Bigger ≠ better

No big surprises here:

 Antibiotics are important drugs, often restoring health and even saving lives. But like all drugs, they can have unwanted and serious side effects, some of which may not become apparent until many thousands of patients have been treated.

Such is the case with an important class of antibiotics known as fluoroquinolones. The best known are Cipro (ciprofloxacin), Levaquin (levofloxacin) and Avelox (moxifloxacin). In 2010, Levaquin was the best-selling antibiotic in the United States.

As a pediatrician, I’m in an easy position to criticize other doctors for over-prescribing this kind of antibiotic.  Fluoroquinolones are contraindicated for use in children, and I very rarely have reason to prescribe them in my practice.  (Every so often I have patients with certain potentially serious infections that warrant such use despite the usual recommendation against doing so, so the contraindication is not absolute.)  Since this class of antibiotic is essentially off the table for most of my patients most of the time, I feel no temptation to overuse them.  Perhaps if they were more commonly used for patients such as mine I’d feel differently about them.

However, I doubt it.  The misuse and overuse of antibiotics is a signal preoccupation of mine, and little frustrates me more than seeing medical providers prescribe them in clinical situations (eg, colds) that do not require them.  Along the same lines, it drives me bananas when antibiotics with an inappropriately broad spectrum of activity are prescribed when another, narrower-spectrum medication will do.  It’s a theme I’ve touched on before.

Why do medical providers dole these medications out?  In some cases, I suspect it’s because they’re more convenient to take.  Azithromycin (aka that handy, dandy Z-pak, which lackluster doctors hand out like so much candy) is only taken once a day for five days, so very much easier than thrice-daily amoxicillin, which I foist on people for a whole ten days.  But I suspect there’s another reason.

In an interview, Mahyar Etminan, a pharmacological epidemiologist at the University of British Columbia, said the drugs were overused “by lazy doctors who are trying to kill a fly with an automatic weapon.”

Dr. Etminan directed a study published in April in The Journal of the American Medical Association showing that the risk of suffering a potentially blinding retinal detachment was nearly fivefold higher among current users of fluoroquinolones, compared with nonusers. In another study submitted for publication, he documented a significantly increased risk of acute kidney failure among users of these drugs. [emphasis added, along with a hearty “amen”]

Let us say that there is a hornet nest stuck somewhere on your house.  One possible option for removing it is to call an exterminator and have them deal with it.  But that’s a hassle, and one that may require you to wait for them to arrive.  A much faster and more definitive approach is to burn your house down.  Voilà!  No more hornets.

And so it is with using a broad-spectrum antibiotic when a much narrower one will do.  There is this pervasive perception out there that the bigger and badder an antibiotic, the better a patient will fare.  This belief, sad to say, is not limited to patients.  In order for Levaquin to have been the best-selling antibiotic in the United States, an appallingly high number of medical providers had to have been prescribing it for common conditions where it was far too big a gun.  Will it cure a bacterial sinus infection?  Sure.  It will also lay waste to your body’s healthy bacterial flora, and significantly increase your risk of getting a much worse infection with a nasty little bug called clostridium difficile, which nobody wants.

And that’s to say nothing of its potential ill effects on connective tissue like tendons (which I which it is not to be used in children) and other neuromuscular complications.  These medications are not benign!  They are not to be used cavalierly, or for the purposes of “covering all the bases.”  If you have a mild bacterial infection and your doctor dispenses a prescription for one of them, your doctor is doing you no favor.  It may seem like better treatment to get the most potent antibiotic you can get, but it quite often is not.

Are there severe infections that warrant treatment with a fluoroquinolone?  You bet.  Are your irksome but mild upper respiratory symptoms a sign of one of them?  Unlikely.  And if your medical provider writes a prescription for one of these medications, it’s not a bad idea to ask why, and if there isn’t something else to try first.  As in so many situations, in medicine and in life, less is more.