The analogy between antibiotic resistance and climate change is an apt one in the sense that both require local and global responses. Flagrant antibiotic prescribing in outpatient settings, for example, can certainly undermine a judicious hospital response. Similarly, what good is it if one country fights to save fading antibiotic efficacy but another nation passes out pills like candy?

Reaffirming an all-too-common theme, a recent study found that 45% of patients with respiratory tract infections (RTIs) were inappropriately prescribed antibiotics in an outpatient practice of general internal and family medicine.

The study found that family medicine providers were more likely than general internal medicine providers to engage in inappropriate antibiotic prescribing for treatment of RTIs.1

“For a long time it’s been known that respiratory infections have been overprescribed,” says lead author Tamar Barlam, MD, MSc, director of the Antimicrobial Stewardship Program for Boston Medical Center. “Many studies show that acute bronchitis does not need an antibiotic — it’s definitely a viral process.”

Colds and nonspecific RTIs also do not require antibiotics, she adds. The researchers looked at data from family doctors and general internal medicine doctors to assess their prescribing habits when presented with RTIs, which were coded in various ways.

“Prior studies have found that antibiotic prescribing practice is pretty good when they get out of medical school, and then it gets worse,” Barlam says. “We didn’t find that at all. We found the practice was pretty poor whether the physician was in practice for less than a year or for 30 years.”

The researchers conducted a retrospective analysis of outpatient visits for patients who sought care for respiratory tract infections within a general internal medicine and family medicine practice at Boston Medical Center. During the two-year study, researchers recorded 4,942 visits.

Bronchitis was associated with the highest amount of inappropriate antibiotic use (71% of patients received an antibiotic), followed by sore throat (50%), and nonspecific upper RTI (28%). Additionally, the researchers found that women were prescribed antibiotics more often than men, and black patients were less likely to be overprescribed antibiotics than white patients.

“It is concerning that there may be a different approach to patients depending on race or gender, which may suggest inequities in care,” Barlam says.

Researchers also compared those who prescribed antibiotics for only 20% of visits with those who prescribed antibiotics for 65% of visits.

“High prescribers had young, white, and more likely to be privately insured patients,” Barlam says.

High prescribers also coded more often for bronchitis, and the low prescribers coded for unspecified RTIs, she adds. Researchers found that high prescribers tended to work in a practice with other high prescribers, and low prescribers worked with other low prescribers. This finding suggests that as hospitals acquire physician practices, they can have an effect on antimicrobial stewardship, Barlam says.

“Hospitals should not forget that overseeing hospital stewardship should extend into outpatient practices and the emergency room,” Barlam says.

Barlam and colleagues suggest implementing comprehensive education about antimicrobials and stewardship into medical school curricula to prevent establishment of poor prescribing practices. Other suggestions include enlisting low prescribers as physician leaders alongside high prescribers to influence efficient use of resources.

OTHER APPROACHES

Another possible antimicrobial stewardship intervention is a one-hour, on-site clinician education session, followed by a year of personalized, quarterly audit and prescription feedback.2

This intervention led to improved adherence to prescribing guidelines for common bacterial acute respiratory tract infections (ARTIs), according to a study led by Jeffrey S. Gerber, MD, PhD, an infectious disease physician at the Children’s Hospital of Philadelphia (CHOP).

“We have already translated this from research to a quality improvement initiative at CHOP,” Gerber says. “We have trained primary care pediatricians, who are members of these practice groups, to help implement this program, including educating their peers and serving as liaisons to help improve the data delivery for feedback reports.”

This generic approach should be generalizable when a health system has an electronic health record, staff to prepare and present antibiotic prescribing data, and willing, front-line clinicians, Gerber adds.

Another study reviewed parent and clinician views regarding prescribing decisions for acute childhood infections in primary care. Researchers found that pediatricians often prescribed antibiotics for childhood infections as a “just-in-case” precaution.3

“By ‘just in case’ we mean that even when doctors do not think antibiotics are likely to help the child get better, they sometimes prescribe them because they do not want to take any chances,” says Patricia Lucas, PhD, senior lecturer at the University of Bristol in Bristol, United Kingdom.

