Patient Demand Outweighs Guidelines When it Comes to Appropriate Prescribing of Antibiotics

When it comes to appropriate antibiotic prescribing practices, clinicians working in outpatient settings feel they are doing the best they can within their control, according to a study of 3 health systems conducted by investigators from Johns Hopkins Medicine and others.

With the startling recent increase in antibiotic-resistant pathogens around the world, appropriate antibiotic prescribing practices are of utmost importance to help curb further development of resistance. Health care providers working in hospitals are particularly aware of this resistance, handling many patients impacted by multidrug-resistant pathogens such as Clostridium difficile and methicillin-resistant Staphylococcus aureus on a daily basis. As such, most institutions have a dedicated antibiotic stewardship program comprised of providers from pharmacy, infection control, physician staff who are committed to educating staff on the importance of antibiotic stewardship.

Outpatient clinics, which have been estimated to overprescribe antibiotics at a rate of 30%, according to Mike Kohut, PhD, a qualitative researcher at the Armstrong Institute of Johns Hopkins Medicine, have been missing out on such dedicated support for stewardship. The resources are out there if these prescribers look hard enough, but are they using them? Would they be amenable to a dedicated antibiotic stewardship program in their setting?

Dr. Kohut and colleagues from multiple institutions set out to learn outpatient prescribers’ attitudes on the overuse of antibiotics when also provided an antibiotic stewardship intervention, as well as their attitudes on what role they play in the overuse / overprescribing of antibiotics. The results of the study were presented at the SHEA 2018 Conference in Portland, Oregon.

“What the program attempted to do was to give these different sites, tools in order to improve antibiotic use,” shared Dr. Kohut. “This was done primarily through monthly webinars that were targeted at health care workers/providers, as well as nurses and pharmacists, in order to give strategies for the best antibiotic usage, and then also, how to set up their own antibiotic stewardship program.”

“Another aspect of the program was a comprehensive unit-based safety program (CUSP),” he continued. “The idea of this program is that you form a multidisciplinary team that works to identify patient safety concerns, and in this case, that would be [actions] associated with antibiotics, and then to try and design interventions to address those concerns, at the local level.”

The investigators conducted the study in 5 outpatient practices from 3 health systems. After developing an antibiotic stewardship intervention, the investigators conducted semi-structured interviews with the clinicians at the practices. A total of 24 practitioners were interviewed (17 physicians and 7 nurse practitioners/physician assistants). Participants were interviewed about their perceptions as to the barriers and facilitators that lead to optimal antibiotic prescribing. Dr. Kohut described the study in further detail in the interview (see video).

Dr. Kohut and colleagues found that the prescribers who were interviewed all agreed that appropriate antibiotic prescribing practices ultimately fall on the responsibility of the individual clinician; however, most cited reasons outside of their personal practice as to why they were unable to comply.

He described 1 particularly surprising response he heard that sometimes providers would, “prescribe [a patient] a Z-Pak, with the justification that, ‘antibiotic resistance has reached the point where this Z-Pak is ineffective anyway and so, I might as well give them a Z-Pak.’ In that case, antibiotics would be used as a placebo or just to satisfy the patient.”

The most commons reasons providers indicated for unnecessarily prescribing an antibiotic included:

• Patient demand
• Inconsistent messaging among clinicians
• Different models of care between urgent and primary care clinics
• Systemic issues: Patient satisfaction metrics Reimbursement

Furthermore, several of the respondents indicated that they abdicated the responsibility of appropriate use on to their patients. “One primary care physician shared that, ‘Where there is a patient who is just adamant, I’ll print [out the prescription] and hand it to them,’” said Dr. Kohut. “They will tell the patient, ‘It’s not going to help you. It is at your discretion to fill it if you feel it’s necessary. Once you leave these doors I can’t tell you how you’re going to do it.’”

Several of the participants felt that they were already prescribing antibiotics appropriately and their role was limited in improving the use of antibiotics. Indeed, many felt that antibiotic stewardship interventions should focus elsewhere and instead felt that there needed to be an increase in public education targeted at patients. It is for these reasons that Dr. Kohut feels it’s imperative that antibiotic stewardship interventions in the outpatient setting need to focus on getting to the root of the problem of why patient demand translates into a prescriber writing that prescription.

“When providers are saying something like, ‘[I’m writing a prescription because] I worry about patient satisfaction scores,’ then you can look at your interventions to [perhaps] filter out those negative scores that are due to not receiving antibiotics, so that the providers would not feel that pressure to prescribe,” he said. “Or, if [the provider] feels they are obligated to [give their patients something] then we can come up with some strategies [as to something] else you can give the patient as compensation for their trouble taking off work, paying their copay, etc.”

Interventions should include components to educate clinicians on the role they play in antibiotic overuse and arm them with the knowledge to help inform patients on why they are not receiving an antibiotic, while at the same time, acknowledging issues that may be motivating prescribers to write unnecessary prescriptions and taking steps to mitigate those factors.