Solving the Problem of Antibiotic Over-Prescribing and Resistance One Provider at a Time: Public Health Watch

Most of us remember the playground taunt, “It takes one to know one.”

Turns out, there may be some truth to the slight—even into adulthood. As the United States continues to struggle with the challenges posed by antibiotic-resistant bacteria, which are of course on the rise because of the over-prescribing of certain drugs, researchers from Atrium Health—formerly Carolinas HealthCare System—in Charlotte, North Carolina, are looking into the question: Who are the clinicians still improperly administering these agents and why are they still doing so? Their findings were published in the January 30 issue of Infection Control and Hospital Epidemiology.

“Everyone wants to do the best for their patients and, often, the driving factors for prescribing is not lack of knowledge, but pressure from patients and families,” study co-author Lisa Davidson, MD, Medical Director, Antimicrobial Support Network, Atrium Health, told Contagion^®. “By focusing on communication training, as well as the knowledge base, we can help guide these providers in their conversations with patients.”

According to the US Centers for Disease Control and Prevention (CDC), some 2 million illnesses and 23,000 deaths have been linked with resistant bacteria. The agency estimates that at least 50% of all antibiotic prescriptions written in the United States do not fall under currently accepted practice guidelines.

However, what’s troubling is that these figures are hardly new. In fact, the CDC and several professional societies have been sounding the alarm about resistance—and the need for enhanced antibiotic stewardship efforts—for more than a decade.

And yet…

Dr. Davidson and her colleagues initiated their research as part of a larger effort to “reduce inappropriate antimicrobial prescribing across ambulatory care.” The key, though, was not simply their understanding that the problem exists. They wanted to know why it exists, and in so doing hopefully identify approaches to address it within their health system.

For their retrospective cohort study, the investigators collected data from 448,990 outpatient visits for common upper respiratory conditions that should not require antibiotics (acute bronchitis, bronchiolitis, nonsupportive otitis media, and upper respiratory infection; based on International Classification of Disease, Ninth and Tenth Revisions, Clinical Modification criteria). The visits, which occurred over the period between January 2014 and May 2016, were to Carolinas HealthCare System urgent care, family medicine, internal medicine, and pediatric practices, and encompassed 898 providers and 246 practices. Prescribing rates were reported per 1000 patient visits.

Overall, the antibiotic prescribing rate in the study cohort was 407 per 1000 visits. Notably, adult patients seen by an advanced practice practitioner—defined as nurse practitioners, and/or physician assistants—were 15% more likely to receive an antimicrobial than those seen by a physician provider (MDs and/or DOs). Among pediatric patients in the study sample, older providers were 4 times more likely to prescribe an antimicrobial than providers who are 30 years of age or younger.

“Performance of advanced care providers for appropriate prescribing of antibiotics has been recognized by our study and others as an important area of educational focus,” Dr. Davidson said. “Advanced practice practitioners are now increasingly in positions where they see a higher frequency of urgent or same-day visits for common viral conditions.”

In terms of specific prescribing patterns, pediatric practices were nearly twice as likely as their colleagues in internal medicine to prescribe an antibiotic for nonsupportive otitis media (463 prescriptions per 1000 visits vs 248 prescriptions per 1000 visits). Prescriptions per 1000 patient visits for acute bronchitis among urgent care, family medicine, internal medicine, pediatric practitioners were 739, 678, 651, and 801, respectively. Acute bronchitis was the diagnosis for which the most antibiotic prescriptions included in the analysis were written.

According to Dr. Davidson, Atrium Health has taken these findings on-board and sought to address them. They have developed patient education/communication “scripts” for clinicians as well as “printable tools and educational fact sheets that they can walk through with patients, to help explain the difference between viral and bacterial infections and make suggestions for appropriate over-the-counter medications.” Some of the system’s practices distribute these fact-sheets to patients at check-in so that they can review them while waiting to see their provider. They’ve also added an informational page on antibiotics to their website, which includes some “do’s and don’ts.”

“Educational initiatives and interventions need to be targeted not just to the provider, but to everyone in the practice,” Dr. Davidson said. “The message needs to be communicated to patients from the moment they make the appointment. [And], provider education needs to be easily accessible. Transparent reporting of antimicrobial utilization is a key part of educating providers—the more they understand their own prescribing practices, the better they can understand and make adjustments.”

It’s this kind of thinking that may resolve the problem of antibiotic over-prescribing—and related drug resistance—once and for all. Here’s hoping, anyway.

Brian P. Dunleavy is a medical writer and editor based in New York. His work has appeared in numerous health care-related publications. He is the former editor of Infectious Disease Special Edition.