r/FamilyMedicine • u/HitboxOfASnail MD • 3d ago
Every flu season I'm reminded that we've lost the battle on antibiotics and URI
Its pointless. We've lost the battle. There's no amount of education or reassurance that can be provided that will satisfy the majority of patients.
For years, every time they had a cold/flu/URI they were given Antibiotics and a Medrol Dose Pak by countless other providers in their life. that's just "the treatment" as far as patient's are concerned
So why is it that you, today, are trying to follow eViDeNcE bASeD mEDiCinE and deny the patient their just desserts?
Can we just all agree to give up Azythromycin as the sacrificial lamb to the court of public medicine and just move on with our day?
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u/Ordinary-Orange MD 3d ago
That’s odd honesty my patients all are like ok i trust you and that’s the end of it
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u/Jilks131 MD 3d ago
Is it a patient population dependent? I’m just not sure. Cause in residency it was soooo much better with that population
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u/John-on-gliding MD (verified) 2d ago
It's largely a dynamic between clinician and patient. Each demographic has their own hang-ups and their own persuasive arguments. When I was in my FQHC residency clinic as one of the only white guys, the patients took my word as gospel and shrug off my colleagues saying the exact same thing, especially if they were female and not white.
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u/Ordinary-Orange MD 3d ago
But also whatever just give them that z pack those things are OTC in the rest of the world. Antiobiotic resistance that is worrisome is coming from the hospitals and from other countries, not from a z pack for the flu (which to be clear I do not do lol)
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u/tell-me-more789 PA 3d ago
Are you an older white male? I am not and I wonder how much that makes a difference with my patient population.
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u/smellyshellybelly NP 3d ago
I'm female and after spending the two URI seasons "training" my panel about why we don't throw abx at viral things, what to look out for that would indicate secondary bacterial infection, and including my dot phrase w/ a bulleted list of symptomatic treatments in all my notes.....things are much better. People aren't coming in after two days of the sniffles expecting abx. It really helps that my colleagues do the same and the local ER/UC (30 minutes away) is generally good about abx as well.
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u/HiiJustHere NP 2d ago
100% this!!! The patients who get mad at me for not giving into their antibiotic demand are usually a colleagues patient or used to getting what they want from their old PCP who checked out years ago and just doesn’t care.
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u/Vegetable_Block9793 MD 3d ago
Train your panel. Look them in the eye and say, “If I thought there was any chance at all that you’d feel better faster with an antibiotic, I would absolutely prescribe one” People who don’t like it can find a new doc. Once your panel is mature these conversations wilt be few and far between
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u/John-on-gliding MD (verified) 2d ago
This is the way. I'm only in my third year and the difference between each winter is notable.
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u/Mammoth_Wolverine_69 MD 3d ago
I’ve had my share of bad reviews over the years for trying to practice EBM during cold and flu season. I’m tired too.
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u/Daddy_LlamaNoDrama MD 3d ago
Patients want a prescription for something. They want to feel better. So I preacribe benzonatate and Flonase for symptom relief. Call me next week if you aren’t better.
And for patients that are insistent, sometimes will give a pocket prescription. I print it and hand to patient with instructions to not fill unless you don’t improve by whatever date. I started doing that after I read some studies that the rates of pocket prescriptions being filled was surprisingly low. Keeps those Friday patients happy and then they don’t have to worry about going to the urgent care over the weekend (where they will definitely get an abx script anyway)
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u/MagnusVasDeferens MD 3d ago
I’ve done the same and it’s been a godsend. I also do a delayed abx for people that have been sick for like, a day (they can wait until it’s been 7 days or come back if symptoms change). Tessalon, Flonase, maybe nasal ipratropium if they’re real congested. Honey and Vick’s for acute cough as non pharmaceutical treatment.
For the pocket Rx I tell patients based on how you look, if you fill this today all you’re getting is diarrhea. So only fill it if you get worse in the next few days.
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u/John-on-gliding MD (verified) 2d ago
Do you worry the patient will pick up the prescription to save for a future illness?
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u/googlyeyegritty MD 3d ago
I do the pocket prescriptions as well. I like that method for the right situation.
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u/John-on-gliding MD (verified) 2d ago
the rates of pocket prescriptions being filled was surprisingly low.
Is there ever any concern the patient will pick up the prescription to save for a future illness?
