Retail clinics are controversial in healthcare. Physicians want more control over an industry almost entirely dominated by nurse practitioners and nurse practitioners have low opinion of retail clinics because they appreciate the ethical issues of extending healthcare from a company that profits off those recommendations. While these companies often claim to be good stewards of antibiotic prescribing, they simultaneously share with their applicants that the bulk of their care will largely be giving antibiotics, steroids, and immunizations to consumers. These clinics even craft competitions among their prescribers, offering extra paid time off and swag items for those who sell the largest quantity of vaccines. Being good stewards of risky pharmaceuticals and directly profiting off those recommendations are not one-in-the-same.
Antibiotic resistance is one of the world's most pressing health threats, and antibiotic use is the primary contribution to this growing issue. While antibiotics are not indicated in the first two weeks of sinusitis or bronchitis, 90% of prescribers offer them anyway whether this is due to pressure placed on them by the consumer, lack of knowledge, or personal gains. Eighty percent of antibiotics prescribed for acute respiratory tract visits are unnecessary, according to the Centers for Disease Control and Prevention (CDC) guidelines (Scott et al., 2001).
Approximately 30% of all antibiotics prescribed in acute care hospitals are unnecessary (CDC, 2022; Denny et al., 2019). One in three emergency department antibiotic prescriptions are inappropriate, and at least 28% of antibiotics prescribed in the outpatient setting whether primary care offices, urgent care facilities, or retail health clinics are unnecessary, meaning no antibiotic was needed at all. Horrifically, if we look at overall prescribing such as choice of drug, dose, and duration just in the outpatient setting, more than half are inappropriate.
Antibiotic resistance has been recognized by the World Health Organization as one of the top 10 global public health threats. It is a simmering pandemic ready to reverse a century of medical progress, rendering antibiotics ineffective in treating even the most common bacterial diseases. Without action, it is predicted that antibiotic resistant infections will cause more than 10 million deaths per year by 2050 with an economic impact of more than $100 trillion US dollars (O'Neill, 2014).
Antibiotic overprescribing contributes not only to bacterial antibiotic resistance but also to poor client outcomes in terms of complications and adverse drug events. Antibiotic-resistant infections are more challenging and costly to treat and are associated with worse health outcomes. Where antibiotics are more frequently prescribed, communities also have higher incidence of non-susceptible pneumococcal disease indicating that these prescribing practices contribute to resistance patterns within each community (Hicks, Chien, Taylor, Haber, & Klugman, 2011).
With the rapid growth of these clinics, I am hoping to empower my readers through education. Much of what is seen in the convenience care centers can be managed well at home, without antibiotics. Admittedly though, the prescribing practices in these retail clinics has shown to be similar, meaning exceedingly too high and often unnecessary, in family practice clinics as well, so antibiotic stewardship simply isn't appreciated in conventional medicine. The typical nurse practitioner, for example, in primary care prescribes 21 prescriptions per day, often for antibiotics (AANP, 2022). Sadly, data regarding antibiotic prescribing in the pediatric clientele finds that 58% of all antibiotic prescriptions written in the outpatient setting are for upper respiratory infections that are found to be viral in nature. Automobile manufacturers have about a 3% margin of error. I am not sure how we might extrapolate that math into healthcare, because I suspect there is no margin for error in our industry, but I feel like 58% succeeds all parameters.
My own brief experience in retail therapy just recently revealed a pretty consistent belief among practitioners that their clients expected antibiotics and the reality is that many do present to the front desk stating they are there to get antibiotics, but studies have revealed that providers overestimate the frequency that consumers and parents expect to receive an antibiotic prescription. In one study, pediatricians prescribed antibiotics 62% of the time if they perceived parents expected a prescription compared with 7% of the time if they did not feel parents expected a prescription (Mangione-Smith et al., 2004). It is my position that clients simply want options. They don't know what the options are so they simply say, "I need antibiotics," when what they mean is "I need relief." I believe they want to understand why they are suffering and what can be done about that, which is often indifferent to whether that is an Rx or OTC or even botanical, although most actually prefer a more natural approach that is effective. An open discussion about this is respectful, builds a trusting relationship, and ultimately improves healing. They don't want to be dismissed.
Educating those who aren't feeling well in understanding how they can achieve relief is really the goal of the practitioner when treating common illnesses, particularly when their offender is a virus. It's important that consumers understand what to expect, how to comfort themselves, and trust that if things aren't progressing that they will be respected when they return for further assistance. Antibiotics may prove necessary in some scenarios, but these scenarios are not the norm and they certainly aren't the first-line approach for most seasonal illnesses. Interestingly though, even when practitioners have this knowledge, they are still unlikely to change their practice (Schwartz, Bell, & Hughes, 1997). Let me give you some tips so you can be a more informed consumer.
