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The Dose Transcript for November 9, 2023

Host: Brian Goldman

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BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. I have lost count of how many times people with a cold have asked me to prescribe them an antibiotic. And to be clear, antibiotics do not get rid of a cold. The U.S. Centres for Disease Control says at least 28% of the antibiotics prescribed by doctors are considered unnecessary and contribute to superbugs. Antibiotic stewardship is an effort to promote the correct use of these powerful medications, and we want to break that down for you. So this week, we're asking, what do I need to know about using antibiotics correctly? Hi, Lynora. Welcome back to The Dose.

LYNORA SAXINGER: Thanks for having me again.

BRIAN GOLDMAN: Do you think most people understand what antibiotics are good for?

LYNORA SAXINGER: I'm going to say yes and no because certainly, a lot of people are aware that, you know, viral infections, you don't need an antibiotic. At the same time, I think that a lot of people are in the habit of still seeking antibiotics if they're finding that their illness is prolonged or more severe just in case. And I think it's the just in case piece where we tend to run into more trouble. So I think there's increasing awareness of problems with antibiotic overuse and misuse, but that it still remains, as you've said already, very, very common.

BRIAN GOLDMAN: So let's see if we can try to make things clearer for people who listen to our show. But before we begin, can you give us a Hi, my name is? Tell us what you do and where you do it. Just adlib.

LYNORA SAXINGER: Sure. Hi, my name is Dr. Lynora Saxinger. I’m an infectious diseases specialist at the University of Alberta Hospital in Edmonton.

BRIAN GOLDMAN: Tell us first about the prescribing and use of antibiotics by patients that has led us to this crisis point where we're trying to do something about it.

LYNORA SAXINGER: Right. Well, I think there's actually probably two different forces at play. One thing that's really, really clear is that resistance always develops in response to use of antibiotics pretty much across the board. And if you do not need the antibiotic and you're exposed to antibiotics, you are increasing the risk of, I guess, resistance in the bacteria that you carry and that this, in fact, is not something that might just affect you. It also affects the rest of everyone else because bacteria, some strains especially, can spread person to person. And so it's kind of an ecological problem. It's not just a problem for the person taking the antibiotic. And that makes it unlike a lot of other treatments where if you take the drug, it affects you and that's where it stops. The other issue is that medical care has gotten really, really complicated and very effective at treating people with, you know, immunosuppressive medications and chemotherapeutic medications where these individuals frequently need antibiotics, sometimes for a very long time. And so on the in-hospital side, we often see completely warranted antibiotic use driving increasing resistance as well. And so it's really been a combination of both of those things. And in some places, I mean, the antibiotic resistance rates in the communities is very, very high, even places where people can get antibiotics over the counter, and that's a big concern.

BRIAN GOLDMAN: This gets into behaviour, the behaviour of prescribers. Why do people like us prescribe too many antibiotics?

LYNORA SAXINGER: There is some literature in this. Like I I've been involved in stewardship since before it was cool. And the literature in this area actually usually has a few different things that come to the top. One of them is when you're a physician looking at a patient and they're ill and they're worried, you kind of feel like you want to do something for them. And we lack good diagnostics for a lot of viral infections. And so we say, well, our default is to think it's viral, but can we say for sure? And in that uncertainty is where a prescription sometimes happens. And that can really be pushed along when the individual is coming in with a request, because frankly, in our overloaded health care system, it takes a lot longer to counsel people through a visit that doesn't end in antibiotic prescription than it is to just give an antibiotic. So I think that there is also volume and stress related issues. So, you know, it is a very difficult thing. And there's even some literature that, you know, if you kind of try to highlight the societal requirements or societal importance of avoiding over-prescription, there does tend to be an impact on use. But it often kind of goes back to the average after a period of time. So getting a sustained change in, you know, patient and prescribers, both can be very, very challenging.

