Antibiotics: Helping decrease inappropriate use

Why Antibiotics?

(From the CDC Be Antibiotic Aware)

• Antibiotics can save lives when prescribed appropriately. The use of antibiotics always creates a risk of contributing to development of antibiotic resistance. Indiscriminate and overuse markedly contributes to the development of germs with antibiotic resistance.
• The CDC believes antibiotic resistance to be one of the most urgent threats to the public’s health.
• More than 2.8 million antibiotic-resistant infections occur in the United States each year and more than 35,000 people die as a result.
• Antibiotic-resistant germs can quickly spread through communities through contact, the environment, and other methods.

Why Now?

According to a 2021 article by John Hopkins in the Oxford University Press, antibiotic use in 2015-2018 was flat compared to 2007-2010, after years of steady decline.

• Prescription Antibiotic Use among the US population 1999-2018: National Health and Nutrition Examination Surveys (researchgate.net) [PDF]

There are some indications of rising antibiotic use during the COVID pandemic.

• Could Efforts to Fight the Coronavirus Lead to Overuse of Antibiotics | The Pew Charitable Trusts (pewtrusts.org)
• COVID-19 pneumonia and the appropriate use of antibiotics – The Lancet Global Health

There’s some indication that the increased use of telehealth is associated with increased antibiotic prescriptions, even before the pandemic.

• Balance Between Best Practice and Patient Satisfaction: Antimicrobial Stewardship in Telemedicine | JAMA Internal Medicine | JAMA Network

How to address?

Commitment Posters

From a 2014 JAMA Intern Med study (JAMA Intern Med. 2014 Mar; 174(3): 425–431. doi: 10.1001/jamainternmed.2013.14191)

• Nudging Guideline-Concordant Antibiotic Prescribing (nih.gov)

Intervention included displaying poster-sized commitment letters that feature clinician photographs and signatures, stating their commitment to avoid inappropriate antibiotic prescribing for acute respiratory infections. With this intervention, inappropriate prescribing rates decreased 10% from baseline rates for the 12-week intervention period, compared to an 8% increase for controls.

Keys are:

• Posters were written at a high school level so a patient viewing the poster would understand it.
• The poster was at eye level in the examination room.

Cold Kits/Prescription

Give the patient something concrete. Variations include:

• Directing the patient to use OTC medications.
• “Prescription” for OTC medications, bed rest, etc.
• Actual materials or coupons (for OTC meds, chicken soup, vitamin C, tea, cough drops, VapoPatch, etc.).

Reassure the patient with a follow-up plan:

• A patient may be re-assured by either scheduling an appointment or a follow-up call in several days to check if symptoms persist or by directing the patient to follow up as needed.
• Illness or discomfort had to reach a certain point to make an appointment.

Patient Education and Communication

Messages you can deliver verbally to patients

The messages that worked:

(In order of preference, based on patient recall 30 days after message receipt):

• “Antibiotics aren’t for all illnesses.”
• “Antibiotics aren’t for chest colds.”
• “Antibiotics don’t work for a virus.”

Less effective:

• “Antibiotics can do harm or cause side effects.”

Other resources:

• CDC has launched its campaign Be Antibiotic Aware. The following link contains an accompanying toolkit.cdc.gov/antibiotic-use/week/toolkit.html
• The AAFP’s article “How to Prescribe Fewer Unnecessary Antibiotics: Talking Points That Work with Patients and Their Families” can be found at aafp.org/afp/2016/0801/p200.html.

Written material for patients

• Colds, Flu and Other Respiratory Illnesses | Choosing Wisely (Infectious Diseases Society of America)
• RSI_antibioticuse_patientflyer-2016.pdf (thephysicianalliance.org) [PDF]
• CDC Be Antibiotic Aware – Patient Handouts and Prescription pads
• Consumer Reports article ‘When to Say No to Antibiotics for Infection’

Clinical Information: How does delaying antibiotics fare?

