Prescribing antibiotics based on tele-health appointment

In My Humble Opinion
21

The doctor may have done so either a) because there’s an expectation to Do Something, or b) because of a combination of factors to do with that patient’s history.

Bronchitis CAN lead to a secondary infection. If it’s been going on for a while without getting better, that might be a clue that this has, in fact, happened. Some patients are more susceptible to this happening - e.g. I have asthma, and a respiratory virus can either cause a flare (in which case, a burst of steroids can make a huge difference), or settle in the lungs and allow nasty stuff to start brewing - in which case, steroids won’t help me much, while antibiotics do.

I have actually NEVER had a doctor attempt to do any kind of culture or test to determine whether I had a bacterial infection. I wish they would, actually - I’m not big on unnecessary antibiotics.

it’s been somewhat interesting to see different doctors’ biases toward one approach or the other. Once, 12 or 13 years back, I started going downhill over a weekend. I called my doctor’s on-call service, got a colleague who was covering for her, described the asthma symptoms flaring, and his reaction to the suggestion of prednisone was “Oh NOOOOOES!!! I’ve seen patients break hips after doing this too often!”. He prescribed an antibiotic, which I picked up and started; it maybe helped a little but 3 days later I was getting worse again. I called MY doctor, who sent a prescription for steroids, and also a different antibiotic. Oh, and yeah, too-frequent use of steroids is a risk factor for osteoporosis, but every 2-3 years for an asthma flare, not so likely. I honestly don’t know of the antibiotics were appropriate, in this scenario, I think the steroids definitely were. This is the closest I’ve come to the scenario described by the OP.

Another time, I had some kind of cold that had caused coughing - but I wasn’t really in any kind of respiratory distress… however, my voice completely left the premises and it felt like someone was jabbing daggers into my eardrums. The doc at urgent care said antibiotics were almost certainly not appropriate (and I agreed with her 100%) but did give me a short course of steroids. Spot-on - it just felt like there was pure inflammation going on from the virus.

But about 5 years back, I had a cold that turned into bronchitis, and after 2 weeks I was not improving - in fact I was getting worse. I went to urgent care (next door to my primary care’s office) and was given oral steroids. For a regular asthma flare, that would have made a significant difference within 24 hours - but 2 days later, I was WORSE. I went back - and they gave me MORE steroids (injection, this time). And, very reluctantly, a scrip for some kind of antibiotic “don’t fill it until tomorrow”.

Well, when I started the antibiotics, I started feeling better 24 hours later. I think I mentioned that on the boards once before, and the response was “it takes several days for xx to have any effect, it was probably just the steroids finally kicking in”… but knowing my own pattern and response to such in the past, I’m leaning toward the antibiotics being the winner (though I think the 'roids were appropriate also). I really think that the doctors (it was a different person, the 2 visits) were following the guidelines of assuming it’s viral, but not using their judgment in my specific situation.

Re purulent sputum (yellow or green): I thought that had largely been discounted as a signal that things had gone bacterial?

It’s a pity there aren’t more ways to at least mitigate the misery-making symptoms of a respiratory infection. OTC cough suppressants don’t do a hell of a lot; prescription ones do seem to help (me, at least) a bit, but with a productive cough, you don’t WANT to suppress it that much. Sneezing and sniffling isn’t much fun, but is not nearly as soul-destroying as the kind of cough that keeps you from sleeping for 2 days straight. If there was some better way of handling that sort of thing, I’d bet there would be less demand for unnecessary antibiotics.

22

Yeah other than swabs for strep and urine cultures the assessment of bacterial is generally clinically based on history and exam more than tests.

23

Our doc will often order sinus CTs to rule out chronic (>4wks) sinus infections.

Some insurers will deny our suggestion that the screening procedure is “medically necessary”, because their clinical guidelines for “medical necessity” require 2-4 weeks of antibiotics with no improvement.

~Max

24

Does COVID play into this at all? I know Mrs. Charming and Rested tested negative but I’m talking more about having her come in to be seen. Pre-COVID, my doctor was not the type to hand out a prescription with every visit but in January, my husband was feeling sick. Pre-COVID, this would have been an in-person appointment - but it wasn’t pre-COVID and therefore it was a telehealth visit. I don’t remember what the symptoms were but the diagnosis was either sinusitis or bronchitis or very possibly both and he definitely ended up with a prescription for antibiotics and one for steroids and he was told that the prescriptions were in part based on his history*. It’s possible that he would not have been prescribed antibiotics if he had been seen in person - but the doctor certainly didn’t want him to come into the office with the symptoms he had. ( and when he got tested as the doctor advised , he did come up positive so it was a good thing he wasn’t at the office)

* - he has asthma and ends up with sinusitis/bronchitis/walking pneumonia at least once a year.