BRIAN GOLDMAN: There is, you know, we'll call it a kind of a little secret, maybe a dirty little secret amongst prescribers that one way to close an encounter with a patient, if it's perceived that it's going on longer than you wish it would, would be to close it with a prescription. Does that still happen? Do people prescribe the antibiotic because they'd rather just end the encounter than then spend that extra time explaining why it's not necessary?

LYNORA SAXINGER: I think that there probably is an element to that. I tend to think that, you know, at least as far as I can tell, a lot of community-based prescribers, physicians are aware of the problems. And to my mind, I actually feel like probably more of the prescribing is driven by you can't call them and follow up, you can't see them and follow up. They might be getting kind of sick. They're asking for this. And you can't actually say for sure, for sure that it is viral. And I'm going to also point out that there's this phenomenon of, you know, when people start getting ill with a virus, they, you know, keep on getting sicker. And then as they're getting sicker, they call for an appointment, then they go to the appointment. It's now probably peak illness. They're miserable. They look terrible. They get a prescription. It's for a virus. But they start to get better shortly after because they've just peaked in their illness while this whole process was going on. And so there's also a learned behaviour where people associate getting better with having had an antibiotic prescription. And you hear that a fair amount. So they kind of have their own experience that when they get an antibiotic, they tend to get better. Well, I would argue that often, that's because they were due to get better then anyway. But it's a tough sell. I actually wish we had, you know, a Star Trek tricorder that would just tell us what the person has. It would make it a lot easier for everyone to do the right thing.

BRIAN GOLDMAN: You're a Trekkie. You're… You know something? I thought I knew everything about you, and now I realize that there's still so much more good stuff to learn. So thank you. Yes, we don't have a tricorder, unfortunately, but we do have antibiotic stewardship. And you said you were into antibiotic stewardship before it was cool. We aim to make it cool here on The Dose. So go ahead. What do we mean by antibiotic stewardship?

LYNORA SAXINGER: Antibiotic stewardship is really about making sure that we're using antibiotics at the right time, for the right people, at the right amount and the right dose. And so it's trying to get it right. And so that avoids… trying to avoid, you know, overuse, obviously, but it's not just the antibiotic police. It's also making sure that when we use it, we're really optimizing use in all possible ways for the best outcome, because sometimes, let's face it, antibiotics are popular because they really do help people a lot. They are lifesaving drugs and that's why we all like them. So it's not like you're trying to, you know, restrain the use of something that's not useful or toxic. It's not like crack cocaine or cigarettes. You're not trying to decrease it to zero. If you decrease antibiotics to zero, you're running into some trouble as well. So it's really getting it right and it's really trying to do all the things that support that. So you want to know what the resistance patterns are where you are to make sure that you're using the right drugs and guidelines. You want to make sure that the diagnostic tests are being used properly. You want to make sure that people have tools and knowledge to avoid excess prescriptions. And it's interesting because you sometimes feel like you're the antibiotic police if you're in antimicrobial stewardship, but it is definitely more than that.

BRIAN GOLDMAN: You said something that's really interesting. You want to know the local resistance patterns. So that means knowing, for instance, for a urinary tract infection, whether ciprofloxacin, whether there's a lot of ciprofloxacin resistance, where if you kept prescribing it, you would not be making people better. You'd probably just be increasing the amount of resistance, wouldn't you?

LYNORA SAXINGER: Yeah. And that's actually kind of a perfect example because I mean, even when you look at the resistance patterns on a very, very local level, in nursing homes, they commonly have ciprofloxacin resistance rates that are just astronomical, like 50% and higher because antibiotics are so commonly used in that setting. And, you know, in that setting, you're giving all the risk of an antibiotic without really much of a chance of benefit. And a lot of, you know, asymptomatic bacteria in the urine are being treated. And we now know that that's not really going to help the patient at all. So, you know, there's a lot of kind of culture shifts honey, I guess, and also lore that we have to really look at critically and start to change in order to address some of those problems. And the resistance rate patterns are usually attainable for people. Like they're usually available from the microbiology lab that would be a regional or provincial lab because they are supposed to, as part of their accreditations, have that information available. But you do have to sometimes look for it, unfortunately, and theoretically, it should be updated. So you should never have data that's more than about a year old for the most common bacteria drug combinations in your area.

