An extraordinary tale of an ordinary case

Case reports in medical journals often concern rare conditions that, courtesy of quick-witted doctors, are correctly diagnosed and successfully treated. The case report of Loose and co-workers is quite the opposite. It concerns a very common condition that becomes the subject of a very common overtreatment. What is rare is that the patient was triply unfortunate: He received unnecessary treatment, experienced side effects of the treatment, and then experienced side effects of the treatment for the side effects. Rare too is the authors' bravery in exposing their own judgements and choices that turn out to be flawed. Everyone makes mistakes, but few choose to write about them. There is something to learn here for both the authors and their readers.

Overtreatment of respiratory tract infections with antibiotics occurs frequently in general practice. A recent Dutch study of symptoms, signs and prescribing practices for respiratory tract infections revealed that 46 % of patients who received antibiotics should not have done so according to national guidelines for antibiotic usage (1). The Netherlands has far lower levels of antibiotic usage than Norway (2), and there is reason to believe that overuse is equally rife in Norwegian general practice. A certain degree of overuse is, in a sense, understandable. Time pressures, expectations of patients and the diagnostic uncertainty that is an inevitable part of practising medicine in the primary health care service, often result in prescription of antibiotics «for safety’s sake». Both patient and doctor are keen for the problem to be solved here and now. And yet overuse is highly undesirable, leading to side effects both for the individual in the short term, and for society as a whole in the longer term.

Effective methods exist for reducing overuse of antibiotics in general practice. One method that leads both to reduced prescribing and to better choice of antibiotics (3), is to do in a sense as Loose and co-workers have done here: to expose one’s own practices. When general practitioners review and discuss their own prescribing practices with colleagues, learning and change ensue.

The authors state that an ongoing mycoplasma epidemic influenced their choice of treatment. The last major mycoplasma epidemic in 2011 led to significant overuse of macrolide antibiotics (4). It seemed that doctors were treating patients with positive polymerase chain reaction (PCR) results for M. pneumoniae regardless of whether they actually had symptoms and signs corresponding to pneumonia. For the next epidemic that will probably come in one to two years, we should be better prepared. Patients with an upper respiratory tract infection and positive PCR test for M. pneumoniae have nothing to gain from antibiotics.