25

Doctors sometimes prescribe antibiotics since they might assume the patient prefers this, the patient does not want to or may not come back for a second visit, and it sometimes helps. These are not great reasons. Some studies suggest patients want education and would often prefer not to take extra stuff of limited benefit. I have had few patients demand antibiotics.

Many cases of bronchitis are caused by viruses. Up to 90% in many populations - but sometimes lower and not always rare. However, it might be more likely to be bacterial if the person is very young or fairly old, has lung disease, gets many viral bronchitis infections, has other chronic diseases, is immunocompromised, there is known community spread, is in hospital or lives in a facility or institution, uses medical apparatuses, etc. Certain symptoms might also suggest bacterial involvement or progression to pneumonia. In this Internet example one assumes it is bronchitis and not one of several similar things. The mode of presentation is also a factor, I would guess telemedicine and ER settings increase script rates.

However, it is also more likely to be bacterial the longer it goes without resolution. In the given example, it is not that unreasonable to give antibiotics since it has been there over a week and the fever suggests it may be getting worse (if it happened at the end of this time). It would be worth considering the ease of reassessment, what might happen if it is bacterial and not treated now, and what happens if it is viral and is treated with a given drug which is not needed.

Still, as a clinician I would weigh what the consequences might be if the bronchitis became a pneumonia. It may still be more likely to be viral than bacterial depending on certain things, so offering a “delay filling this prescription” prescription might also be sound practice.

I am reluctant to criticize another physician without being confident I know all the facts, and there may have been other symptoms or issues. The choice of antibiotic is also relevant since some work better and some cause resistance issues with widespread use and should often be reserved for ICU or admitted patients or complicated patients.

26

Juat to give what i think is a legitimate counter-situation: I’m at a 2-week out of town conference where all of us are pretty much stuck for 15 days in a convention center in the middle of a tourist district with no cars and a brutal work schedule. A lady here has a tooth flaring up. Antibiotics for a tooth abcess are, in my experience, absolutely standard. With tele health, she got a script filled at the only grocery store in walking distance and now she’s fine and will see her dentist whwn she gets back in town. Before that was normal, she’d’ve either suffered for days and then flown with an abcess, or it would have been an expensive, logistical nightmare.

27

Except for the digestive tract, the mouth is ab area of the anatomy that is uniquely laden with pathogenic bacteria such that any deep injury is likely become infected and potentially spread into the circulatory system. As with deep penetrating trauma in the torso (or in extremities if there is significant contamination) a course of antibiotics may be prophylactically prescribed because of the high likelihood of infection even in an otherwise healthy patient. Generally speaking, however, the dermis (skin) is quite effective in preventing infection from the Staphylococcus and other pathogenic bacteria that are all around us.

Stranger

28

Bleh.

I actually had a sinus CT, back in the early 90s, in this exact scenario - had been on antibiotics for weeks, and had nonstop problems.

That’s true. I have certainly had swabs for strep, and had urine checks a few times. I hate the strep swabs - they really trigger my gag reflex. One time, I finally had to have the nurse hand me the swab, I stood in front of a mirror and did it myself (then upchucked a bit into the sink).

But there’s never been any attempt to verify what crud has been brewing in my lungs or sinuses.

29

Interesting question! I have to wonder if there are any studies showing any change in the level of abx prescribed in this manner.

Also: I don’t know if Covid is especially tied to secondary bacterial infections - I remember once googling this a while back and couldn’t find anything discussing it.

And tell your husband he’s really overdoing it with the annual sinusitis/bronchitis/pneumonia thing. I manage with just doing that every 3 years or so. He’s an overachiever and is making the rest of us look bad. (speaking of 3 years… it’s been about that long, so I’m due. I do NOT look forward to the next bad cold I catch).

30

Not much to add to what I said - trying an antibiotic if things have not improved after a week is commonly done; this should usually be a mild antibiotic and possibly a “here is a prescription if it has not improved by itself in a few more days”.

However, here is an interesting article implying that the usual pattern of when viruses occur seems to have been much disrupted by Covid.