Common Cold
All colds are caused by viral infections. Despite misconceptions, a cold can last two weeks and your nasal drainage may be all shades of yellow and green, but this doesn't mean a bacterial infection is more likely. The common cold is self-limiting so it will resolve without much effort of your own. Antibiotics should never be prescribed for treatment in these scenarios.
Hydrate. Use humidified air. Ingest warm fluids. Rest. Hylands Cough & Cold. Zicam. Use acetaminophens or NSAIDs if uncomfortable with fever or aches, otherwise let the fever do its job. Decongestants and saline nasal sprays can relieve congestion and antihistamines, alone or combined with a decongestant, can treat the runny nose. Throat Coat tea is phenomenal for relieving sore throat. Sudafed is the strongest over-the-counter medication, although now sold behind the counter. Afrin can be used twice a day, but for no more than three days or you'll suffer rebound nasal congestion. Flonase is another excellent option for nasal and sinus congestion. These help open the eustachian tubes and keep the sinus draining, reducing potential for bacterial infection. Robitussin can help minimize coughing. Coricidin is similar to Mucinex, both of which are excellent, but Coricidin more so for those with elevated blood pressures.
Seasonal Influenza
The flu has an abrupt onset of fever, and true to many viruses, these fevers can be quite high but also tend to bounce around. Viruses are also characterized by having a number of symptoms such as muscle pain, headache, fatigue, nonproductive cough, sore throat, runny nose, ear infection, and even nausea and vomiting. Testing really isn't needed, as this doesn't change management, but it may be important for ruling out other concerns.
Antivirals can be offered to those with high risk for complications such as those older than 65 years, those who have asthma or heart disease, chronic lung disease, immunosuppressed, or morbidly obese but if not high risk, the concern for psychosis and suicide aren't worth the relief of a single day of symptoms.
Acute Bronchitis
These are the cases where the primary complaint is cough. The discomfort is primarily in the chest. More than 90% of the time, these symptoms are viral in nature and therefore, antibiotics are not indicated. Acute bronchitis, or often times respiratory syncytial virus (RSV), will self-resolve in one to three weeks. Robitussin and Delsym can help suppress cough. Mucinex will help cough up the mucous accumulating in your airways, which is good because you don't want that to sit stagnant, a medium for bacterial growth. Hydrate. Utilize a humidifier.
The most important component of the provider's assessment is to rule out pneumonia, so if there is new and significant chest pain after having had the cough for a while, then there is growing concern. Shortness of breath, higher heart rate, and a fever will raise suspicion for pneumonia. It is important to understand though that green or even bloody sputum is not indicative of bacterial infection, or need for antibiotics, although this once was believed to be true by many clinicians. We know today that this is the result of our immune system intervening and our body's attempt to heal and expel that mucus so it doesn't harbor bacterial growth in our lungs.
RSV is the leading cause of bronchiolitis and pneumonia in infants within the U.S. It does start like the flu, includes the fever, runny nose, and cough. Again, multiple symptoms which tells us it is viral, but about 40% of little ones will develop a wheeze with their first RSV infection, upwards of 2% will require hospitalization. This is much more mild in children who are not exposed to cigarette smoke and in those which are breastfed.
Croup
The hallmark of croup is a tight cough that occurs predominantly at night and sounds like a barking seal. The cause of the cough is inflammation in the upper airways, usually due to a virus. Our mothers of generation past use to believe that the Moon helped heal the croup, and we know today that the cool, night air can be very relieving and children actually can be improved by sitting on the porch to ease their croupy cough.
If breathing does become severely impaired, treatment may be needed; however, most all kids get better on their own in about a week. Most always this happens in little ones younger than five years, and also more likely in those exposed to smoke or those that did not benefit from breastmilk.
Acute Pharyngitis
Pharyngitis, or sore throat, may be accompanied by other nonspecific symptoms including cough, congestion, and fever. Viruses are easily identified by their causing a multitude of symptoms. When the underlying cause is bacterial though, we tend to see a very localized complaint without all the ancillary complaints. A sore throat without the cough and congestion is much more suspicious of Group A streptoccocus (GAS). Unlike acute otitis media (AOM) and acute bacterial sinusitis, the diagnosis of GAS can be assisted by a confirmatory laboratory test. Antibiotics will then be offered, not to treat the strep itself, but because the strep can cause a number of secondary infections that can be quite catastrophic. When strep is negative, the clinician may consider antibiotics if at least two of these additional symptoms are necessary, indicating bacterial infection: fever, tonsillar exudates, tender lymph nodes, and absent cough.
