Sir William Osler (1849-1919), Aphorisms from his Bedside Teachings (1961) p. 105
That two small Appalachian states, with a struggling healthcare system, would be at the top of the list for outpatient antibiotic utilization is not unexpected. West Virginia at number 1, with an average 1.22 dispensed prescriptions per person per year and Kentucky closely following, with 1.20 prescriptions per person consume antibiotics at over twice the rate of Pacific states and 40% higher than the rest of the country.
What explains the higher rates of antibiotic utilization?
Several potential reasons may explain the high antibiotic consumption in these two states. First, we must consider the potential for overutilization of care (i.e., that people in these states are not experiencing bacterial infections at a greater rate than other states). Overuse of care occurs when the potential for harm of a health care service exceeds the possible benefits. Overuse is one of the six priorities of the National Priorities Partnership which was convened by the National Quality Forum. With overuse comes the risk of allergic reactions (for example, to sulfa and penicillin) and serious toxicity (i.e., gentamicin causing nephrotoxicity) to vital organs. Dangerous cross-reactions with other common medications such as blood thinners and asthma medications may also occur. Not to mention the diminishing returns of long-term antibiotic effectiveness that comes with overutilization.
We speculate that one of the causes of overuse may be attributed to physicians treating viral infections as if they were bacterial ones. In rural Appalachia, healthcare providers are in short supply and offices are often packed with patients, leaving little time for education. The situation is also compounded by poor patient compliance for follow-up to obtain the results of Strep Screens and cultures. Patients may also be demanding antibiotics for viral infections, for which doctors prescribe to rapidly appease them rather than taking the time to educate the patient. This is not an excuse; the physician must spend the needed time with the patient and do what is best for the patient and society.
Increased public education also needs to be done. This can be difficult and must be tailored to both the patient s education and culture. Many Appalachians still do not have internet access, and are often distrustful of medicine and government. Their social unit is often the church with trust placed in their preachers. Working and educating all segments of their social support system will yield the best results.
When Sir William Osler, the father of modern medicine, described the first duties of a physician, he understood that patients would come to see medicine as a cure all. We believe that he was right in advising physicians to educate their patients on taking medications on a need-only basis.
High smoking rates may also be responsible for antibiotic overuse in the Appalachian region. Both West Virginia and Kentucky have the highest smoking rates in the country, 26.5% and 25.2% of adults are smokers, respectively. West Virginia ranks 51st and Kentucky 49th among the states (and DC) for smoking rates. There is evidence that smokers have a higher likelihood of developing upper respiratory infections, potentially leading to a greater demand for antibiotics in these states.
The influence of drug marketing also cannot be dismissed. Just 12 drug companies do voluntary reporting of payments to Kentucky healthcare practitioners. According to data posted on ProPublica.org, over a two and half year period, Kentucky physicians were paid approximately $7,000,000 by pharmaceutical companies for speaking, travel, consulting, and the nebulous other category. This is an underestimate given that data comes from companies with less than 50% of the total pharmaceutical sales in the United States. Evidence suggests that pharmaceutical gifts to physicians may affect prescribing habits, and at the very least, presents a disturbing temptation to a rural doctor with a mostly indigent medical practice. These factors may also be affecting the overprescribing of antibiotics.
Another possibility for the high antibiotic utilization in these states is that people are actually experiencing more bacterial infections, thus, necessitating greater antibiotic utilization. Unfortunately, assessing this requires surveillance of infections across states and an effective system does not currently exist.
What can be done?
In lieu of these high utilization states legitimately having more infections, several things can be done to curb overuse. We believe that healthcare must be patient-centered, with closer relationships between doctors and patients. Physicians must be in a practice environment which allows them to spend enough time with patients. This is important so doctors can explain that antibiotics are not for everything, and are not magic pills. Education on antibiotic stewardship is necessary for both patients and physicians; mainly that more is not better, and usually worse. Only recently (November 15), the Centers for Disease Control and Prevention (CDC) and the Institute for Healthcare Improvement (IHI) announced the creation of a new tracking system to be piloted in 8 acute care hospitals for the purpose of preventing chronic overuse of antibiotics. The joint initiative, called the CDC/IHI Driver Diagram and Change Package for Antibiotic Stewardship, was announced as part of CDCs Get Smart About Antibiotics Week . Systems like this can inform hospitals antibiotic administration practices, and seek to reduce overuse when identified.
What can happen if overprescription of antibiotics proliferates?
The alternative, doing nothing and continuing to overprescribe antibiotics, can have dramatic public health consequences. Broad spectrum use of antibiotics for viral infections has contributed to the increase of Methicillin-resistant Staphylococcus aureus (MRSA) and multi drug resistant organism (MDROs) infections and a decline in the effectiveness of current antibiotics. Specifically, healthcare acquired infections are becoming more difficult to treat because of the emergence of antibiotic resistance. Last resort broad spectrum antibiotics have also become ineffective against superbugs. For instance, NDM-1 (New Delhi metallo-beta-lactamase-1), first detected from a Swedish patient of Indian origin in 2008, is an enzyme that makes bacteria resistant to almost every single antibiotic except tigecycline and colistin (both relatively toxic drugs).
Finally, potent antibiotics are on the decline and the current last-resort drugs date back to the 1950s. Antibiotic pharmaceutical companies are getting out of the market due to nonprofitability caused in part by the need to perpetually create new antibiotics. The 2004 Infectious Diseases Society of America report, Bad Bugs No Drugs, foretold of this situation. Currently, it costs well over one billion dollars to bring a new antibiotic to market.
What can happen seems grim. In reality, it is already happening, at a rapid pace too. Antibiotic stewardship, coupled with greater education of when to prescribe antibiotics and a closer physician-patient relationship may slow down antibacterial resistance. We must all be careful in taking antibiotics, as taking too much (or not completing a full regimen) affects the public s health.
About the Authors:
Dr. Daniel M. Saman, DrPH, MPH, CPH, recently completed his DrPH in epidemiology (November 14) from the University of Kentucky College of Public Health. He currently works as a research assistant and is a member of Health Watch USA.
Dr. Kevin T. Kavanagh, MD, MS, is a non-practicing otolaryngologist in Somerset, KY, and founder of Health Watch USA, a 501(c)3 organization whose mission is to promote healthcare transparency and patient advocacy.