Antibiotics are dangerous

A study in this week’s NEJM is getting a lot of media attention, reporting that azithromycin use is associated with an increased risk for cardiovascular death--especially among those with underlying cardiac risk factors.  The increased risk found in this large retrospective cohort study (performed with a big ole’ Medicaid database) was relative to amoxicillin, and was no different than the risk of cardiovascular death among levofloxacin recipients. 

Now, we can quibble about the study design, and about the small absolute risk found (this NY Times article provides some sample quibbling), but to me the larger point to make (again) is this: ANTIBIOTICS ARE UNSAFE.  They can be lifesaving, to be sure, but they carry risks for all manner of adverse reactions, including life-threatening allergic reactions, organ failure, C. difficile disease, cardiovascular death, emergence of multiple drug resistance, etc., etc. 

I don’t prescribe chemotherapy for treatment of cancer. There are many reasons for this, not least of which is that I am not an oncologist, but one is certainly the widely acknowledged toxicity of chemotherapeutic agents. Somehow, though, antibiotics have developed a different reputation--as generally safe, well-tolerated, with few downsides. Why else would they be so widely prescribed to patients who don’t need them, or made available over-the-counter in some locales, or allowed to enter our food supply?  As John Bartlett points out in the Times piece:

“We use azithromycin for an awful lot of things, and we abuse it terribly,” Dr. Bartlett said. “It’s very convenient. Patients love it. ‘Give me the Z-Pak.’ For most of where we use it, probably the best option is not to give an antibiotic, quite frankly.”

Perhaps spurring stewardship efforts requires striking more fear into the hearts of antibiotic prescribers.  Those who understand the many downsides of antibiotic use will be much more parsimonious about their use.