For example, some clinicians said that if they feel a parent is very anxious, or if they are not certain a parent will be able to cope well with caring for their child, they might give antibiotics, she explains.

“In these cases, they are not prescribing according to their assessment of the child’s illness, but prescribing to avoid the possibility of negative outcomes, such as a repeat consultation, or a panicky parent,” Lucas says.

However, the researchers concluded that physician uncertainty was the most relevant factor.

“Actual pressure from parents is rare,” she says. “We think that parent demands for other things, such as reassurance, medical evaluation, information, and time, are misinterpreted by doctors as demands for antibiotics.”

The solution would be for doctors to spend more time establishing what parents are looking for in a consultation, Lucas says.

“Many parents have a no-treatment preference, but they want to make sure that a doctor agrees that it is OK to focus on symptomatic relief only,” she says. “A full examination and history taking, reassurance that the illness will pass without treatment, and clear information about the symptoms of severe illness helps parents feel confident that they are taking care of their child.”

Sometimes the language physicians use gets in the way of providing reassurance to parents, Lucas adds.

“When doctors call self-limiting illness ‘minor,’ this does not reflect the major impact it can have on family life if children are home from day care, work is missed, and no one in the family is sleeping very well,” she explains. “Focusing on what might help this child on this occasion feel better should reduce the chances of miscommunication.”

MORE STICK, LESS CARROT

Back in the United States, a presidential advisory panel recently recommended that the Centers for Medicare & Medicaid Services (CMS) develop antibiotic stewardship regulations that would include quality measures assessing inappropriate antibiotic prescribing in the Physician Quality Reporting System (PQRS). This would tie best practices to reimbursement through the use of payment penalties for non-participation in PQRS. An antibiotic-reporting module would be mandatory.

“Most antibacterial drugs prescribed for humans are administered in outpatient settings rather than in hospitals,” the President’s Council of Advisors on Science and Technology (PCAST) reported.4 “The vast majority of antibiotics are used for ARTIs. Yet most RPIs are caused by viruses, against which antibacterial drugs are useless. Such inappropriate use contributes directly and substantially to increased antibiotic resistance, increased adverse drug reactions, increased C. difficile infections, and increased cost of care.”

Yet even if doctors muster the will and determination to put their own formulary in order — both in hospitals and outpatient settings — there is that aforementioned global problem. It is now abundantly clear that a pathogen that emerges anywhere can very quickly cause problems just about anywhere else. A pan-resistant pathogen from a country that flagrantly disregards antibiotic stewardship will not respect any borders or boundaries.

Michael Bell, MD, a veteran epidemiologist at the CDC, recently wrote an editorial that cited a disturbing example of this problem, as evidenced by a study running in the same journal.5,6

Wang et al describe “a striking and widespread example of medical misuse that can rapidly drive the acquisition and spread of antibiotic resistance,” Bell wrote. “They assessed China’s primary care system, a network of mostly rural facilities that provide two-thirds of that country’s healthcare — amounting to 3.7 billion outpatient encounters each year. More than 60% of antibiotic prescriptions were found to be inappropriate, with 78-93% of respiratory infections being treated with antibiotics. In addition, they describe a system supported by staff with little training and education; their ability to restrict antibiotic misuse is further hampered by an innate conflict of interest wherein the facility must sell antibiotics to maintain its operating budget. Unfortunately, China’s situation is not unique.”

REFERENCES

  1. Barlam T, et al. Antibiotics for respiratory tract infections: A comparison of prescribing in an outpatient setting. Infect Control Hosp Epi2015; 36:153-159.
  2. Gerber JS, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA 2013;309:
    2345-2352.
  3. Vodicka TA, et al. Reducing antibiotic prescribing for children with respiratory tract infections in primary care: A systematic review. Br J Gen Pract 2013;63:e445-e454.
  4. President’s Council of Advisors on Science and Technology. Report to the president on combating antibiotic resistance. September 2014. Available at: http://1.usa.gov/1qhDgF6.
  5. Bell M. Antibiotic misuse: A global crisis. JAMA Intern Med 2014;174:1920-1921.
  6. Wang J, et al. Use and prescription of antibiotics in primary health care settings in China. JAMA Intern Med 2014;174:1914-1920.