By Rose Hoban
Fewer North Carolinians are getting and filling antibiotic prescriptions over the past five years, and according to infectious disease experts, that’s a good thing.
Data released last month by the national Blue Cross Blue Shield Association showed fewer North Carolina patients filled prescriptions for antibiotics than in any other Southeastern state.
Researchers looked at claims submitted by people covered by Blue Cross Blue Shield in almost every state and saw how many people were getting prescriptions for antibiotics. In North Carolina, the number of claims had dropped from 87.4 prescriptions per hundred patients in 2010 to 66.8 prescriptions per hundred patients last year, the second fastest rate of decline in the U.S.
This is seen as a positive by researchers and clinicians because of a growing problem of bacteria evolving to become resistant to antibiotics, said Jennifer MacFarquhar, an infectious disease expert who works in the North Carolina State Epidemiologist’s office.
“People are taking, or have taken, more and more antibiotics over the previous few decades so, with the increased use, it allows the microorganisms to change and become resistant to the current antibiotics that we have,” she said. “Those antibiotics are not useful against those resistant organisms,” driving up costs and leading to more disease and deaths.
Growing threat
Many people have heard of MRSA (short for “methicillin-resistant staph aureus”) which can infect people in hospitals or even people who encounter the bacteria in the community. It causes dangerous infections resistant to one of the strongest antibiotics in the pharmaceutical arsenal, making the costs of treating such infections eye-poppingly expensive.
According to MacFarquhar, more bacteria have shown resistance to one, or even combinations of antibiotics. Some are old foes such as tuberculosis and gonorrhea, some types of fecal bacteria and, more recently, a form of the fungus Candida which the head of the Centers for Disease Control and Prevention said “poses a “catastrophic threat” to the public.
-Multidrug-resistant Acinetobacter
-Drug-resistant Campylobacter
-Fluconazole-resistant Candida (a fungus)
-Extended spectrum β-lactamase producing Enterobacteriaceae (ESBLs)
-Vancomycin-resistant Enterococcus (VRE)
-Multidrug-resistant Pseudomonas aeruginosa
-Drug-resistant non-typhoidal Salmonella
-Drug-resistant Salmonella Typhi
-Drug-resistant Shigella
-Methicillin-resistant Staphylococcus aureus (MRSA)
-Drug-resistant Streptococcus pneumoniae
-Drug-resistant tuberculosis
On the other side of the coin, drug companies have not invested a lot of research into developing new antibiotics.
“Companies would rather develop a new type of Viagra because it’s more financially beneficial than developing a new antibiotic,” said David Weber, who heads up infection control at UNC Health Care.
He said the economics of drug development and sales stack the deck against antibiotics which are used only occasionally.
“If tomorrow you came up with an antibiotic that has no resistance, works for everything, the ideal antibiotic, you’re not going to want to give it to everybody right away, because we want to preserve it so it doesn’t develop resistance,” Weber explained “So it’d be reserved for that 3 or 4 or 5 percent of patients with multi-drug resistant organisms.
“It’s hard to make a lot of money when you only reserve it for a small number.”
He did say some new drugs have come on the market, but there are more resistant bugs and more antibiotics to which they are resistant.
“The bugs are winning, and the pace of new antibiotic development has not kept up,” he said.
Just give me something, Doc
Weber said that the right way to treat an infection is to culture whatever bacteria is causing the infection, wait for days for the microbiology lab to say what the organism is and what antibiotic it’s susceptible to.
However, “if someone has a potentially life threatening illness, like bacterial meningitis, then we want to pick a drug that will work almost all the time. So what we will do is we start with a broad-spectrum drug and then as our data accumulate, on day two or day three, we deescalate, and we move to the narrowest drug,” Weber explained.
In cases where the infection is not life-threatening, physicians are supposed to start the patient on the drug most likely to work, then change to a more targeted drug after lab results come back.
But Weber admitted that’s not always the way things work, something that’s borne out by researchers from the Centers for Disease Control and Prevention who reported in 2013 that as many as half of antibiotic prescriptions are unnecessary.
Sometimes he said that’s a function of a doctor rushing, sometimes it’s about patient demand.
“People walk into the emergency department, they just spent two, or three, or four hundred dollars to walk into the ER, they’re there because their 4-year-old has an earache and they may not want to hear, ‘We think it’s a virus, just go home,’” Weber said.
“They want that kid better so he’s not up at night crying. And they ask, ‘Are you 100 percent sure it’s not bacteria’ and the doctor says, ‘No, I’m not 100 percent sure,’ and then the kid gets an antibiotic.”
Sometimes the system forces everyone’s hand.
“If you don’t give them an antibiotic, the daycare will say, ‘Oh, you didn’t get an antibiotic, he can’t come to daycare for the next week,’ and they’ll exclude the kid,” Weber said. “What parent can stay home for a week?”
Fewer drugs overall
In the country as a whole, rates of antibiotic use dropped by about 9 percent between 2011-2016, according to the BCBSA study. States surrounding North Carolina had more modest declines in use, while some parts of North Carolina had even lower rates of use.
causes gonorrhea, a sexually transmitted
disease that can result in discharge and inflammation. Image courtesy CDC
Larry Wu, a family medicine doctor who’s the medical director for Blue Cross Blue Shield of North Carolina, said that in general, the Southeast tends towards more antibiotic overuse.
“As long as 20 or 30 years ago, I got the feedback that when compared to the West, the Southeast did resort to taking pharmacy cures much more readily than other parts of the country,” Wu said. “We have a habit of pill takers in the Southeast generally.”
He said the research finds that rural providers tend to write for antibiotics a little more frequently. He speculated that in part, that’s due to the presence of large research hospitals in North Carolina’s cities.
“They do a lot of educating, and they share a lot of the evidence-based information with their providers and I think that has a halo effect,” Wu said. “In the rural areas, they don’t have access to that kind of interaction.”
He also said there are “local cultures” of providers; physicians in one area know that their colleagues and competitors will likely prescribe an antibiotic so they do too.
That behavior has been challenged by a nationwide “Choosing Wisely” campaign that BCBSNC and others have embraced which encourages physicians of all types not to unnecessarily prescribe antibiotics.
Wu said that, for example, clinics at Duke now have posters in waiting rooms to educate patients about correct antibiotic usage and Cornerstone, a large physician practice in the Piedmont Triad, has had a grant to teach both patients and physicians about overuse. He said both practices have seen drops in antibiotic usage of more than 20 percent.
“As a practicing doctor myself, one of my sales pitches that I need to provide is to convince a patient that their infection will resolve without antibiotics,” Wu said. “It does take one or two minutes longer per interaction, to reassure a patient that they’ll be fine without antibiotics, and if it’s a viral infection, that the antibiotic will cause more side effects.”
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