Monday, October 2, 2017

Antibiotic overuse

I went to med school in a place where Lyme disease was endemic.  So when I was on my Medicine rotation and one of my co-students complained about feeling tired and achy for a few days, our attending immediately said to him, "Get tested for Lyme disease."

The student was reluctant.  He didn't have a rash.  Our student health plan was crappy with a huge deductible, so he would have had to pay for the test out of pocket.  Also, I pointed out (from a personal Lyme scare) that he could get a false negative this early on.

"Well, if you don't want to get the test," the attending said, "I'll write you a prescription for doxycycline and you can just treat it."

And then we saw another attending, who totally agreed with this.

Even years later, I still find this offensive.  The course of treatment for Lyme is 10-21 days of antibiotics.  Would you really give someone up to THREE WEEKS of antibiotics because they were tired and achy a few days?  I took doxycycline and it made me throw up... not something I'd personally be excited to take for weeks for no reason.  And... hello, antibiotic resistance?

I'd like to believe that the attendings were just overtreating because it was a colleague and not something they recommend to all their patients.


  1. I m really concerned about this! I recently had an ear infection and after 3 days on antibiotic (can't remember) they put me on another. Thankfully the other worked but it scares me non the less. _ Blogger doesn't like me My name is Mary

  2. I completely agree with you that it was wrong to write a script for enough doxy to treat Lyme. I'm not excusing your attendings for their thinking, but at least you live in an area where Lyme is endemic. I live in a part of the US where you are very unlikely to encounter the either the vector or the bug, and yet some of my colleagues wouldn't think twice about giving doxy or minocycline to a patient who thought they had the disease but had no exposure risk.

    Similarly, my good friend who is an ID doc, would give his daughter prophylactic Cipro to ward off traveler's diarrhea. He would never do this for a patient, but his own flesh and blood was somehow an exception.

  3. I have a splinter. hmm that might get infected, cause sepsis and require IV antibiotics. Better start the antibiotics

  4. Hmm I don't mean to start a debate on a different matter, but as a french canadian, this makes me happy that everyone here can afford a test before being treated for no reason.

    1. Yes! I am also Canadian, and my first thought reading this was that I am so glad that no one in Canada has to think about the financial cost of getting proper healthcare.

    2. It's sad. I can't even fathom this! And I don't exactly have a lot of money but at least I can pay for most things I need. And still I question following up on medical concerns I have or even with my kids. It's in my head. Even if I dismiss it and follow up anyway, it's a thought I have to shoot down. I can't even imagine what it would be like to not have the luxury to shoot down that thought -which is the reality of probably half of our citizens. Despicable.

  5. I had Lyme disease (confirmed with a test and an erythema migrans rash and all of that), and that course of several weeks doxycycline was one of the most miserable things I've had to take (and I have lupus, so I'm no stranger to meds with awful side effects). Definitely would not be signing up for that if I didn't know for sure that I needed it.

  6. > "I'll write you a prescription for doxycycline and you can just treat it."

    AFAICT, that is a valid, maybe even the correct, second-line response. Untreated borreliosis is a totally un-fun disease; think neuroborreliosis and becoming a vegetable, either acutely or chronically.

    Doxycycline is not a bad choice either. at least it works against a whole bunch of tick-borne diseases.

    I'll go one farther and say that in some cases, antibiotics are indicated immediately. Just consider a meningitis with unclear cause: First you start the antibiotic and think about mannitol. _Then_ you get cultures started and all that.

    It's the same with neuroborreliosis. You get a patient who went from highly coherent to complete lack of reaction, non-recognition of family, and confusion about place and time over the course of twelve hours, MRI is negative for bleeding and ischemia, the patient now runs a 40.3 C (104+ F) fever -- and she has been to an area with endemic Lyme disease just three weeks prior.

    Are you really going to start with a lumbar punction and then do nothing until the cultures come back? No. Or at least I hope you won't, because I like having my family members around.


    1. Right but there's a difference between starting empiric abx on someone who has a dangerously high fever and someone who has a few weeks of low grade fatigue in no immediate danger.