Sep. 17, 2001 Most adult patients who see their doctors for a sore throat receive a prescription for an antibiotic, despite the fact that antibiotic treatment may be appropriate for only 10 percent of such patients. And even though the inexpensive traditional antibiotics penicillin and erythromycin are the recommended treatment for sore throats that do require antibiotics, physicians often prescribe newer, more expensive "broad-spectrum" antibiotics. These findings from research conducted at Massachusetts General Hospital (MGH) appear in the Sept. 12 issue of Journal of the American Medical Association.
The vast majority of sore throats are caused by viral infection, which antibiotics do not treat. Only in cases of bacterial infection -- commonly referred to as "strep throat" -- can antibiotics be useful. The current study, which analyzed physician practices from 1989 through 1999, supports previous research finding excessive antibiotic use in sore throats and is the first to delineate the trend to prescribe inappropriate classes of the medications.
"There are pretty well known criteria for diagnosing strep throat and predicting its incidence in a population" says Jeffrey Linder, MD, of the MGH General Medicine Division, the paper?s first author. "If you go in to see your doctor for an upper respiratory infection, including a sore throat, nine times out of ten you should not be given an antibiotic."
Linder and senior author Randall Stafford, MD, PhD, analyzed data from the National Ambulatory Medical Care Survey. In this annual survey, conducted during a specific week each year by the National Center for Health Statistics, paraticipating physicians answer questions about patients' diagnoses and the treatments provided after each outpatient visit. Among patients seen for sore throats during the study period, 73 percent received an antibiotic prescription. And of those prescriptions, 68 percent were not for one of the two recommended antibiotics.
While the dangers of overusing antibiotics -- most significantly the development of antibiotic resistance in bacteria -- are well known, there are many forces that could lead physicians to prescribe them inappropriately. The study's authors note that many patients expect antibiotics when they visit their doctor for a sore throat or even colds, which also do not improve with antibiotics. Antibiotic use also may needlessly place patients at risk for allergic reactions.
"The best solution for physicians, educating their patients about the proper use of antibiotics, often is not feasible because of the time pressures many physicians face," says Stafford. Formerly a member of the MGH Institute for Health Policy and General Medicine Division, Stafford is now an assistant professor of medicine at the Stanford Center for Research in Disease Prevention.
Prescribing newer antibiotics, which can be as much as 20 to 40 times as expensive as penicillin and erythromycin, can also be attributed to patient demand as well as to promotional activities by pharmaceutical companies. In addition, earlier inappropriate prescriptions can further compound the problem. "Patients who previously received antibiotics for viral conditions, probably received no benefit from those prescriptions," Stafford says. "On their next episode of sore throat, they may feel they need a newer antibiotic because of their unsatisfying earlier experience.
In addition, some physicians may assume, from evidence that broad spectrum antibiotics are better in situations like pneumonia, that the same is true for strep throat, when in fact it is not."
The study authors note that efforts are already under way to educate physicians and patients about the dangers of overprescribing antibiotics. "We did see a small decline in antibiotic prescriptions in 1999, the last year of this study, which may be evidence that these educational efforts are starting to bear fruit," Linder says. "We need future studies to confirm that observation and expanded efforts to support good prescribing practices."
Stafford adds, "The issue of antibiotic overuse relates to the fundamental conflict between the practical need for cost effectiveness in medicine and societal demands for the latest health care technology. This particular situation is unique in that the more expensive care may actually produce worse health outcomes."
This study was supported by a National Research Service Award grant to Linder and a National Heart, Lung and Blood Institute award to Stafford.
The Massachusetts General Hospital, established in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of almost $300 million and major research centers in AIDS, the neurosciences, cardiovascular research, cancer, cutaneous biology, transplantation biology and photomedicine. In 1994, the MGH joined with Brigham and Women?s Hospital to form Partners HealthCare System, an integrated health care delivery system comprising the two academic medical centers, specialty and community hospitals, a network of physician groups and nonacute and home health services.
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