Antibiotic Safety: Strategies for Combating Inappropriate Prescribing

By Michelle LaPlante

With broadly resistant “superbugs” on the rise, it is more important than ever for health care professionals to prescribe antibiotics responsibly and to change the current culture of overprescription.

We spoke with primary care clinician-investigator Jeffrey A. Linder, MD, MPH, FACP, Associate Professor of Medicine at Brigham and Women’s Hospital in Boston, to discuss challenges facing clinicians regarding appropriate antibiotic prescribing and strategies for combating overprescription. Dr. Linder’s research interests include using behavioral science and electronic health records to improve clinical care and the care of ambulatory patients with acute respiratory infections.
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What is the most common misconception clinicians have about antibiotics?
I think there is a fundamental belief that antibiotics are basically safe and that there is no harm in prescribing one. Also, physicians seem to focus only on this nebulous idea of balancing prescribing with antibiotic resistance, but that is the wrong thing to consider. Instead, we should be thinking, “Does the benefit outweigh the harms for my patient?” Antibiotics have real harms, so we should avoid prescribing them in many cases in which they are given inappropriately today. 

The most important factor a physician should consider when prescribing an antibiotic is whether the patient has a diagnosis that warrants treatment with antibiotics. I believe the major problem we need to address is the prescription and use of antibiotics for viral illnesses.

Can you talk about some of the side effects and harms that can happen when prescribing an antibiotic?
The prescribing decision is all about balancing harms and benefits. For example, there are 40 years of randomized controlled trials showing that antibiotics do not help with acute bronchitis. If we prescribe an antibiotic for acute bronchitis, that means we are giving patients a drug that is not only ineffective, but can also cause rashes, yeast infections, interactions with other medicines, and severe diarrhea, such as seen in Clostridium difficile infection. Additionally, some people have severe allergic reactions to antibiotics. 

Development of antibiotic resistance in the individual patient is further down the list of concerns, but it is a very real concern. Taking an antibiotic changes the nature of the bacteria in our body for weeks, including the nature of the good bacteria we have in our gut. These changes are what lead to diarrhea and to C difficile infection. However, if an individual has a condition that warrants antibiotics, I prescribe antibiotics. If a patient has pneumonia, for which antibiotics do work, then the same risks are there, but there are benefits to the antibiotics because they are going to help treat the bacterial infection.

What are some of the scenarios in which antibiotics are prescribed unnecessarily?
The most common scenarios involve sore throats, sinus infections, and acute bronchitis. Most sore throats are viral; most sinus infections are viral; and acute bronchitis is almost always viral. Of course, we obviously should not prescribe antibiotics for colds or nonspecific upper respiratory infections. For respiratory infections, there are only four diagnoses for which antibiotics are indicated, and those are ear infections, the minority of sinus infections, strep throat, and pneumonia. Thus, if you have diagnosed the patient as having anything else, an antibiotic is not needed.

How do you approach the patient who insists on an antibiotic anyway? How do you educate the patient to better understand the reason a prescription is not necessary?
I think there is an assumption on the part of doctors that all patients want antibiotics. It is true that some patients do want antibiotics, and that is those patients’ main mission in coming to see the doctor. However, I think we over extrapolate unpleasant experiences we may have had with one or a handful of patients to  all patients. 

The vast majority of patients want to get the right treatment that matches the illness they actually have. I believe it is a mistake to assume that all patients want antibiotics. Qualitative research¹ shows that clinicians are sometimes almost afraid to discuss the inappropriate use of antibiotics with patients for fear that they are going to say, “oh, yeah, I want an antibiotic,” so we just do not even bring it up. 

I believe we need to change our mindset and approach prescribing antibiotics the way we approach any prescription medicine—we need to ask ourselves whether the benefits outweigh the harms. If someone comes in with a cold, acute bronchitis, the flu, or with most sinus infections, then they have a viral illness, and an antibiotic is not going to help. In those scenarios, giving patients an antibiotic is giving them a chemical that is not going to help them, but has the very real potential of hurting them.

Are you seeing any antibiotics in particular that clinicians should be cautious about using, such as broad-spectrum antibiotics, or the more traditional ones such as penicillin?
One infection where there is definitely a case of overprescribing is strep throat. Only 10% of adults who come into the office with a sore throat are going to have strep throat.² There are very good tests we can do, both rapid test and culture, to determine which patients have strep throat. If we actually do diagnose the patient as having strep throat, we should be giving penicillin (for adults as long as they don’t have an allergy), because the organism that causes strep throat is never resistant to penicillin. 

There is a tendency for patients, and even doctors, to think, “I want a new, strong antibiotic” to treat strep throat. However, Group A streptococcus, which causes strep throat, is sometimes resistant to newer drugs like azithromycin (also known as the Z-pack)—but it is never resistant to penicillin. 
Regarding sinus infections, only a few of them need to be treated with antibiotics, and there are clear clinical criteria to indicate which patients with sinus infections should get antibiotics. The recommended antibiotic for those few sinus infections is amoxicillin/clavulanic acid, and many of the antibiotics that physicians often prescribe for sinus infections do not make sense. So, physicians often prescribe broader spectrum antibiotics that have worse coverage for the bacteria and are the most likely to cause sinus infections. 

What role do diagnostic tests play? Is it ever feasible to do the right test for the right origin of the illness?
For most respiratory illnesses, I am skeptical that we are ever going to have a magic test that can reliably differentiate between a bacterial illness and a viral illness and yet still be an inexpensive test. Frankly, we do not need such a test. We have all we need to know today.

If patients have a cold, I know they have a cold, and I do not need any other testing to make that diagnosis. Regarding sinus infections, there are clear criteria³ that indicate if the patient has persistent, severe, or worsening symptoms. In addition, each of those categories has very specific criteria for when antibiotic treatment for a sinus infection is needed, so I do not need any additional testing to make the decision.