Cochrane Review (2017) on delaying antibiotic prescriptions:

Delayed antibiotic prescriptions for respiratory infections (nih.gov)

For acute respiratory infections:

• “Delayed antibiotics” strategies achieved lower rates of antibiotic use compared to “immediate antibiotics” without significant difference in patient satisfaction or increase in complication rates.
• When clinicians are confident that it’s safe to not prescribe antibiotics immediately, an approach of “no antibiotics with advice to return if symptoms persist” is likely to result in the least antibiotic use while maintaining similar patient satisfaction and clinical outcomes.
• Where clinicians aren’t confident in using a no antibiotic strategy, a “delayed antibiotics” strategy may be an acceptable compromise to significantly reduce unnecessary antibiotic use while maintaining patient safety and satisfaction levels.

For otitis media and sore throats

• Modestly improved by “immediate antibiotics” compared with “delayed antibiotics”. No differences in complication rates.
• Delaying prescribing didn’t result in significantly different levels of patient satisfaction compared with immediate provision of antibiotics.
• “Delayed antibiotics” achieved lower rates of antibiotic use compared to “immediate antibiotics.” The strategy of “no antibiotics” further reduced antibiotic use compared to “delayed antibiotics.”

Antibiotic Report

References for antibiotic report

If you receive an antibiotics report from HMSA, the following are the citations in the report.

• Chua K et. al. Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross sectional study BMJ 2019; 364; https://doi.org/10.1136/bmj.k5092.
• Ginsburg AS, Klugman KP. COVID-19 pneumonia and the appropriate use of antibiotics. The Lancet Global Health Dec 1 2020; 8(12); https://doi.org/10.1016/S2214-109X(20)30444-7.
• Hersh AL et. al. Unnecessary Antibiotic Prescribing in US Ambulatory Care Settings, 2010-2015. Clin Infect Dis. 2021;72(1):133-137; https://doi.org/10.1093/cid/ciaa667.
• Olesen SW et. al. The distribution of antibiotic use and its association with antibiotic resistance. Elife. 2018 Dec 18;7:e39435. doi: 10.7554/eLife.39435. https://elifesciences.org/articles/39435.
• Petersen et.a. Prescription Antibiotic Use Among the US population 1999–2018: National Health and Nutrition Examination Surveys. Open Forum Infectious Diseases May 2021; 8(7). https://doi.org/10.1093/ofid/ofab224.
• Pew Charitable Trusts. Could Efforts to Fight the Coronavirus Lead to Overuse of Antibiotics? Study shows more than half of hospitalized COVID-19 patients in U.S. received antibiotics in pandemic’s first six months. Issue Brief, March 10, 2021. Retrieved from https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2021/03/could-efforts-to-fight-the-coronavirus-lead-to-overuse-of-antibiotics April 25, 2022.
• Zhuo S et. al. Association of a Clinician’s Antibiotic-Prescribing Rate With Patients’ Future Likelihood of Seeking Care and Receipt of Antibiotics, Clinical Infectious Diseases, Volume 73, Issue 7, 1 October 2021, Pages e1672–e1679, https://doi.org/10.1093/cid/ciaa1173.

Specifications for antibiotic report

If you receive an antibiotics report from HMSA, the following are the specifications for that report.

Patients ages 3 months and older with a visit (an outpatient, telephone, observation or ED visit, e-visit or virtual check-in) for a diagnosis of acute bronchitis/bronchiolitis who were dispensed an antibiotic.

