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INTRODUCTION

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Jane, a 27-year-old woman, arrives to your busy clinic at the end of the day. She looks miserable and describes a lingering cold for the last few days, including sore throat, cough, congestion, and sneezing. Before you are even able to do an exam, she asks you for antibiotics. You examine her and decide she most likely has a virus, not a bacterial infection that would require antibiotics. In fact, you do not really think she will need any further diagnostic testing at all.

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So you ask the patient why she wants antibiotics. She tells you that she is getting on an airplane the next day to go to a series of important meetings. She is worried about strep throat. “How will I get antibiotics if I get sicker?” she asks. You look at your watch and notice you are running 30 minutes behind schedule. You worry Jane will be upset if you do not give her what she wants. With a deep sigh, you quickly write her a prescription for azithromycin.

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Antibiotics are among the most remarkable advances in modern medicine and have saved countless lives over the better part of the last century. However, when used incorrectly, antibiotics pose serious risks to both individual patients and the public health at large (we often wonder if the drug-resistant infections that catalyze the apocalypse in every modern Zombie movie are really that far off). Using antibiotics when they are not needed increases drug-resistance, leaving populations of patients vulnerable to resistant infections. Antibiotic overuse can also place individual patients at risk for allergic reactions, antibiotic-associated diarrhea, and other highly unpleasant and dangerous side effects.1 These risks are well known to clinicians—as are the decades of clear evidence, guidelines, and quality measures that argue against prescribing antibiotics in certain conditions, such as routine sore throats and acute bronchitis.2-4 Sir Alexander Fleming, the discoverer of penicillin, even warned in a 1945 New York Times article: “… the microbes are educated to resist penicillin and a host of penicillin-fast organisms is bred out…. In such cases the thoughtless person playing with penicillin is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism. I hope this evil can be averted.”5,6

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And yet, currently when someone is diagnosed with a viral sore throat, like our patient Jane, antibiotics are prescribed approximately 60% of the time.7 For acute bronchitis, patients are prescribed an antibiotic more than 70% of the time—a rate that has remarkably been increasing over time.8 Why is this happening?

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In many cases, clinicians overprescribe antibiotics knowingly and are “caving” to perceived patient demand. In a world that often forces clinicians to see more patients in less time (see Chapter 9), it may be easier to just write out a requested prescription rather than spend the time educating a ...

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