BRIAN GOLDMAN: I know these are kind of early days, but how effective is antibiotic stewardship in curbing the incorrect use of antibiotics?

LYNORA SAXINGER: So it really started probably mostly as an in-hospital programs would be the most well-established. And they show that you can reduce days on antibiotics, reduce antibiotic costs, improve outcomes with no evidence of risk of poor outcomes, and even reduce the frequency of isolation of resistant organisms in some cases when there's an active stewardship program kind of helping people along the way dealing with, you know, especially the super high octane antimicrobials. On a community basis, it's a little bit harder because there's so many prescribers and so many settings for prescription. But there are some community-based stewardship programs where really, it's about giving people feedback on their own prescribing, for example, and how they compare to others and making sure that you're making people aware of local guidelines that are based on local susceptibility. And so there's definitely a long way to go in both community and hospital stewardship, but it appears to be a pretty good investment, honestly, across the board.

BRIAN GOLDMAN: We've already talked about ciprofloxacin and urinary tract infections. What are some of the most common conditions where antibiotics are used incorrectly?

LYNORA SAXINGER: Oh, good one. So yeah, when someone has bacteria in the urine and they don't have specific urinary symptoms or, you know, whole body infection symptoms associated with it, there's no evidence that treating that helps with kind of vague issues that often cause the urine to be sent, such as increased confusion or weakness. And so that would be a really, really high priority one in hospital settings and in elder care situations where there is evidence that not treating asymptomatic bacteria in the urine is not harmful in any way and probably beneficial to patients. Then the other ones, you kind of alluded to earlier. You were talking about respiratory tract infections. And, you know, cough is almost never needs an antibiotic unless it's accompanied by signs of pneumonia. And that's something that can be assessed. And if someone has a cough and even a bronchitis, that does not mean they need an antibiotic. The other time that it might be worthwhile, aside from when they have pneumonia, would be if they have an exacerbation of chronic obstructive lung disease. So if they have chronic lung problems with a worsening status, there's some limited evidence that antibiotics can help them improve more quickly. But, you know, you don't want to… you don't want to overtreat. You just want to give the kind of guideline associated treatment in that period. The other ones would be like middle ear infections or otitis media don't always need an antibiotic. My paediatric colleagues would probably be able to go over that in more detail. And sore throats are frequently bacterial and don't always need antibiotics either. So all those kind of from the neck up very common infections, there's sort of a discretionary clinical assessment that should guide antibiotic use for those. And there should always be, and I just have to point this out because of course, the things that people remember is when you said, oh, you don't need antibiotics and they came back sicker, right? So those more rare cases are the ones that stick in your mind. There should always be some ability to kind of touch base in a day or two to make sure things aren’t going off the rails, and the patient should always be counselled about what to look out for. But the vast majority of times, it's a weeded out kind of supportive symptomatic care situation.

BRIAN GOLDMAN: Since you've mentioned it, let's talk about it some more. Sometimes, what you're talking about is called watchful waiting. What are some of the conditions? You mentioned middle ear infection. Even in kids, sinus infections. First of all, what do we mean by watchful waiting and what are some of the conditions for which watchful waiting would be appropriate instead of immediately getting an antibiotic?