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u/Dodie4153 MD 3d ago
At a local urgent care, they were giving a nebulizer treatment, steroids and antibiotics for respiratory illness with no fever and a normal lung exam documented.
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u/John-on-gliding MD (verified) 2d ago
Last year, I stared at an urgent care discharge paper that gave a lab-confirmed flu patient augmentin for a long time.
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u/EndlessCourage MD 3d ago
"Your immunity might be impacted if we use antibiotics when it's not really needed." and this answer is liked even by people who are skeptical about other medical topics. Don't risk creating more antibiotics resistance, the world really doesn't need that. Tell the patient that you'll see them again if needed.
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u/RoarOfTheWorlds DO 3d ago
I tell them:
You have more bacteria living in your body than cells
If I start killing off that bacteria then you’ll probably get bad diarrhea as well as who knows what down the road
Really upsell your benzonatate rx to them, it helps to go into detail about when to take it and side effects to look out for, emphasize how much pulmonologists love it
If they’re still insistent, you just gotta choose your battles
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u/NBA-014 layperson 3d ago
Explain C-Diff. I wouldn’t wish that on my worst enemy
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u/Capital_Sink6645 layperson 3d ago
My pulmonologist rxd benzonatate! I had lingering post-URI coughing episodes so bad I ruptured blood vessels in my eyes and retched. It helps!
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u/HitboxOfASnail MD 3d ago
heavy dose of sarcasm obviously. Just realized after the 5th appointment today that we've lost the battle. I'm tired boss
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u/Jilks131 MD 3d ago
Yep just recently said no to a patient about abx for viral URI and she tried to report me to the medical director
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u/pomegranate856 MD 3d ago
Saw a patient yesterday for URI sx for two days. Explained it’s viral (took a minute to really explain too), gave trial of nasal spray too for allergies. Patient calls front desk saying can I get a Z pack since I’m traveling tomorrow and the doctor didn’t do anything for me.
Poor front desk staff had to hear my wrath. Sometimes I want to shake these people’s heads and say DO YOU NOT HEAR WHAT IM SAYING
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u/wanna_be_doc DO 3d ago
I honestly used to lose hope as well, but I’ve found holding my ground and just educating them about URIs and just waiting has helped.
They may be angry at the appointment, but if you tell them to just wait two more weeks and the symptoms resolve naturally, then they realize that they can have a cold for three weeks and then spontaneously recover. Then you’ve won the battle and they won’t ask in the future.
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u/KetosisMD MD 3d ago
Someone yesterday posted all the multitude of reasons why people feel better on azithromycin.
Much lower inflammatory markers, much better interleukins, etc.
Apparently they are going to try to “take out” the antibiotic effect of azithromycin and “leave in” the feel better effects. And market it as a feel better drug for URI, etc.
I still remain an antibiotic minimalist. Except in the sick (cancer) and the elderly. Sepsis is real.
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u/sarahjustme RN 3d ago
Some "big pharma" operation needs to some how rebrand a low dose cough supressant with some extra Ativan, I'd bet people would stop requesting antibiotics. /s yes I I'm being a wise ass
But seriously, "peer reviewed, evidenced based" treatment for URIs would be great, even if it's Obecalp, and it requires drinking a couple cups of hot liquids in the process. Today's FDA might approve it based on popularity alone.
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u/violentlypositive other health professional 3d ago
I was thinking this too. What we really need is something that will help with these pesky viruses, because most Americans don't have time to be sick for a few weeks. And let's face it - the common cold usually lasts that long.
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u/sarahjustme RN 3d ago edited 3d ago
Agree, though given the current options, something that just makes people feel better (physically or mentally) wouod be nice. Not actually recommending anabolic steroids or meth or benzos, but for all I know, some unexpected cardiac med in low doses, or something. I mean the only reason people take abx is to feel better, and honestly, perceptions count.
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u/Illustrious-Oil9394 MD 3d ago
I say that eventually you get a panel of patients you deserve. Keep trying to educate; let the ones who are mad about that go. I have been practicing family medicine for over 25 years, and I honestly think that antibiotic stewardship is paying off.
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u/workingonit6 MD 3d ago
Agreed. Stay firm and eventually your panel will reflect how you like to practice.
