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Graphic images from the antibiotic resistance movement

If you need an image for a talk on antibiotics, please help yourself to anything on my Pinterest board, “Antibiotic Resistance Movement.”

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Evidence-based antibiotic usage

Stop prescribing antibioticsIn my ongoing quest to show that “antibiotic” is a word that does more harm than good to public health outreach, I frequently encounter people on the Internet who insist that confusion over antibiotic efficacy is not due, at all, to the word itself.  I value these people’s insight, of course, because their views certainly might be true for the planet they live on. There are probably a lot of habitable planets in the Universe (40 billion just in our galaxy!), and I don’t presume to know what reality is like for those places.

On Earth, however, the belief that antibiotics treat viruses is rampant, generates over-prescription, and is clearly related to the word itself. Here are Exhibit A (from answers.com) and Exhibit B (from Google definitions):

What does antibiotic mean?What is a germ?  Definition from Google.People believe that antibiotics treat viruses because on Earth we regularly use a word’s roots to infer meaning. So for the average person who doesn’t remember any biology from middle school, parsing the meaning of antiviral, antibacterial, antifungal, etc. is easy … as long as he/she knows what anti-, viral, bacterial, and fungal mean.  But that same trick doesn’t work for antibiotic.  And because people don’t realize their inference is incorrect, the misconception becomes forever entrenched in public opinion, and on the internet.  The CDC (and others) waste millions of dollars each year trying to quash the misconception, but such efforts will always fail because the strength of the “antibiotics” misnomer is always truthier to the average Joe than a bunch of patronizing posters on a doctor’s waiting room wall.

[As an aside, misnomers are words (you can probably guess, based on the roots … if you live on Earth) that deliver an incorrect meaning.  “Pencil lead” (two words, of course) is a great example, and there are thousands of parents each year who call their doctors in a panic after Jimmy gets stabbed during math class with a pencil. Or they search the internet for “pencil lead poisoning“.  Luckily, pencil lead is graphite (always has been), a harmless crystal of carbon that is not going to cause Jimmy to be developmentally delayed.]

So how bad a misnomer is “antibiotics”?   How should physicians decide whether to use “antibiotics” or “antibacterials” when discussing treatment of illnesses?  Like any medical question, the decision should be evidence-based.  Here is how to get the evidence (Pew Research Center folks, this means you):

Antibiotic versus antibacterial poll dataResponses for questions #1 and #2 show that approximately 10% and 36% (pdf) of adults are confused about the correct answers, respectively.  That’s a HUGE fraction given the daily importance of bacteria and viruses in our lives and in the news.  Unfortunately, there are no poll data for #3 and #4.  But my guess is that the fraction of incorrect responses for #3 and #4 will be 1% and 5%, respectively.  “Antibacterials” clearly suggests the drug kills bacteria — only people unfamiliar with English might be clueless.  And I’m guessing that 5% of the public think viruses are bacteria (I’ve asked dozens of virologists … and none knew of poll data on classification ignorance).  No matter what the actual numbers, the level of confusion for “antibacterials” is going to be dramatically less than that caused by “antibiotics.”

So if you are a doctor hoping to improve patient understanding and patient care, using “antibacterials” is a no-brainer.  And if you are worried that “antibacterial” is a rare word, stop worrying: it’s from the 1890s (that’s old!) and is found 13,200,000 times on the internet (that’s less than the 23.8 million for “antibiotic”, but still totally respectable).  Don’t wait for the CDC, WHO, AMA, ACP, APA, etc. to recommend the change, because chances are they won’t — they love the word, “antibiotic” (I’ve emailed them all, trust me).  So just tell your colleagues and staff on the floor to get on board.  And then let me know how it goes.

Below are my other posts on the topic, if you need further convincing.  All posts have graphics that you are encouraged to use for your talks on the topic (this week is Antibiotic Awareness Week, after all). Please consider sharing these links with others on Twitter and Facebook if you are on board with my suggestion, and if you can forward to impressionable medical students, you get bonus points.

  1. Curbing the misuse of antibiotics
  2. Antibiotics are antiviral
  3. How doctors can reduce antibiotic demands from patients
  4. Antibiotic Awareness Week poster
  5. Antibiotics work against viruses
  6. How to improve Antibiotic Awareness Week
  7. Seasonal plea for informed antibiotic usage
  8. Antibacterial soap
  9. The Walking Dead need antivirals, not antibacterials (Shopping list for anti-infectives)
  10. Venn guide to pills that kill things

[If you’re curious why I am so interested in this issue, it’s because I witnessed, first-hand, confusion over “antibiotics” when I lectured on antibacterial resistance in my evolution courses at Swarthmore College.  My students were (largely) bright, and were often bound for medical school … yet they frequently made the same incorrect assumptions about efficacy that totally uneducated people make.  Misuse of “antibiotics” became one of my pet peeves.  Because I have a blog, I thought it would be worth a try to effect some change.]

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How doctors can reduce antibiotic demands from patients

New recommendations for reducing the number of patients demanding antibacterials for viral infections:

1.  Remove all of the educational signage that is currently in your waiting room. It doesn’t work (more evidence), probably because most posters are targeted at elementary school brains.  The average adult in the United States reads with the understanding of an 8th grader, so posters should be designed for that level, or above.  What you put in your waiting room really does matter, and you (the doctor) should dictate this, not your interior decorator or office manager, even though they might have strong opinions on the matter.  And be critical of all the glossy posters you can receive for free from health organizations — I’ve looked at hundreds, and the vast majority are simply awful. They should spend their money on something else.