Acute Sinusitis
In general, most cases of sinusitis are due to uncomplicated viral infections. Bacterial sinusitis should be considered when symptoms have been present for more than 10 days without improvement, and when symptoms are severe or worsen after initial improvement from an initial viral infection. We call this a "double sickening," so the virus came first but the sinuses weren't well drained so that stagnant mucous became a breeding ground for bacteria.
Acute Otitis Media
The rapid onset of signs and symptoms of inflammation in the middle ear is also, most often, viral. Upon evaluation, the clinician may recognize a bulging and red tympanic membrane. Individuals may complain of ear ache (otalgia), ear drainage (ottorhea), fever, and irritability. Over six months of age and within reason, most often a "watchful waiting period" is appropriate, assuming the client can return for follow-up if symptoms do not resolve or worsen. Bacterial infection is considered when there is fluid build up in the ear, along with erythema or reddened tissue. This fluid may drain from the ear or the practitioner may see it bulging or bubbling behind the tympanic membrane. It can take a few weeks to resolve on its own. Rarely it persists and surgery is required, but even then, it may not be bacterial.
Another way to understand otitis media with effusion is to understand eustachian tube dysfunction. Pronounced "you-stay-shee-un," this tube runs from the middle ear to the back of your nose and throat. These are located on the sides of your face and if you look into the back of your mouth to either side, in many people you can see the eustachian tube opening. They close most of the time, but when you yawn, chew or swallow, they open. Like any tube, they can become congested and clogged so the fluid building up in your sinuses and ears can become a bit stagnant, ultimately leading to bacterial growth. When you have pressure in your ears, it's pretty indicative of a clogged eustachian tube. Decongestants can help move this fluid. Little ones have more undeveloped tubes which are more likely to clog, as will those who also have enlarged lymph tissue or inflamed adenoids that may affect speaking or breathing. When we see fluid causing moderate to severe bulging of the tympanic membrane or drainage and inflammation, then antibiotics may be recommended by your clinician.
Conjunctivitis: Pink Eye
Tearing, redness, itching, and crusty eyelashes are all signs of conjunctivitis, commonly called pink eye. Often caused by the same virus as the common cold, pinkeye spreads rapidly in schools and child care centers. Again, almost always just a virus and not treatable with antibiotics. Most all cases clear up in four to seven days. If you have other symptoms, almost certainly this is viral, so try chamomile tea bags on the eyes, even a cool washrag, but wash your hands frequently.
If the symptoms aren't improving in five days, then the conjunctivitis might be bacterial and require antibiotics. Contacts can certainly increase the possibility of a bacterial infection, and when there is pus oozing from the eye, not just the crusty stuff, then bacteria may also be to blame. Certainly some get sexually transmitted infections in their eye too, and this can create blindness. Throw away all your eye makeup after a bacterial conjunctivitis so you don't reinfect yourself, as well as your used contact lenses.
Transparent Prescribing
Rather than giving incentives to those who push immunizations, it would be intriguing to see employers report antibiotic prescribing practices. For example, if the clinician documents presence of bronchitis and prescribes an antibiotic, do they note why? Was there indication? If they note sinusitis, how many are prescribing antibiotics? There certainly may be rationales. Maybe the individual is 83 years old and traveling across the country in a few days, concerned they may advance into a bacterial infection and not have resources for treatment so they came in to be extra cautious? Maybe they have a history of severe sinusitis that always requires antibiotics, but with better understanding, they recognize that although once they did progress into a bacterial infection and antibiotics were required, all subsequent prescriptions were provided prior to bacterial growth and were really being administered alongside a virus that was self-resolving. Certainly a bacterial infection can repeat, but it won't occur in the earlier days of signs and symptoms of a virus.
Evaluating symptomatic relief and even education can really alter the course of prescribing as well. If the clinician is not confidently knowledgeable in how the virus transitions into a bacterial infection, then their recommendations for both symptomatic relief and prevention of advancing illness may not be on point. This will then reaffirm the client's belief antibiotics are necessary ultimately because early interventions were not effective so the virus will in fact advance towards bacterial infection.
References
American Association of Nurse Practitioners (AANP). (2022). NP Facts. NPFacts_11022.pdf
Centers for Disease Control and Prevention (CDC). (2022). Health equity and antibiotic resistance fact sheet. Health-Equity-Antibiotic-Resistance_FS-508.pdf.
Denny, K. J., Gartside, J. G., Alcorn, K., Cross, J. W., Maloney, S., & Keijzers, G. (2019). Appropriateness of antibiotic prescribing in the emergency department. The Journal of Antimicrobial Chemotherapy, 74(2), 515–520. https://doi.org/10.1093/jac/dky447
O’Neill, J. (2014). Antimicrobial resistance: Tackling a crisis for the health and wealth of nations. Review on Antimicrobial Resistance. https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20-%20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20of%20nations_1.pdf
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