Excluded cases:

• Visits that resulted in an inpatient stay.
• Patients who had a new or refill prescription for an antibiotic medication dispensed within 30 days before the date of service.
• Patients who, in the 12 months before and including the date of service, had one of the following conditions: HIV, malignant neoplasms, emphysema, COPD, tuberculosis, allergic bronchopulmonary aspergillosis, sickle-cell disorders, pancytopenia, agranulocytosis, neutropenia, genetic anomalies of leukocytes, myelofibrosis, other specified diseases with participation of lymphoreticular and reticulohistiocytic tissue, sarcoidosis, cystic fibrosis with pulmonary manifestations, unspecified acute lower respiratory infection, chronic bronchitis, bronchiectasis, lung diseases due to external agents, acute respiratory distress syndrome, pulmonary edema, pulmonary eosinophilia not elsewhere classified, other interstitial pulmonary diseases, abscess of lung and mediastinum, pyothorax, other diseases of the pleura, intraoperative and postprocedural complications and disorders of respiratory system, respiratory failure, mediastinitis, disorders of diaphragm, respiratory disorders in diseases classified elsewhere, rheumatoid lung disease with rheumatoid arthritis, certain diseases with lung involvement (polyarteritis, systemic lupus erythematosus, dermatomyositis, polymyositis, dermatopolymyositis, systemic sclerosis, sicca syndrome), Wilson-Mikity syndrome, chronic respiratory diseases originating in the perinatal period, congenital malformations of great arteries, congenital malformations of the respiratory system, congenital malformations of esophagus, congenital asplenia, situs inversus, disorders of the immune system.
• Patients who, on or within three days after the date of service, were diagnosed with one of the following: Pharyngitis, certain infectious or parasitic diseases (intestinal infectious diseases, whooping cough, bartonellosis), infections with a predominantly sexual mode of transmission, other spirochetal infections (stomatitis, Lyme disease), other protozoal diseases not elsewhere classified (babesiosis, acanthamebiasis, naegleriasis), cutaneous strongyloidiasis, other specified bacterial agents as the cause of diseases classified elsewhere, disorders of zinc metabolism, suppurative and unspecified otitis media, otitis media in diseases classified elsewhere, mastoiditis and related conditions, intraoperative and postprocedural complications and disorders of ear and mastoid process, acute sinusitis, acute tracheitis/laryngotracheitis/obstructive laryngitis/epiglottitis, pneumonia, acute bronchitis due to mycoplasma pneumoniae/hemophilus influenzae/streptococcus, chronic sinusitis/tonsillitis/adenoiditis, hypertrophy of tonsils/adenoids, other chronic diseases of tonsils/adenoids/larynx, other diseases/abscesses of upper respiratory tract, certain infections (impetigo, acute lymphangitis, cellulitis, acute lymphangitis, other local infections of skin and subcutaneous tissue, other granulomatous disorders of the skin and subcutaneous tissue, pyogenic granuloma, eosinophilic cellulitis), osteomyelitis of vertebra, infection of intervertebral disc (pyogenic), other disorders of bone, acute/chronic pyelonephritis, other chronic tubulo-interstitial nephritis, hydronephrosis with ureteropelvic junction obstruction, pyonephrosis, renal and perinephric abscess, renal tubulo-interstitial disorders in diseases classified elsewhere, pyelitis cystica, pyeloureteritis cystica, ureteritis cystica, cystitis, urinary tract infection site not specified, inflammatory diseases of prostate, inflammatory diseases of female pelvic organs, Z codes indicating infections with a predominantly sexual mode of transmission
• Fulfilled the requirements above any other time in the previous 31 days (i.e., each prescriber-patient incident is only counted once per 31 days).

Medications included were:

Aminoglycosides, aminopenicillins, beta-lactamase inhibitors, first-generation cephalosporins, fourth-generation cephalosporins, ketolides, lincomycin derivatives, macrolides, natural penicillin, penicillinase resistant penicillin, quinolones, rifamycin derivatives, second-generation cephalosporin, sulfonamides, tetracyclines, third-generation cephalosporins, urinary anti-infectives and miscellaneous agents (aztreonam, chloramphenicol, dalfopristin-quinupristin, daptomycin, linezolid, metronidazole, vancomycin).

A prescription is considered active if the “days supply” indicated on the date when the patient was dispensed the prescription is the number of days or more between that date and the relevant service date.

Revision History