In addition, if an individual presents with a sore throat, there are clear clinical criteria⁴ about whether testing is needed. If a test is warranted, the patients should only be treated with an antibiotic if the result was positive. For pneumonia, there are vital sign abnormalities or an abnormality on a chest radiograph, so between chest radiographs and a strep test, there’s virtually no other testing that you need to do to decide whether or not somebody needs an antibiotic. 

How do you educate physicians and keep them mindful about overprescribing antibiotics? You had done some studies where you had found that even just hanging a poster in a hallway can change both physician and patient behavior. Can you tell us a little about that?
The point of the poster is to change the nature of the conversation. In our study,⁵ we hung posters of commitment letters in the offices, with photographs and signatures from each clinician, which stated their commitment to avoid inappropriate antibiotic prescribing. Without it, there may be an unspoken tension when a patient comes in with a respiratory complaint, and clinicians think, “Oh, boy, they’re here to get their antibiotics, and I don’t want to have any unpleasantness. I don’t want them complaining, and I want them to like me.” In fact, the patient may not be thinking about wanting antibiotics at all. Thus, the poster serves to externalize the thought process and get the doctor and patient on the same page even before the visit happens. The posters make the patient aware of how the doctor thinks about antibiotics, and it makes the doctor aware that the patient is aware of how the doctor thinks about antibiotics. 

The poster will have language in it such as, “I’m committed to only prescribing antibiotics when they’re going to help you,” and it delves into the risks and benefits, particularly the risks of antibiotics when there is no potential for benefit. When the patient visit begins, everybody is closer to being on the same page. I think the poster describes the mindset that doctors should cultivate, which is doing the right thing for our patients. Giving an antibiotic to someone who has acute bronchitis is not guideline concordant, and that type of prescription does not benefit our patients. We are putting them in harm’s way by prescribing antibiotics when they are not needed.

What are some ways that technology can help with inappropriate prescribing?
We have done a couple of interventions with electronic health records in which we ask doctors before they prescribe an antibiotic to provide a quick, Tweet-length justification for why they are prescribing the antibiotic. That intervention had a dramatic effect in reducing the antibiotic prescribing rate.⁶

We give doctors feedback in particular ways too. We measure their inappropriate antibiotic prescribing rate and then tell those who had the lowest antibiotic prescribing rate that they were “top performers.” It also lets clinicians know that they have colleagues who are not prescribing antibiotics for respiratory infections at all—because our top-performing antibiotic prescribers had an inappropriate antibiotic prescribing rate of 0%. There are doctors out there who are able to keep their antibiotic prescribing rates down, and this method lets other physicians know that their colleagues can have low rates and that patients are not leaving their care. In fact, patients are very satisfied. Literature shows that as long as patients feel that you have heard their complaint and explained their illness to them, antibiotics make no difference in terms of satisfaction.¹

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Methicillin-resistant Staphylococcus aureus (MRSA) and other antibiotic resistant infections have been in the public eye the last few years, but really, how prevalent are these types of bacteria? How big is the actual risk, and how likely is it that you are going to have a patient walk in with MRSA?
I think the threat of MRSA is becoming more and more real. However, it would be stretching the data too far to say that I know that by giving an individual patient an inappropriate antibiotic that they are going to have a drug-resistant infection within some fixed period of time.

We clearly know that giving an antibiotic changes the nature of the bacteria that are in and on your body for a few months, but there are no data showing that people within those few months are dying from drug-resistant pneumonia or a bacterial infection. Nonetheless, evidence clearly indicates that the higher the antibiotic prescribing rate is in a community, the higher the antibiotic resistance rates are in that community. Every antibiotic prescription to some degree contributes to resistance. We need to use these powerful, important medicines as judicially as possible, in a way that best meets the needs of individual patients, so that we do not prescribe a drug they do not need. I think that strategy will preserve the effectiveness of antibiotics for all of us for when we have infections that really do require an antibiotic. 

Do you foresee a day when most antibiotics will no longer work? Or is there still time to keep that future from becoming a reality?
I think we have the potential to reverse antibiotic resistance. There have been studies in large areas where changing the antibiotic prescribing rate led to a change in the proportion of infections caused by antibiotic-resistant bacteria. If we use antibiotics only when they are needed, and use the least broad-spectrum antibiotics, we can preserve the effectiveness of individual antibiotics for longer. I do not want doctors to obsess about the big picture of antibiotic resistance for their individual patients, but we can get 95% of the way there by thinking about the benefits and risks for the individual patient in front of us. We need to think: “Is this more likely to help the patient, or hurt the patient?” If we approach the prescribing decision with that mindset, then we will make the right choice.

References

1. Mustafa M, Wood F, Butler CC, Elwyn G. Managing expectations of antibiotics for upper respiratory tract infections: a qualitative study. Ann Fam Med. 2014;12(1):29-36. doi:10.1370/afm.1583.

2. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Beneden CV. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2012; 55(10):e86-e102. doi:https://doi.org/10.1093/cid/cis629.

3. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015;152(2 Suppl):S1-S39. doi:10.1177/0194599815572097.

4. Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2013;(11):CD000023. doi:10.1002/14651858.CD000023.pub4.

5. Meeker D, Knight TK, Friedberg MW, et al. Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA Intern Med. 2014;174(3):425-31. doi:10.1001/jamainternmed.2013.14191.

6. Meeker D, Linder JA, Fox CR, et al. Effect of Behavioral interventions on inappropriate antibiotic prescribing among primary care practices. JAMA. 2016;315(6):562-570. doi:10.1001/jama.2016.0275.