Do you practice in an antibiotic-prescribing hot spot?

In West Virginia, where family physician David Avery, MD, practices, people develop chronic illnesses blamed on pollution from the state's coal mining industry. That could be one reason why doctors are more likely to prescribe so many antibiotics, he said.

But he suspects that the more likely driver behind the state's elevated antibiotic use is physicians' overuse of the drugs.

"In a lot of the smaller towns, you can't get culture results quickly, so the doctor gives the patient an antibiotic and hopes they feel better," said Dr. Avery, of Parkersburg. "That is wrong. But if you don't give it to them, they'll go somewhere else and get it."

New research shows that in 2007, West Virginia had the nation's highest outpatient antibiotic use per capita, with 1,222 dispensed antibiotic prescriptions per 1,000 people. That is more than two times higher than Alaska, where there were 546 dispensed antibiotic prescriptions per 1,000 people. The national average was 858 antibiotic prescriptions per 1,000.

The findings were issued Nov. 16 by scientists with Extending the Cure, a project of the Washington-based nonprofit Center for Disease Dynamics, Economics & Policy. The organization aims to use research to improve health policy on issues such as antibiotic resistance, environmental health and malaria.

The research did not explain why the rates vary so widely by state. But absent hard data, the most logical answer for the disparity in rates is that physicians are not using antibiotics properly, said William Schaffner, MD, chair of the Dept. of Preventive Medicine at Vanderbilt University School of Medicine in Nashville, Tenn. He said it is possible that doctors in states with a lower-than-average rate are not prescribing antibiotics enough. The consequences of that could be untreated infections, which increase patients' risk of medical complications.

Dr. Schaffner said the more pressing concern is that high-prescribing states could exacerbate the nation's problem of antibiotic resistance. Many U.S. physicians already are treating patients with older, more potent antibiotics as bacteria become resistant to widely used drugs, experts say. In some instances, a bacterium is resistant to all available antibiotics, leaving doctors with few ways to help patients.

To prevent further resistance, local and national health organizations, including the Centers for Disease Control and Prevention, have launched educational campaigns for physicians and the public on proper antibiotic use. Following the release of the Extending the Cure data, however, some experts are questioning why those efforts seem to be more effective in certain states than in others.

In a pocket of states, a majority of which are in the South, residents use significantly more antibiotics than residents of the Pacific region. Those states are Alabama, Kentucky, Louisiana, Mississippi, Tennessee and West Virginia, according to the Extending the Cure data.

James Powell, MD, an internist and pediatrician in Franklin, Tenn., said some physicians might prescribe antibiotics, even if they are not warranted, to avoid conflict with a patient who is asking for the drugs.

Public health expert Ramanan Laxminarayan, PhD, MPH, who co-wrote the Extending the Cure report, said more research is needed to determine why physicians in these states are prescribing antibiotics. Regardless of the reasons, he said informational campaigns on proper antibiotic use need to be tailored to the specific needs of individual states and communities.

"An increase in antibiotic use is not a bad thing if it results in more disease being treated," said Laxminarayan, director of the Center for Disease Dynamics, Economics & Policy. "But that's not what's going on here."

Pressure to prescribe

Nearly every day in Crossville, Tenn., parents pressure pediatrician Robert Berman, MD, to prescribe antibiotics that are not warranted for their children's conditions. But he does not give in to their demands.

Rather, he often tells parents, "These symptoms are consistent with a viral upper respiratory infection. Research shows that when you give antibiotics in these cases the child doesn't get better any faster. We wouldn't recommend antibiotics now."

When parents continue to push Dr. Berman to prescribe the medication, he said, "I stick to my guns." He tells parents, "I'm sorry. It's really inappropriate in this circumstance."

Some parents listen to him. Others respond by seeking out physicians who often will prescribe an antibiotic.

This is a common situation throughout Tennessee, where doctors are having a difficult time convincing patients that antibiotics are not necessary for viral infections, said Dr. Powell, who is on the Tennessee Medical Assn.'s Public Health Committee.

To address the problem, the medical association in 2012 will begin a program to educate health professionals and the public on appropriate use of prescription drugs, including antibiotics.

"I can't think of anything in the state that would make us need more antibiotics" than people in other states, Dr. Berman said. "I have to attribute [Tennessee's high rate] more to the expectation of parents and perhaps the habits of providers not practicing evidence-based medicine."

Overall in the United States, rates of antibiotic dispensing in the outpatient setting decreased by 12% between 1999 and 2007. But data show that the use of broad-spectrum drugs, such as fluoroquinolones, is rising. The concern is that while those antibiotics can treat an assortment of bacteria, they are more likely to promote resistance than narrow-spectrum drugs, experts say.

The finding indicates that doctors are saying: "I don't know what's wrong with you. But take a [broad-spectrum] antibiotic and hopefully it will make you feel better," Laxminarayan said. "It's not a really good way to use antibiotics."

Before writing a prescription, doctors should be able to name the bacteria afflicting the patient, infectious diseases experts say. If a physician is not sure what he or she is treating, antibiotics probably are not the proper treatment.

Education called key

Mary Ann Foland, MD, a family physician in Anchorage, Alaska, is not sure why doctors in her state prescribe antibiotics less frequently than doctors in other states.

But she says patient demand for the drugs has decreased during her 30 years in practice, and physicians' knowledge on how to use them properly has improved.

"I don't know if it has anything to do with differences in illnesses in the states. I think it's more a difference in the physician community," said Dr. Foland, president of the Alaska State Medical Assn.

Although health professionals are unsure why antibiotic prescribing rates vary by state, they agree that education is the key to rein in unwarranted use of the drugs.

"We need to change the social norms," Laxminarayan said. It is neither acceptable for patients to demand antibiotics, nor for physicians to prescribe them when they are not appropriate, he said.

If doctors do not change this practice, he added, "we will harm all of society."