In this age of antibiotic resistance, researchers and health experts are warning that doctors need to prescribe significantly fewer antibiotics to prevent an antimicrobial-resistance crisis that could plunge modern medicine back into the Dark Ages. But a new study shows that almost half of all antibiotics are prescribed without an infection-related diagnosis.
Researchers analyzed more than 500,000 antibiotic prescriptions and found that nearly half were written without an infection-related diagnosis, and 20% were given without an office visit – usually over the phone. The authors can’t be certain of how many of the medications were inappropriately prescribed, however.
In looking at patient records, Dr. Jeffrey Linder, of Northwestern University’s Feinberg School of Medicine in Chicago, and his team found that part of the problem could be a result of “bad coding,” referring to the system doctors use to record diagnoses.
Years ago, I worked in medical coding. There is not always a specific code to accompany a specific diagnosis, so doctors and coders alike often have to find a code that is most like a diagnosis. It’s possible, then, that the wrong codes are sometimes chosen.
But even if diagnostic codes are a part of the problem, Linder said the findings are still concerning. They suggest that many doctors prescribe antibiotics not to treat an established infection, but because they assume patients want them, he explained.
Antibiotic resistance commonly makes news headlines, yet many people still don’t understand that antibiotics are only effective at treating bacterial infections. They don’t work against the common cold and other viruses. When people use these medications inappropriately, bacteria are exposed to the antibiotics and it gives them a chance to mutate and become resistant.
Rampant Outpatient Overprescribing
Linder and his colleagues looked at 510,000 antibiotic prescriptions written at 514 medical clinics over 2 years. Prescribers included doctors, nurse practitioners, and physician assistants in primary care and specialties such as gastroenterology and dermatology.
- Overall, no documented diagnosis of an infection accompanied 46% of the antibiotic prescriptions the team analyzed.
- Another diagnosis, such as hypertension, was documented in 29% of cases.
- 17% of prescriptions lacked a diagnosis altogether.
- Additionally, 1 in 5 prescriptions was made without an in-person visit.
Linder explained: 
“We found that nearly half the time, clinicians have either a bad reason for prescribing antibiotics or don’t provide a reason at all. When you consider about 80% of antibiotics are prescribed on an outpatient basis, that’s a concern.”
It is OK, sometimes, to prescribe an antibiotic by phone, Linder said. He gave the example of a woman with a history of recurrent urinary tract infections (UTI) who calls her physician to report that her symptoms have returned. In a case such as this, it may be “perfectly appropriate” to just call in an antibiotic without seeing the patient, according to Linder. 
It is also acceptable to prescribe antibiotic refills for someone with acne, but in most cases, the patient should be seen by his or her physician in the office before a prescription is given, Linder advised.
Dr. Ebbing Lautenbach, chief of the infectious diseases division at the University of Pennsylvania, said that patients should feel free to ask questions when they are prescribed an antibiotic.
“Sometimes an antibiotic is an appropriate choice, and sometimes it’s not. Providers should explain, ‘Here’s why I think an antibiotic is necessary.’ And there should be a discussion of the pros and cons of taking one.”
Why are antibiotics doled out so often?
There are multiple reasons why a doctor might prescribe an antibiotic without a solid diagnosis of a bacterial infection. Pleasing the patient is one. Patients sometimes demand antibiotics. In other cases, a doctor might be strapped for time, so it’s easier to just hand out a script.
Linder said: 
“Despite 40 years of randomized controlled trials showing antibiotics don’t help for most coughs and sinus infections, many people are convinced they will not get better without an antibiotic and specifically call the doctor requesting one.
At busy clinics, sadly the most efficient thing to do is just call in an antibiotic prescription. We need to dig into the data more, but we believe there is a lot of antibiotic prescribing for colds, the flu, and non-specific symptoms such as just not feeling well, none of which are helped by antibiotics.”
But in most cases, according to the researcher, “the problem is the doctor’s perception that patients want antibiotics.” 
Linder said patients need to take a more proactive role when it comes to medications.
“You can tell your doctor that you only want an antibiotic if it’s really necessary. That will automatically shift the doctor’s default position on it.”
The study was presented at ID Week 2018 in San Francisco. The findings are considered preliminary until they are published in a peer-reviewed journal.
 Pharmacy Times