Aaron Carroll:
   The best way to prevent transmission of Ebola in the United States, or any country, for that matter, is to identify and quarantine those with the disease as soon as possible. However, the first person diagnosed with Ebola in the United States was, unfortunately, released after coming to an emergency department, even though he had symptoms indicative of the disease.
   He was sent home on antibiotics. The inappropriate use of antibiotics is the subject of this week's Healthcare Triage.

   [Healthcare Triage Intro]

Aaron Carroll:
   You can argue that antibiotics could help treat secondary infections in people who have Ebola, but remember, those docs didn't think he had Ebola, and the antibiotics wouldn't, of course, be effective in treating Ebola.
   They'd be of no use for any viral infection, for that matter, yet antibiotics are routinely prescribed in this manner. In this case, their use highlights a real but often ignored danger from their overuse: a false sense of security.
   As a pediatrician and a parent, I've seen many protocols and procedures that require the use of antibiotics for a number of illnesses that may not necessitate them. Those plans are in place, ostensibly, to protect other children from getting sick. They rest on the idea that someone on antibiotics is no longer contagious.
   That is, tragically, often not the case. If you've had a small child with pinkeye, you know that few diseases can get your toddler banned from preschool faster. Most of the time, he won't be able to go back to school till he's been on antibiotic drops for 24 hours. 
   This assumes, of course, that the pinkeye is caused by bacteria. Often it's not! Up to 20% of conjunctivitis can be caused by adenovirus alone, and that's just one of the viral causes. Pinkeye caused by a virus will be completely unaffected by any antibiotic drops; children will be infectious long after receiving them.
   Physicians are pretty much unable to distinguish between bacterial and viral conjunctivitis. Studies show we can't tell the difference. Even if we could, there's little evidence that 24 hours of antibiotic drops do much of anything to render a child non-contagious. Most of the outcomes studied include things like "early microbiological remission" by day two to five of therapy. However, some children still haven't achieved this outcome even by day six to ten.
   Strep throat isn't much better. Resistance in Group A streptococcus, the cause of strep throat, yet even with proper therapy, it can be very difficult to eradicate the pathogen from carriers. This has led to outbreaks among family members and closed communities, even when people are properly treated.
  Even in the best-case scenario, being "on an antibiotic" isn't much protection for others. Often, though, antibiotics offer no protection at all. Only about a quarter of children who have acute respiratory tract infections have an illness caused by bacteria, but about twice that number are prescribed antibiotics for their symptoms. These extra drugs provide no useful benefit. They certainly don't prevent transmission of non-bacterial pathogens from one person to another. 
   So if they give people a false sense of reassurance that they're no longer contagious, leading them to relax their usual sick precautions, they're likely doing harm. Every time a parent comes in the office with a child with an upper respiratory infection and we prescribe an antibiotic, we imply that we've taken care of the problem. We give patients an incorrect impression that the drug will make them better and will begin to kill off the germs infecting them. We also give the impression that they will be less of a risk to their friends, family and close contacts. After all, they're "on an antibiotic."
   Confronted with this information, physicians will often fall back on the excuse that their patients demand it, but too often, it's physicians, not patients or parents, who are the problem. A study published in 1999 in the journal Pediatrics examined expectations and outcomes around visits to the pediatrician for a child's cold symptoms. The only significant predictor for an antibiotic prescription was if a physician thought a parent wanted one. They wrote one 62% of the time when they assumed a parent expected a prescription, but only 7% of the time when they thought parents didn't.
   Turned out the physician prescribing behavior was not associated with what parents actually wanted. The doctors often guessed wrong as to what parents actually desired. Another study published in 2003 in the Annals of Emergency Medicine had similar findings. Doctors were more likely to prescribe an antibiotic for diarrhea when they assumed that patients expected it, but they correctly guessed patients' expectations only a third of the time.
   Physicians were also more likely to prescribe antibiotics for patients with bronchitis or other respiratory infections if they believed patients wanted them but correctly identified those expectations only a quarter of the time. In yet another study, physicians even prescribed antibiotics to 29% of patients who didn't want them.
   It's time we stop viewing the overuse of antibiotics as a victim's crime. According to reports, Thomas Eric Duncan, the one patient who died of Ebola in the United States, presented to the emergency department with a 103-degree fever, a headache, and abdominal pain. He stated that the pain was 8 on a scale of 1 to 10. After receiving tests, he was thought perhaps to have sinusitis and was given an antibiotic. I can't guess as to what was in the physicians' heads that day, but I think it's likely they thought the antibiotics would do little harm and potentially some good. In this case, that doesn't appear to be true.
  We may believe that antibiotic prescriptions are what patients want, but it may be time to recognize that sometimes there's more for physicians than for patients.  Moreover, the false sense of security they provide may do more harm than good.

   [Healthcare Triage Outro]