Inappropriate Prescription of Antibiotics and Other Causes of Antimicrobial Resistance

John Nosta, BA: What’s a better tool, the carrot or the stick?

Debra A. Goff, PharmD, FCCP: You know how people respond to sticks—people don’t like them. If I’m talking to a surgeon, and I’m trying to tell them, “No, you can’t have this new antibiotic because you have to call me and I have to approve it,” right away you have set up a brick wall. It’s defensive medicine. “You can’t have this. You have to have me approve it.” Nobody likes to say, “I have to have your approval to do something that I think I’m an expert in.” And so we have to change the way we operate. It’s not as simple as, “Here’s a set of guidelines.” Everybody is supposed to follow them, but they don’t. You’re not going to follow a guideline if you don’t understand why you are being asked to do this.

John Nosta, BA: But one of hot button phrases we hear a lot about today is “big data.” We have so much more data to make smarter decisions. Is that helping?

Debra A. Goff, PharmD, FCCP: John, you might have access to that. Try working in a hospital with electronic healthcare records that were designed to be an efficient billing system. We’re trying to make them decision-support tools, big data. I walk into my hospital today and go, “Tell me how many patients got admitted last night for community-acquired pneumonia.” I cannot get that data. I can get it once they’re discharged, but I cannot get it in real time. So we actually don’t have great access, in real time, to data that would empower us to do better.

John Nosta, BA: So let’s get back to the notion of risk and reward. Is the mistreatment of nosocomial pneumonia, which is a high-mortality issue, more of a problem? Or is the mistreatment of a urinary tract infection that has broad consumer implications a bigger problem? How do you scale that or put that into perspective?

Debra A. Goff, PharmD, FCCP: They are all a problem—every single misused antibiotic, such as an inappropriately prescribed antibiotic or an antibiotic that’s prescribed and actually turns out not to be the correct one—because we don’t have rapid tests to tell us what the organism is when you’re infected. So we take our best educated guess. It might be 4 days before I actually know, “Yes, I picked the right antibiotic.” Or it actually may have been the wrong antibiotic. And so that all contributes to the problem.

John Nosta, BA: But that’s with in-hospital use. Right?

Debra A. Goff, PharmD, FCCP: Correct.

John Nosta, BA: In the outpatient setting, you get your antibiotic and then the issue is, will you even take it? So is underuse sort of a reciprocal dynamic here?

Debra A. Goff, PharmD, FCCP: Part of that is consumers or patients, when you give them an antibiotic prescription, generally stop it when they feel better. They save it for the next time. So duration of antibiotics is a big topic of discussion. We’ve actually learned that they might be right. Maybe we have just started to use antibiotics for 7, 14, or 21 days. I call them football scores. When you look at the evidence of how that duration ever came to be, there’s really not good data. So you’re correct. Patients don’t always follow the directions that we give them. Sometimes that contributes to the development of antibiotic resistance if you stop before you’ve actually eradicated the infection.