year. They usually give me Zithromax and it goes away.” He admitted to having a cough and fever, but no other symptoms. He denied any previous medical or surgical history, and told me he smoked half-a-pack a day.  “Zithromax always works,” he added before I pointed the otoscope into his ear.

I could have told him, even before I examined him – you probably don’t have it – but that isn’t what he wanted to hear. He’d already called for his antibiotic of choice, like a customer yelling ‘Big Mac Meal’ into a speaker at the drive through. His ears were normal, as was his throat, and his lungs. His vital signs were perfect. Not only did he have no signs of strep throat, he didn’t look ill in the least – no congestion, no cough, and a clear and even voice.

“It’s very unlikely that you have strep. It’s uncommon after the age of eighteen, it almost never exists with a cough, you have no fever, and your throat looks normal.”

“I get it every year right about this time.” He clears his throat and points to his neck. “I just need Zithromax.” He stretches out his fingers: “Five days.”

“I’ll take a swab,” I told him, knowing that even this was unnecessary. “But it will likely be negative.”

“Can I have a prescription in the meantime?”

“You don’t need a prescription.”

“Why are you being so difficult?”

I explained that his illness is viral, and that antibiotics are indicated for bacterial infections. He still asked again, and when I told him again he didn’t need it, he began swearing. I moved on to the next patient.

A year earlier on a Thursday afternoon, I saw Micah Stanton, a hefty five-year old wheeled into the department by his mother. He’d been on antibiotics for three days – Amoxicillin – prescribed at a walk-in clinic for an ear infection.  He’d vomited a few times before midnight, but then diarrhea started – first every hour, then twice an hour. He’d had at least twenty episodes. Micah’s respirations were quick, his skin pale, his eyes sunken. His mother had wrapped his bottom in an adult diaper. He was severely dehydrated, and his stool tested positive for Clostridium Difficile – a sometimes deadly stomach bug associated with antibiotic use. His belly was tender, he was limp and lethargic, but his ears were perfect . His mother had taken him to the clinic after 24 hours of a low grade fever. If there had indeed been an ear infection, it was likely mild – and current guidelines suggest that antibiotics are likely not needed for mild episodes.

When antibiotics destroy normal gut bacteria, Clostridium Difficile can flourish, produce toxins, and cause unrelenting diarrhea. Different antibiotics are used to treat C.Difficile, and when those fail, some have tried fecal transplantation. Think about it: A disease so bad that patients would consider having someone else’s crap shot into their rectum for relief. That’s some bad shit.

Another patient I’d seen in the E.R., had a cough and cold for four days. On the fourth day, she developed severe diarrhea, and was unable to stand because of weakness. She told me that she’d been to a walk-in three days in a row, and because her cold wasn’t resolving. She’d been given a new antibiotic at each visit.

“Your illness is viral,” I told her. “Antibiotics won’t help you.”

“Then why,” she asked, “did the doctor give them to me?”

I resisted asking her why she’d gone to see a doctor three days in a row for a cold. When I’d tried suggesting to Roland that his illness was viral and he didn’t need antibioitcs, it didn’t register. It was as if I were simply making a suggestion -like I was trying to dissuade him from buying Apple Care, when he really wanted the added security. It’s staggering, that in grade school I learned that hockey great Bobby Clarke was from Flin-Flon, Manitoba, but I didn’t learn that antibiotics don’t treat viral infections. A 2015 World Health Organization study showed that Roland is not alone; Sixty-four percent of respondents believed antibiotics could treat colds and flus.

For more than forty years, it has been known that antibiotics are not effective for the treatment of acute bronchitis. However, a 2010 study suggested that 71% of cases between 1996-2010 were treated with antibioitcs. Walk-in clinics are not the only ones to blame. Overprescribing happens daily in doctor’s offices, as well as hospitals. In an era where patient satisfaction is a widely emphasized indicator of health-care quality, antibiotic prescribing has been consistently shown to improve patient satisfaction scores.

If the possibility of C.Difficile wasn’t bad enough, there is the issue of antibiotic resistance, which is in part due to antibiotic overprescribing. The emergence of a treatment-resistant Gonorrhea has recently been making headlines.

Eight months after Roland was escorted out of the ER, I saw him again with another minor ailment. He didn’t remember me, and I didn’t remember him, until I looked up his prior medical record. He was already on a first-line antibiotic, but wasn’t improving. Attached to his record was every prescription he’d filled since his last visit to the E.R. – twelve in total, including Zithromax, Amoxicillin, Clavulin, Clindamycin, Metronidazole, and Cefixime. Even more astonishing, was that each was from a different doctor – including three different antibiotics from three different physicians, all on the same day. Many of the physician’s names were familiar – local doctors, working in evening walk-ins, likely with waiting rooms full of patients. His chart was gloating, sticking it’s tongue out at me, thumbs in it it’s ears: na, na, this is how easy it is to get antibiotics.  Say no and I’ll get them elsewhere. What’s simpler – explaining viral versus. bacterial illness, or writing a script and moving on. Walk-ins, like hospitals, thrive when their metrics are good – wait times, lengths of stay, patient satisfaction. Roland asked if I’d prescribe “stronger” antibiotics.

I told him I couldn’t do it, and without much fuss, he thanked me and left.

Even I give in  – occasionally –  when tired, when I’m taking care of a critically ill patient, running back and forth, trying to keep the department flowing. Most patients, however, will listen, when there’s time to explain that antibiotics aren’t needed, and that they can often cause more harm than good.

And that throat swab, from Roland’s initial visit? Predictably, it was negative.

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  1. Curious – do you ever suggest that patients take probiotics after a round of antibiotics to restore normal healthy gut flora since antibiotics are non specific, erradicating both bad and good bacteria? A good brand like Genestra, Metagenics, AOR, etc. Probiotics are also great for children entering the germ infested land of daycare. Good bugs to crowd out the bad.

  2. Retired pharmacist here (2019)
    This story hit a few height marks for me. With 40 plus yrs of working in retail pharmacy I saw many people who used Emerg and walk in clinics as a form of entertainment ( if I can be so bold as to suggest)
    Again I will be politically incorrect , most if not all were on some sort of drug plan, most the government plan. When they appeared in the pharmacy not only did they look healthier then me , they also said not to worry, they would pick up their rx the next day. So much for acute.
    Unfortunately meds were dispensed , but I did admire the occasional md who would prescribe
    A week of ferrous gluconate daily once daily .no harm but the patient got that hot rx in their hand.

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