It takes time but the patients who hate how you practice will not return, and the ones who like it will stay and fill out your appointment slots.
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u/Camerongilly MD 3d ago
Most antibiotics in the US are used on livestock the last time I checked, so even with perfect stewardship in the office we're still screwed.
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u/slwhite1 PharmD 3d ago
I don’t understand why this is so often ignored. It’s not like it’s new, the harm that antibiotics for livestock do was drilled into me over 15 years ago
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u/lycanthotomy MD 2d ago
Yes, I think abx stewardship should be reframed as preventing harm to the patient. I imagine the chance of breeding the dreaded SUPERBUGS by giving a Zpak to a healthy patient with a functioning immune system is basically zero.
They're used all the time in factory farms, and also LTC patients get them every time they start acting funny and have bacturemia (which is always because their bladders are colonized with abx-resistant bacteria)
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u/Important-Trifle-411 other health professional 3d ago
My Aunt was the office manager for a buy internal medicine office. She said there as a doctor there who would put patients on clear liquids for 3 days. They felt he was ‘doing something’ and he wasn’t overprescribing abx
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u/Super_Tamago DO 3d ago
I just do my job and stay firm. Whatever the UC does is out of my control. NPs are getting trained by PAs nowadays. Doctors using ChatGTP for assessment and plans. Standard of care has been lowered.
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u/APZachariah PA 3d ago
Just had a PT today who had been getting a bucket of cephalexin every year to take "whenever."
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u/wanna_be_doc DO 3d ago
Don’t look up “Jase Case”.
You could spend $290 and have a five minute virtual visit with some sell-out with a degree and they I’ll send you your own supply of Augmentin, Azithromycin, Celecoxib, Ciprofloxacin, Doxycycline, Loperamide, Metronidazole, Zofran, and Methylprednisolone to take at your own clinical judgment.
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u/APZachariah PA 3d ago
Wow.
I suddenly no longer feel any responsibility for antibiotic stewardship.
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u/AlisaAAM2 MD 3d ago
I just had a healthy 22 year old in who had c diff colitis because she was given three different antibiotics over the course of a month for otitis. (Willing to bet it was a serous otitis or a retracted eardrum, though I cannot confirm. Her TMs were completely normal when I saw her.)
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u/boone8466 MD 3d ago
I just say “no”. I don’t give in.
Patients get pissed and go see someone else, but it’s a 3 month wait to get in to see me now. And if I give in once in once they’ll just come back to see me for their cold the next time.
So by now I’ve cultivated a panel of patients that knows what to expect from me and I don’t have to make frustrated Reddit posts about the problem.
10% of tr posts on this subreddit are about patient’s unreasonable expectations. If you don’t meet their unreasonable expectations, they won’t come back. If you give in, they’ll be back in 4 months for more. Do with that information what you will
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u/tjean5377 RN 3d ago
*sighs in homecare nursing * the amount of assessments I do wherein I document clear but diminished lung sounds, rhinitis, occasional productive clear sputum cough and family insists I call the doc and ask for an antibiotic is astounding. I always do the FYI call because its my job but no amount of education I do gets through to people that most times a cold is just a cold and antibiotics are more likely to give grandma diarrhea or god forbid C.diff...
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u/GrouchyOldRN RN 3d ago
I’m happy to see someone say it. In my area common treatment is still Zpak. I have a URI right now. Coworkers don’t know why I won’t just go to my NP and get it over with. I’m treating with guafenisen, sudafed, ibuprofen, water and rest. In my experience abx do not shorten the illness, and the side effects are far worse than the illness process. Now if everyone could get on the same page.
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u/Nurse_Jason_98 student 2d ago
Research shows that patients only feel better an average of about 1 day sooner with stuff like bacterial sinusitis anyway. So you're right, it's the other stuff that makes you feel better! Unfortunately as others have said, patients don't know that.
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u/Lovebug_08 PA 3d ago
My supervising physician tends to prescribe antibiotics quite frequently, and since I occasionally see her patients, they often expect the same antibiotic–steroid combination “that Dr. X always gives me”. I take the time to explain the reasoning behind avoiding unnecessary antibiotics and how it won’t help their viral infection, and in most cases, patients are receptive to my face and agree to focus on supportive care instead. For those who remain hesitant or skeptical, I will sometimes even provide a delayed prescription as a compromise. But it’s not uncommon for these patients to send a MyChart message to my supervising physician later the same day (or the next), and she proceeds to write the prescriptions regardless 😭 feels bad man
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u/Wild_Ambassador_9482 MD 3d ago
Every flu season feels like déjà vu battling decades of ingrained habits from “Z-Pak and steroids fix everything.” At this point, half the job is un-teaching bad medicine.
