A few years ago, parents who arrived at Dr. Steven E. Caplan's office with a cranky toddler tugging at his ear were likely to go home with an antibiotic. These days, if an ear exam doesn't show clear signs of infection, the Baltimore pediatrician sometimes asks parents to wait a day or two to see if the symptoms persist.
Dr. Caplan is one of a growing number of doctors who are trying to reduce the use of antibiotics amid fear that infectious diseases are growing resistant to them. A report issued last month by the Centers for Disease Control and Prevention in Atlanta warned that infectious diseases are on a global rebound. In the U.S. alone, death caused by infectious diseases increased 58 percent between 1980 and 1992, and part of the blame goes to overuse of antibiotics during the 60 or so years they've been around.
The new conservatism has come with a price, though. Sick people get frustrated when asked to wait out an illness, and doctors sometimes see their patients go elsewhere.
Dr. Michael P. Boyle, who is on the internal medicine faculty at the Greater Baltimore Medical Center, recently saw a patient who complained of congestion and cold-like symptoms. Dr. Boyle advised him to rest and take decongestants, but the patient wanted an antibiotic. After he persuaded another doctor to prescribe one and felt better. he refused to pay for his visit to Dr. Boyle.
Dr. Boyle says many doctors will prescribe antibiotics when they aren't sure of the diagnosis to see if they work. Residents now being trained at GBMC, he says, are urged to try to distinguish between bacterial infections, which antibiotics can knock out, and viral infections, which don't respond to antibiotics but often cause similar symptoms. Sometimes that means waiting to see if the infection gets worse or better, and doctors aren't immune to their patients' complaints.
"There's a battle between your professional responsibility and trying to make the patient feel better," he says.
From the perspective of the sick patient or the parent of a cranky toddler, of course, it's not always easy to wait a day or two.
"You're sick and you want to feel better," says Edward W. O'Loughlin of Fallston, who goes to the doctor occasionally for bad colds and coughs.
Mr. O'Loughlin says he has noticed his doctor become increasingly conservative with antibiotics. "It's gone from, 'Come in and I'll give you one,' to 'Come in and we'll make a decision,' " he says.
While he says he can understand the doctor's reluctance, Mr. O'Loughlin says it can be frustrating to walk away from a doctor's visit without medication.
Dr. Joel D. Meshulam, an internist in Baltimore, says some patients walk away and never come back, particularly HMO patients who may assume that they are being treated differently to contain costs.
"My job is to coax my patient to understand why they may have to wait," he says.
Dr. Meshulam has noticed that patients are increasingly well-informed about what antibiotics are on the market, and sometimes want a specific name brand. But most patients aren't yet aware of doctors' increasing reluctance to prescribe antibiotics.
"Patients come to the doctor expecting a prescription," he says. "They don't want to leave empty-handed."
Some of the dramatic increase in infectious disease mortality can be attributed to AIDS and to the aging of the population. But it also reflects a surprising jump in deaths caused by illnesses that were once considered treatable. Deaths due to respiratory tract infections, for example, increased 20 percent between 1980 and 1992. CDC researchers found.
When antibiotics were introduced in the mid-1930s, doctors hoped that deaths caused by infections would be all but eliminated, according to Dr. Mitchell L. Cohen, director of the Division of Bacterial and Mycotic Disease at CDC. But after a half-century of success in treating infectious diseases and developing new antibiotics, doctors are watching some previously treatable diseases, such as tuberculosis, produce strains that are untreatable and therefore deadly.
The new strains have developed, Dr. Cohen says, in part because doctors have prescribed antibiotics too frequently, with the idea that there wasn't any harm.
But over the years, bacteria have mutated to become resistant to many antibiotics, and they're now outpacing the ability of drug companies to produce stronger drugs. One of the few weapons doctors have left is to reduce the opportunities for bacteria to mutate by giving them fewer chances to meet antibiotics.
Since one-third of all antibiotics are used to treat upper respiratory infections in children, that's one major focus of the effort to educate the public about concern over antibiotic resistance, according to Dr. Cohen. Doctors are also being asked to reduce the length of time they prescribe antibiotics to prevent infection after surgery, and the public is being urged to stop demanding antibiotics for ailments such as colds.
"The message has really gotten out in the last year or so," he says.