LYNORA SAXINGER: Sinus infections and ear infections, If we kind of look at them as sort of a group, both tend to be a viral phenomenon upfront. And in an early sinus or ear infection, especially sinus infection in adults, I mean, it can be really miserable. And people will frequently seek care at that phase, but it's not necessarily a bacteria at that point. If they still have symptoms beyond five days, it's not started to turn around in that period of time, or if they have a lot of like fever or tooth pain, then you might start looking to see if they have a secondary bacterial infection. But, you know, over 90% of the time, it's all virus. And so you're talking to people about nasal rinses and decongestants and all these other things that probably would give more benefit than an antibiotic in most cases. But you'd have to counsel people about if the symptoms are worsening, if they're developing fever or if they're developing more tooth pain right underneath the sinuses and things like that. Likewise, ear infections, there's even a move in paediatrics where they think it is bacterial that you can watchfully wait for a short period before giving antibiotics. For sore throat, the reason that we mostly treat a bacterial sore throat like a strep throat is to prevent the consequences of strep throat, like some immunologic follow on issues that are usually fairly rare but significant. And so by itself, treatment of strep throat isn't necessary for people to improve. And because so many sore throats are viral, there's a reasonable case to be made for doing a swab to see what it is and then just waiting to see if it's something that would require treatment. And then urinary, urinary symptoms, symptomatic urinary tract infection, if it does seem to truly be that should be treated. So that's not a watchful waiting situation. The only other one I can think of if I really think would be like diarrhoeal illnesses very rarely need an antibiotic upfront unless it's associated with, you know, blood in the stool, fever, abdominal pain, like a more invasive type infection. And so there again, you just want to make sure the workups being done so that anything that's more significant can be identified and treated.

BRIAN GOLDMAN: Let's turn things around. What are the common bacterial infections for which antibiotics are effective and should be given?

LYNORA SAXINGER: Oh, antibiotics are great if you need them. Like if someone actually has a pneumonia, pneumonia used to be a killer. And now, it really is very uncommon to have that situation because even outpatient, oral antibiotics can be very, very effective. Bloodstream infections, skin and soft tissue infections, or if you can see it and feel it and it has pus, it probably is a bacterial infection with a few exceptions. And really, that is very, very satisfying to treat. I mean, there's all this stuff that I'm seeing in hospital. You know, the antibiotic part of the story is very important. And even though in hospital, we still try to pick the antibiotic that is most targeted to that bacteria without killing all the other ones as much as possible. We also try to make sure that we're not treating for longer than we need to. So we're really looking at things like the choice and the duration. So we're using the right thing for the right time without overusing and monitoring to make sure that that's appropriate treatment. There's a real push in hospital actually to decrease, like shorten the time that we give antibiotics for. And it's been largely successful, but it's something that's still an evolution.

BRIAN GOLDMAN: One of the things that I noticed right away about antibiotic stewardship is that the antibiotic chosen is often not the newest. And, you know, that makes me think about watching those prescription medication ads particularly on U.S. television, you know, those TV commercials for the latest pharmaceutical drugs. And yet, when it comes to antibiotic stewardship, newest isn't necessarily the best. What do you know about that?

LYNORA SAXINGER: You know, it's interesting because we're kind of putting ourselves in a bit of a corner here because we usually when there's a, you know, some gee whiz new drug, especially on an in-hospital side, the pipeline in it for antibiotics is pretty poor. Like it really is not sufficient. Like we do need more antibiotic development to keep pace with resistance. But once something comes out, we're often inclined to save it for when we really need it, which doesn't really help the marketing of that medication. You do find that kind of the old retro chic drugs like doxycycline, penicillin, you know, simple antibiotics are the preferred stewardship choice frequently. And so it is a little bit of a problem where we're saying, hey, develop some new antibiotics, but then we don't want to use them too broadly. The new stuff isn't always broader spectrum, but it frequently is, honestly. And it often is, you know, there was a time when new antibiotics coming out would be very heavily marketed and they get used for everything. And that put us in a situation, to some extent, that we are now where we have such widespread resistance to certain classes of drugs, and they’ve kind of even started to lose their relevance for the things that we found them most useful for in the first place. So it is a bit of a challenge and we probably should be looking at other ways to deal with this marketing issue and the drug development side. But, you know, there is a bit of psychology there too, where newer is usually seen as better psychologically. And that kind of older stuff, people might feel like they're not giving as good treatment to their patients if they're using one of these older drugs, which is why I like to use the word retro chic, because I think it sounds cooler. But frankly, the bacteria don't care if the antibiotic is New or old. They just, you know, if it works, it works. So there is some messaging around that. And you do find the stewardship guidelines do tend to lean on certain kind of workhorse antibiotics. And we often like ones that are a little less likely to select resistance for other antibiotics as well.

