Are Your Antibiotic Prescriptions In Line With Evidence-Based Medicine?

By Ann C. Anderson, DPM, and John S. Steinberg, DPM

   Many of the treatment decisions made on a daily basis in medicine are not founded on or confirmed by the best available science. Some of these decisions are based on historic clinical standards and teachings yet to be scientifically proven while other decisions are made out of habit or sometimes a lack of appropriate information.    The questions raised in this discussion are not intended to imply that every treatment decision must be based on randomized controlled trials. However, we do hope to point out many clinical misconceptions regarding the prescribing and usage of antibiotics.    This article will raise some very controversial points about the practice of antibiotic prescriptions. We are not seeking to establish a new standard of care or question the way one practices. We are simply facilitating discussion regarding the evidence-based practice of medicine and how it might relate to the antibiotic prescriptions we write on a daily basis.

Why DPMs Overprescribe Antibiotics

   In close similarity to the entire medical profession, podiatrists are often guilty of overprescribing antibiotics. There are certainly many reasons for this practice, not the least of which is a fear of being found negligent in a potential legal action. When faced with a dilemma of whether or not to prescribe, the physician will likely decide that he or she can minimize the risk of potential legal action by including an antibiotic prescription in the treatment plan.    While clinicians should not withhold antibiotics if there is reasonable concern for an infection, they should not generally give antibiotics as part of a shotgun approach to an unknown problem. Performing a thorough patient examination and evaluation should enable one to determine whether there is an infection and pursue an appropriate course of treatment.    Patient expectation is another key factor that drives unnecessary antibiotic prescriptions. Just as patients go to their primary care doctor for antibiotics when they have a simple cold virus, patients expect to visit their podiatrists and receive prescription medication to cure their ailments. Many patients do not feel they have received proper attention until they get a prescription from their doctor. Additionally, patients with wounds often do not understand the difference between a chronic wound contamination and an acute wound infection. At the most, one would treat chronic wound contamination with simple topical management whereas an acute wound infection would require oral or parenteral antibiotic management.    As with many medical decisions, proper documentation is essential. When clinicians decide an antibiotic is not medically necessary, they should document that decision and provide an explanation. Conversely, when one decides to prescribe an antibiotic, he or she should discuss the clinical findings of infection in the treatment note for that date in order to justify the risk/benefit ratio of the decision.    Additionally, the local standard of care often drives antibiotic prescriptions. No physician wants to be cited as deviating from the standard of care and therefore is easily swayed by the prescribing habits of the local podiatric community. This overprescribing can lead to the proliferation of resistant organisms and can contribute to gastrointestinal complications and secondary infections from the altered homeostasis, which can result from unnecessary antibiotic prescribing.

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