Sarah is a 30 year-old woman who is a busy attorney with two young children. She presents to your office with a 7-day history of a cough following an upper respiratory infection (URI). She denies fever, shortness of breath or chest pain. She reports trouble sleeping due to the cough and says, "I think I need an antibiotic."

After taking her history and performing a physical exam, you decide she has acute bronchitis, which is almost always viral. What do you do? Her statement leads you to believe she expects an antibiotic, even though antibiotics don't help viral infections. She has been a patient of yours for several years, though, and you don't want her to leave unhappy.

Every day, healthcare providers across the country are faced with the dilemma of whether or not to prescribe an antibiotic, and how they choose to handle it has far-reaching effects. With each unnecessary prescription, providers risk adding to the increasing bacterial resistance to antibiotics; they may also be unknowingly dissatisfying their patients.

Unfortunately, healthcare providers often misperceive patients' desires and assume that they want an antibiotic, when this is not necessarily the case. Understanding common provider misperceptions and actual patient expectations will lead to decreased unnecessary antibiotic prescription and increased patient satisfaction.

Increasing Bacterial Resistance
The U.S. Centers for Disease Control and Prevention and the World Health Organization have stated that growing antimicrobial resistance is a public health threat that crosses all international boundaries.¹ Although there are several causes of antibiotic resistance, it is widely believed that resistant strains of bacteria are a direct result of unnecessary antibiotic prescription in ambulatory care.²

One of the biggest concerns is the growing antibiotic resistance of S pneumoniae, which can cause pneumonia, meningitis and septicemia. It has become increasingly resistant to penicillins over the years and is now exhibiting resistance to macrolides and trimethoprim sulfamethoxazole (Bactrim).³ This increasing antibiotic resistance is leading to the frightening potential for a postantimicrobial era. In turn, healthcare providers must learn to limit their antibiotic prescriptions to those patients who truly need them.

Antibiotic Effectiveness for URIs
Perhaps an even better reason to avoid prescribing antibiotics for URIs is that they don't work, as is demonstrated by a study of 185 patients diagnosed with a URI. Half of the patients were treated with azithromycin (Zithromax), and the other half was given a placebo. The two groups did similarly when comparing proportions of patients improved or cured at 3 days, 1 week and 2 weeks. There was also no difference in the length of their illnesses. ⁴

Several Reasons for Overprescription
Prescribing an antibiotic is a much more meaningful intervention than providers may realize. Writing a prescription signifies that the provider has made a diagnosis and that treatment is possible. It shows that the patient is actually ill and therefore allows him to legitimately take the sick role, which definitely has its benefits. A prescription is also the quickest method to signal to the patient that the visit is over.²

Diagnostic uncertainty is another reason for unnecessary antibiotic prescription. Healthcare providers often come across patients who are ill, but whom they can't confidently diagnose with a specific illness. Patients may also present with an illness that seems viral but then describe symptoms that seem unusually severe. Both of these can cause the healthcare provider to become uneasy, and he may ultimately prescribe an antibiotic "just in case."

Patient Pressure and Prescribing
Perceived patient pressure also plays an important role in the overprescription of antibiotics for URIs, just like it greatly affects most healthcare provider behavior in general.⁵ Sometimes the patient exerts this pressure by specifically asking for an antibiotic, but usually it is much more subtle. Unfortunately, though, providers often perceive this pressure even when the patient did not mean to exert it.

This demonstrates that patient-provider miscommunication also plays a role in the overprescription of antibiotics. Often, when a patient describes severe symptoms or a long illness, or mentions the desire to get well quickly, the provider assumes he is requesting an antibiotic with these statements. In reality, the patient may just want the provider to understand the severity of his symptoms. The patient also wants to be reassured that he does not have a serious illness.⁶

Healthcare providers may also assume that most patients presenting with a URI want an antibiotic and would not be satisfied without one. Patient expectations regarding antibiotics have changed, though: Fewer patients desire antibiotics than in the past. A 2002 study showed that only 39% of adults seeking care for a URI wanted antibiotics, as opposed to the 75% reported in older studies.⁷ It has also been shown that an antibiotic prescription does not affect patient satisfaction.⁸ Therefore, healthcare providers should not prescribe unnecessary antibiotics based on perceived patient desire.

Increasing Patient Satisfaction
If patients don't necessarily want an antibiotic, what do they want from their appointment? Studies show that a thorough physical exam is valued most highly among patients. Patients want to feel assured that their provider has gathered enough objective information to make an informed decision about their care.⁸

Seeing a provider who knows them well is the second most-valued component of an office visit.⁸ Patients gain comfort from feeling their provider understands and cares for them personally. Obviously, in urgent care or retail settings, this probably does not come into play.

Many patients also desire something tangible to show for their visit.² This is understandable, since they paid a copay with the expectation that their provider would help them feel better. If the patient could benefit from a prescription besides an antibiotic, such as an inhaler or cough syrup, this could fill the desire for something tangible. Recommendations for effective over-the-counter medications written on a prescription pad also give patients something to show for their visit.

Putting It All Together
So let's return to the case of Sarah. What should you do for her so you're both satisfied with the visit?

First, you realize that she's not necessarily requesting an antibiotic -- she's just having difficulty sleeping and worried about her health. You listen carefully to her symptoms and perform a thorough physical exam. Next, you reassure her that you think she has  viral bronchitis, which would not benefit from an antibiotic. If she develops shortness of breath or a fever, however, she should return. You then write her a prescription for a cough suppressant with codeine for nighttime, since loss of sleep due to coughing was her biggest concern.

At the end of the visit, you're happy because you satisfied your patient without prescribing an unnecessary antibiotic, and Sarah is glad that she doesn't have a serious illness and will finally get some sleep.  

Erin McKay is a family nurse practitioner student at Pacific Lutheran University in Tacoma, Wash. She plans to provide care to low-income, underserved and Spanish-speaking populations once she graduates. She currently works as an RN in the emergency department at St. Francis Hospital in Federal Way, Wash.   

References
1. U.S. Centers for Disease Control and Prevention. A public health action plan to combat antimicrobial resistance. Available at http://www.cdc.gov/drugresistance/actionplan/index.htm. Accessed on October 19, 2009. 

2. Avorn J,  Soloman D. Cultural and economic factors that (mis)-shape antibiotic use: the non-pharmacologic basis of therapeutics. Ann Intern Med. 2000; 133(2):128-135.

3. Lang M. Antimicrobial resistance in pediatric upper respiratory infection: a prescription for change. Pediatr Nurs. 1999; 25(6):607-618.

4. Batieha A, Yahia G, Mahafzeh, T, Omari M, Momani A, Dabbas M. No evidence of treating acute respiratory tract infections with azithromycin in a placebo-controlled study. Scand J Inf Dis. 2002; 34:243-247.

5. Little P, Dorward M, Warner G, Stephens K, Senior J, Moore M. Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral and prescribing in primary care: nested observational study. Br Med J. 2004; 328:444.

6. Altiner A, Silke B, Sielk M, Wilm S, Wegscheider K, Abholz H. Reducing antibiotic prescription for acute cough by motivating GPs to change their attitudes to communication and empowering patients: a cluster-randomized intervention study. J Antimicrob Chemoth. 2007; 60:638-644.

7. Linder J, Singer D. Desire for antibiotics and antibiotic prescribing for adults with upper respiratory tract infections. J Gen Intern Med. 2003; 18(10):795-801.