BRIAN GOLDMAN: And finally, what's the harm in taking an antibiotic when I don't need one? I know you and I know what it is, but I think we need to spell it out.

LYNORA SAXINGER: Sure. You know, I'm going to actually start with the harms that people often don't think about. But antibiotic adverse events are one of the top reasons for drug adverse events to be seen in emergency rooms. And so, you know, people can have rashes. They can have anaphylaxis. They can have, you know, delayed hypersensitivity reactions. They can have a disturbance of their, you know, bacterial ecology in their gut and get a diarrhoea related to a bacterium called Clostridium difficile, which is something that's, you know, very squarely associated with antibiotic use. So there's some actual risks to taking any medication. And if you didn't have anything that needed it for treatment, you're taking on that risk without a potential benefit. And then the other thing, of course, is if you're taking an antibiotic and it actually results in you then carrying organisms that are more likely to be resistant because they've been exposed to the antibiotic, they've started to figure out the antibiotic and you get sick, you're a little more likely to have a resistant bacteria on this go around. And so antibiotic use within the last three months is a risk factor for having more resistant organisms. So when I see someone at hospital, I look for that history to see if they had any antibiotic exposure recently that would make me think their current bacterial infection might be more difficult to treat. And so it's not a completely benign thing. Although I think people really do, going back to the days when antibiotics, you know, are wonderfully lifesaving sometimes, people think of them as being more of a security blanket or, you know, a huggy kind of stuff. Like it makes people feel safer to be on it. But I think that that's kind of a false feeling, that it is always a double edged sword.

BRIAN GOLDMAN: And thank you for making that double edged sword crystal clear. Dr. Lynora Saxinger, thank you so much for speaking with us on The Dose.

LYNORA SAXINGER: My pleasure. Thank you.

BRIAN GOLDMAN: Dr. Lynora Saxinger is an infectious diseases specialist with the University of Alberta. Here's your dose of smart advice. Antibiotics treat bacterial infections and save lives when used appropriately. But when they aren't needed, they cause adverse effects and other harms. Their use also contributes to antibiotic resistance. When that happens, we have fewer antibiotics to treat serious infections that land patients in hospital. In Canada, an estimated one in four bacterial infections are resistant to the first drugs used to treat them. 15 people die each day in Canada from antibiotic resistant superbugs. Antibiotic stewardship is the global effort to improve how antibiotics are prescribed to and used by patients. This effort is critical to protect patients from harm and to combat antibiotic resistance. You can do your bit to avoid unnecessary antibiotics. Take them only when prescribed and only when necessary. Since colds, flus and COVID are caused by viruses, antibiotics won't get you better any faster. Likewise, you don't need antibiotics to treat most diarrhoeal illnesses since most are caused by viruses. Do your best to prevent infections and stop them from spreading by handwashing, the safe handling of food and by limiting close contacts with others during an illness. Antibiotics are indicated for ear and sinus infections, strep throat, bacterial pneumonia and bladder infections. If you receive an antibiotic, take it as prescribed and for as long as your doctor or nurse practitioner has indicated. If you have any leftover antibiotics, you should return them to the pharmacy. Do not dispose of them yourself. In certain bacterial infections, you might get better without an antibiotic. In that case, your doctor or NP may recommend watchful waiting for two to three days to see if you get better on your own. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca. If you like this episode, please give us a rating and review wherever you listen. This edition of The Dose was produced by Stephanie Dubois and Jason Vermes. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

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What do I need to know about using antibiotics correctly? - Transcript

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