What was thought to be due to unhygienic hospital beds, has been proven wrong - patients are more likely to be infected by drug-resistant Clostridium difficile pathogens due to inappropriate use and overprescribing of fluoroquinolone antibiotics.

Researchers from the University of Oxford focused on data from an epidemic of severe diarrhoea caused by C. difficile that struck the UK in 2006. They looked at the numbers of infections and on the amount of antibiotics used in hospitals and general practitioners (GPs) in the UK, and genetically analysed more than 4,000 C. difficile microorganisms to determine the antibiotics that each pathogen was resistant to.

It was found that the restriction of fluroquinolones - in most cases - led to the disappearance of infections caused by antibiotic-resistant C. difficile, leading to an 80% reduction in the number of superbug infections in the UK.

This leads to the question of why antibiotics are prescribed so often. Many doctors say that the different guidelines on treating bacterial infections are usually disregarded and antibiotics are often prescribed to satisfy patients.

"People come in and demand antibiotics! If you don't give them what they want, they'll go somewhere else and get it," an exasperated ER physician said.

Guidelines on antibiotics disregarded

Many guidelines state that when physicians should not prescribe antibiotics, unless absolutely necessary - and even if needed, should always begin with the weakest possible antibiotic that can combat the infection.

However, in a 2014 study, it was shown that 71% of the time antibiotics were prescribed for patients with acute bronchitis or sinus infections, which are most likely caused by a virus. If clinical guidelines were adhered, the rate should be 0% as antibiotics target bacterial pathogens only.

The overuse of antibiotics is a serious problem and is becoming a pandemic. On 17 January, a patient passed away from a superbug infection that 23 antibiotics could not cure. There are also an increasing number of pathogens that have developed antibiotic-resistance increasing the risk of resistance to the strongest antibiotics available currently and combined with the slow development of new classes of antibiotics, it is likely that 10 million people will die from infections annually, by 2050.

But are patients' demands to blame for this pandemic?

Misinterpretations between doctors and patients

Practicing doctors, primary care doctors or ER doctors are usually interviewed in many articles regarding antibiotic overuse. They are usually asked about their experience, the application of clinical practice guidelines and the rate of prescription of antibiotics.

Often, doctors will say that patients demand antibiotics and they are reported as such. However when patients, advocates who lobby for antibacterial restraint and researchers who study doctor-patient communication are interviewed, there is another side to the story.

Rita Mangione-Smith, a paediatrician and researcher was irked by an American Academy of Paediatrics newsletter article that blamed the overprescription of antibiotics on patients.

"In my personal experience, in emergency rooms and outpatient settings, there wasn't direct demand," she says. She then studied the claim directly.

The need for customer care training for doctors

With her colleagues, they recorded 300 exam room conversations between doctors and parents of sick children at two Los Angeles paediatrics practices. It was found that less than 5% of parents verbally asked for antibiotics.

However doctors reported in a post-visit questionnaire that parents asked for antibiotics 38% of the time. The study also found that when doctors perceive an expectation for antibiotics, they were much more likely to prescribe them.

"It happens in indirect communication," she says. "It leaves a lot of room for misinterpretation."

A follow-up study looked at specific phrasing in the exam room that was associated to lower rates of antibiotic prescribing. When physicians recommend steps for parents to take to reduce their child's symptoms and told them that antibiotics would not help, prescribing rates would drop.

Rather than be feeling the need to satisfy patients, doctors can benefit from customer care training, Mangione-Smith says. Words and attitude play a big role in doctor-patient communications. For example when doctors say, "It's just a virus, there's nothing we can do," patients might interpret it as, "You shouldn't have come in, you're wasting my time."

However if doctors take the time to validate a patient's illness and offer positive recommendations such as follow-up options or consolation, the patient is more likely to be satisfied, even without a prescription. MIMS

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