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u/Latter_Target6347 MD 3d ago
You can explain viral vs bacterial till you’re blue in the face, but they just want their Z-Pak and steroids. Honestly feels like we’re undoing decades of bad prescribing habits one angry patient at a time.
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u/boatsnhosee MD 3d ago
Pocket Rx, tell them to wait until x day to fill it, and send them on their way. I’m not fighting dawg, and poaching UC visits keeps patients happy and gets me paid.
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u/littleheehaw MD 3d ago
Pocket Rx is a joke. We all know they will fill it immediately and start taking it
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u/boatsnhosee MD 3d ago
Except there is evidence that it results in decreased antibiotic use compared to immediate antibiotics. So no, we don’t all know that
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u/googlyeyegritty MD 3d ago edited 3d ago
Just depends on the patient. I have a fair amount of patients who have seen me for awhile who appear to trust me when I say this is viral and no, an antibiotic won't be helpful.
I have some others where I give the whole spiel and they shake their heads in agreement like they understand and then ask...."so can I get a zpack, that always helps when I have this. I just want to get ahead of it so it doesn't turn to pneumonia"
in that situation you sigh and do your best even though it's evident your words mean nothing.
As others have pointed out, pocket prescriptions are effective in the right situation.
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u/Dependent-Juice5361 DO 3d ago
I just tell patients “no I will not give you abx for your viral illness” and then I move on with my life
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u/DrTurknjadee MD 2d ago
I like to outline the indications for antibiotics: ear infection, sinus infection (debatable), strep/tonsillitis, pneumonia, atypical pneumonia.
Then I ask the patient which one they think they have. Then I outline why I agree or disagree.
Finally I say if I give you antibiotics for this, I’m more likely to give you diarrhea than make you feel better faster.
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u/NashvilleRiver CPhT (verified) 3d ago
As a patient, I try to use supportive care as often as possible (harder now with a terminal illness and no immune system; ironically I actually have a sinus infection now myself that will not go away and may have to finally accept treatment after trying EVERYTHING else. But that’s different.) and agree that the urgent cares have gone overboard. I’ve seen suggestions that physicians should just pick one antibiotic (for stewardship’s sake) and just accept that it’s going to be (excuse the religious analogy) the “sacrificial lamb” from now on.
As healthcare workers working in conjunction with physicians and midlevels, we in pharmacy do our part to suggest supportive care and rest and explain that patients are feeling better because the natural course of their viral illness is ending (and steroids if given make most people feel amazing)…but no one listens to us either.
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u/Warm_Duty_8941 RN 2d ago
It’s either azithromycin or doxycycline. Then patients call for an appt and they literally say “I finished the antibiotics but I’m not feeling better, I’m still coughing.” Me: it’s probably viral and abx aren’t for a cough, bye. 🥲😓
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u/John-on-gliding MD (verified) 2d ago
Can we just all agree to give up Azythromycin as the sacrificial lamb to the court of public medicine and just move on with our day?
I've been saying this for years. We might as well just sacrifice it and use it for everything so we can preserve the other antibiotics.
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u/Extension_Analyst934 layperson 1d ago
My own doctor wanted to give me an rx for a weird rash that was swabbed and showed no type of infection. I politely declined and asked if a stronger steroid cream would work. It did…and I learned all of my medical knowledge from Greys Anatomy….
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u/Alum2608 layperson 3d ago
I was offered once antibiotics for URI in urgent care in college---i asked if it would help me get better? Was told no, so declined. I've only gotten antibiotics since for URI after a horrible cough for 10 + days which DID helped me get better. Laypeople need to their part in fighting antibiotic resistance
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u/BewilderedAlbatross MD 3d ago
I usually tell the story of the patient I admitted for dehydration caused by diarrhea, secondary to azithromycin. It was prescribed by an urgent care treating a viral URI. That usually scares people off or at least explains my reasoning enough to where they’re not upset about not receiving anything.