2.  Consider replacing the above posters with the document below (it’s free!). Here’s the PDF version for printing: anti-infectives-poster.pdf.  Make the poster large. Place copies in the examination rooms, too. It introduces your waiting patients to the vocabulary you will use later.  It will prime their brains.

Types of anti-infective drugs

3.  After patient examination, how you deliver the diagnosis matters.  After you tell them that they have a viral infection (flu, cold, etc.), mention that one treatment option is an antiviral (Tamiflu, for example).  Saying “antiviral” is critical — it’s a word used in many television shows and movies so the public knows it. Mention why you think their infection is not bacterial. They came to office hoping to get antibacterials, so you know you have to bring it up.  If they mention “what about antibiotics?,” respond that antibacterials only work against bacteria, and point to the wall chart above.  I.e., use “antibacterial” not “antibiotic.” In the United States, 36% to 45% of adults believe that “antibiotics” are effective at treating viral infections (outside of the US, the number is higher).  Using the word, “antibacterial” avoids this problem, completely, since people understand what the word means just given its roots. Training yourself to stop using the word “antibiotics” will be hard, but it’s worth it — the word is a big source of the over-prescription problem.

The above is my recommendation, of course.  Everyone else on the planet insists on sticking with the word “antibiotics” and with patronizing, bloated signage that most likely is never read. My view is that these old strategies have not really been working, and it’s time to try something different. For more on how linguistic “levers” might reduce patient’s demands for antibacterials, see this paper (PDF).

My other posts on antibiotic abuse.

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Antibiotic Awareness Week poster

Ten interesting facts about antibiotics, for Antibiotic Awareness Week (Nov 18 -24, 2013).  Below is an image that can be used for presentations. PDF version for printing: facts-about-antibiotics.pdf.

Antibiotic Awareness Week poster

I’ve tried to craft the above poster with information that is mildly interesting, with the hope that people (people like you?) might pass the link along. There are 100s of posters on the internet … but they seem to be completely ineffective at educating the public (according to an experiment). In my view, the problem is that all of these posters use “antibiotics” instead of the correct term, “antibacterial.” Please see my page, “Curbing the misuse of antibiotics” for details on why antibiotic/antibacterial choice matters for the public, even if it doesn’t matter to you (who probably have a higher degree).

Below are some links that explore some of statements in the PDF above. I’m putting them below the fold because they are probably TMI for 99% of the people who might be interested in the above PDF. If you are that 1%, go crazy.

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Antibiotics work against viruses

Antiviral antibioticsThe post title will annoy scientists and physicians, but will simply confirm what lay people believe to be true. It’s why the public tends to demand antibiotics for viral infections.  And that’s why health organizations like the CDC should abandon the term in favor of clarity.

If you search Google for the “definition of antibiotic,” the majority of definitions on the first page will return the lay definition, that antibiotics are effective against microorganisms.  Google provides the first definition like that, in fact, which is probably the result 99% of the searchers use. If you want to read a good overview of how various dictionaries and world health groups define “antibiotic,” please see this document (pdf) by the European Union’s Heads of Medicines Agencies. Medical organizations are confused, too.

Google Trends search for antibiotics definitionTo further gauge public confusion over what “antibiotics” actually means, it’s useful to look at Google Trends.  People search for the definition of antibiotics (blue line in graph at right; click image to open in a new window) far more than for meanings of “antibacterials” and “antivirals.” As stated above, these people will be led to definitions saying that antibiotics kill a broad range of microbes (viruses are microbes). And then they march off the doctor to demand the wonder drug that kills all microbes. And, often, the doctor complies just to get rid of them (the patient, that is).

If you have been following my blog, you know where this is going: public outreach campaigns should never, ever use the word “antibiotic”.  This directive is because “antibiotic” used to mean “kills microorganisms”,  and the roots of the word (antibiotic) suggest the original meaning of the word — together, that’s why people think antibiotics will kill viruses. “Antibiotics” is thus a misnomer — in fact, I think it is probably one of the best examples of a misnomer out there (perhaps pencil lead is a competitor).  If your organization truly wants to reduce over-prescription of antibacterials, deleting “antibiotics” from all your outreach efforts (talks, YouTube clips, websites, PDFs, Twitter posts, etc.) will likely be the most important thing your organization could ever do. Really. The question is thus: is reducing over-prescription a true goal, or do you really like the word, “antibiotic,” too much to part with it?

By the way, here are 6 of my past posts with the gruesome details:

  1. Curbing the misuse of antibiotics (page)
  2. How to improve Antibiotic Awareness Week
  3. The Walking Dead need antivirals, not antibacterials
  4. Antibacterial soap
  5. Venn guide to pills that kill things
  6. Seasonal plea for informed antibiotic usage

And below is a slide about Google definitions, just in case you’re giving a talk for Antibiotic Awareness Week (November 18 – 24). Yes, I cringe that they even call it by that name.

Definitions of antibiotic and antibacterial

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