New strategies required to battle antibiotic overuse

As many as one-half of antibiotic prescriptions written in the outpatient setting in the United States may be unnecessary or inappropriate, potentially undermining how the discovery of antibiotics revolutionized physicians' ability to treat bacterial infections.

"The common prescribing of antibiotics is based on a belief system that came about as soon as antibiotics were discovered that, essentially, they have great benefit with almost no biological cost to the patient," said Martin J. Blaser, MD, MACP, the Muriel G. and George W. Singer Professor of Translational Medicine and director of the Human Microbiome Program at New York University Langone Medical Center in New York City. "This is what several generations of physicians, including me, have grown up believing, and the public has become accustomed to that idea as well."

More recently, it has become more widely accepted that the overuse of antibiotics is not without consequences. First among those consequences is the growth of antibiotic resistance. According to the CDC, at least two million people each year in the United States are infected with bacteria that are resistant to antibiotics, and at least 23,000 people die each year as a result of these infections. In addition, overuse of antibiotics can damage the human microbiome, affect nutrient supply and vitamin production, and reduce protection from pathogens.

Despite this knowledge, the overuse of antibiotics continues to be a problem, acknowledged Jeffrey A. Linder, MD, MPH, FACP, chief of the division of general internal medicine and geriatrics at Northwestern University Feinberg School of Medicine in Chicago.

"There are really only four clear indications for antibiotics related to respiratory infections: adult ear infections, the minority of sinus infections, certain patients with strep throat, and patients with pneumonia," Dr. Linder said. "However, these indications account for a relatively small proportion of the antibiotics that are prescribed."

What drives overuse?

According to ACP Member Aaron M. Harris, MD, MPH, of the division of viral hepatitis at the CDC, research suggests that while prescribers are generally familiar with clinical practice guideline recommendations for prescribing antibiotics, other factors may influence their prescribing behaviors.

One factor associated with the overuse of antibiotics is fear, according to Brad Spellberg, MD, FACP, chief medical officer at the Los Angeles County-University of Southern California Medical Center.

"Physicians aren't thinking about guidelines and recommendations when they have a febrile, sick patient coughing in front of them, and they have to make a decision if something is likely viral or bacterial," Dr. Spellberg said. "You think to yourself, 'There is a 90% to 95% chance that this is viral, but what if this is the 5% of people with a bacterial infection and I don't give them an antibiotic? How much harm can this one prescription really do?'"

Despite these concerns, research suggests that infectious complications related to common outpatient infections are rare, Dr. Harris said. "Furthermore, it turns out that physicians perceive that patients want antibiotics more frequently than patients actually do," he said. "It has been shown that this perception further drives physicians to prescribe antibiotics more often."

Dr. Linder agreed that overuse of antibiotics is driven in part by a misunderstanding between what the physician thinks a patient wants and what that patient actually wants.

"I won't discount that many of us have had encounters with a patient that is very unhappy about not being prescribed antibiotics, but the vast majority of patients do not want an antibiotic if they do not need it," Dr. Linder said. "I believe many of us take a bad experience we have had with one or a few patients and extrapolate that to everyone. We erroneously think that everyone wants antibiotics when most people just want to make sure there is nothing worse going on."

Fixing the problem

There are educational resources available for physicians who want to learn more about the appropriate use of antibiotics, including the CDC's Get Smart: Know When Antibiotics Work program, and The Pew Charitable Trusts' Antibiotic Resistance Project. However, educational efforts are not necessarily what is needed to combat the problem of antibiotic overuse, Dr. Spellberg said.

"Every physician you talk to will know that we have a crisis of antibiotic resistance and that you should not prescribe antibiotics for viral infections," he said. Instead, he said that societal and health care system-based changes are needed to motivate physicians to align their behavior with public health concerns.

One way to do that is with peer comparisons, Dr. Spellberg said. A 2016 study published in JAMA that looked at inappropriate antibiotic prescribing for acute respiratory infections during ambulatory visits found that peer comparison, where clinicians received e-mails comparing their prescribing rates with those of "top performers," resulted in a decrease from 19.9% to 3.7%.

"These reports provide feedback and a comparison to other physicians," Dr. Spellberg said. "Physicians are competitive and do not like to be underperformers. These reports may help to provide a psychological counterbalance to the fear that would normally drive antibiotics prescriptions."

Other strategies for change include greater promotion of continuing medical education programs, delayed prescribing strategies, clinical decision tools placed in electronic health records, and public commitments to prescribing antibiotics appropriately, Dr. Harris said.

As an example, a study published in 2014 in JAMA Internal Medicine, on which Dr. Linder was a co-investigator, found that a "nudge"-based intervention for antibiotic overuse decreased inappropriate antibiotic prescribing for acute respiratory infections. In the study, physicians displayed a poster-sized commitment letter in their examination room for 12 weeks featuring their photograph and signature that stated their commitment to avoiding inappropriate antibiotic prescribing. Physicians who displayed the poster had their rates of inappropriate prescribing decrease from 43% to 34% during the study period.

Finally, Dr. Blaser believes that primary care physicians, who are under tremendous time constraints, need to have better resources at their fingertips to make appropriate prescribing decisions. Dr. Blaser is chair of the President's Advisory Council on Combating Antibiotic-Resistant Bacteria (CARB). One of CARB's missions is to develop new diagnostic innovations that can identify and characterize resistant bacteria.

"Wouldn't it be great if physicians had rapid tests to say in the office that an infection was viral or bacterial?" Dr. Blaser said. There has been some research to show that the inflammatory marker procalcitonin could be employed as a marker of bacterial infection, but these tests are not yet readily available.

"Procalcitonin and, in the future, other biomarkers can be useful to guide antibiotic prescribing," Dr. Spellberg agreed. "If you have a patient who is coughing and has a fever but has a procalcitonin level less than 0.25, then the test is telling you that it is most likely safe not to give antibiotics."

When currently confronted with patients who are insistent about antibiotics, physicians can advise the use of therapies to help alleviate symptoms, Dr. Harris said. The CDC has a "Prescription Pad" handout that physicians can fill out for patients explaining that they have been diagnosed with a viral and not bacterial infection, as well as some of the things they can do to relieve their symptoms.

"Providers in medical offices are the most trusted source of health information, and much of the responsibility lies with health care providers to educate patients about appropriate antibiotic use," Dr. Harris said.