November 18-24 was highlighted by the CDC as U.S. Antibiotic Awareness Week (USAAW). Educational materials were made available online to highlight the dangers of antibiotic resistance and the principles of antibiotic stewardship for medical professionals, hospitals, long-term care facilities, and the public. UCA and CUCM supported the CDC’s efforts by sharing resources and bringing attention to the importance of antibiotic stewardship.
For some background, each year, close to 3 million antibiotic resistant infections occur in the U.S. alone, and of those, over 35,000 patients die as a result. These numbers are increasing yearly. In 2021, over 211 million antibiotic prescriptions were dispensed in the U.S., with the highest antibiotic prescription rate being in the southern U.S. Unintended consequences of antimicrobial use include toxicity, side effects, allergic reactions, selection of pathogenic organisms such as C. difficile and Candida albicans, and antibiotic resistance.
In the outpatient setting 13% of visits on average result in an antibiotic prescription. Studies indicate this percentage is higher in Urgent Care. Of those prescriptions written, it is estimated that at least 25% were inappropriate. Other studies have shown that over 75% of patients with respiratory tract infections seen in outpatient clinics result in an antibiotic prescription; more than half of these were unnecessarily prescribed for a viral, not bacterial, infection.
Appropriate antibiotic use can be boiled down to the right antibiotic at the right dose for the right duration. Antibiotic stewardship is the process by which providers commit to appropriate use through the development of programs to identify areas of improvement and implementing change to make that improvement. From where we sit, education is the key to this process.
We all know that the common cold is not treated with antibiotics. So why then are so many patients who clearly have a viral illness leaving Urgent Care with an antibiotic prescription? One of the most common reasons I hear from providers is patient expectations. Many providers believe that the patient is expecting an antibiotic, and if they do not receive that antibiotic it may result in a bad review, loss of business, patient complaints, or other consequences. It is also easier to just write the prescription than explain why you are not. Would you prescribe a drug you know is inappropriate because the patient asks for it for any other disease? Would you write for an antihypertensive for a patient who is concerned they might have high blood pressure without demonstrable proof? Would you order chemotherapy because the patient thinks they might have colon cancer? Of course not. Although these examples may be dramatic, they illustrate the same principle.
But do all patients really expect that antibiotic? The perception by the provider that the patient wants an antibiotic is often incorrect. In a study by the CDC, 54% of providers believed that patients wanted antibiotics for cough or sinus symptoms, when only 26% actually had that expectation. Many just want to know if they need the antibiotic and may be perfectly happy to be told “not this time.” Patient education may be all that is required to satisfy the patient.
Providers should also frequently review clinical guidelines published by reputable organizations to determine if, when, and how antibiotics should be prescribed. Medical literature and recommendations change and it is our responsibility to stay up to date. These guidelines are where you will find evidence-based recommendations for antibiotics choices, strengths, and duration. The CDC offers free—yes, free—CME courses in all aspects of antibiotic resistance and stewardship.
We would like to challenge you for the New Year to take at least one step in the coming months to do your part to combat antibiotic overuse. Keeping in mind the right drug at the right dose for the right duration, identify one practice habit that you could change and do it! Some examples would be trying a little harder not to write that azithromycin or amoxicillin for a cold, cutting down your duration from 10 days to 7 days (very few infections now require 10 days), review a clinical guideline for pneumonia, UTI, sinusitis, otitis media, or others (and follow it), and review treatment recommendations for bronchitis and treat it like the viral infection it is. (We can get around this with patients by calling it a chest cold, not bronchitis.)
Baby steps can make a meaningful difference in both your practice and others’. Whether we realize it or not, those that are younger, newer, or less experienced follow our lead and copy our behaviors. If we set a good example, others will follow.
We urge you to make just one little change to combat the overuse of antibiotics in our country. Commit to using the right antibiotic at the right dose for the right duration. The multi-drug resistant infection you may help to prevent may be your own or your family’s.
For more information about antibiotic stewardship and free CME:
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