Appropriate Antibiotic Prescribing? Some Clinicians Resistant

June 27, 2014

A significant minority of clinicians have antibiotic prescribing habits that worsen the public health crisis of antibiotic resistance, according to a new WebMD/Medscape survey.

One in 10 clinicians who prescribe antibiotics without clinical certainty say the drug "won't hurt if not needed." And when clinicians know an antibiotic is not indicated, 1 in 10 write the script anyway if the patient demands the drug, the survey found.

Patients might not pressure their healthcare provider like this if both parties have discussed how taking unneeded antibiotics can lead to 'antibiotic resistance, but only 53% of patients report having such an exam-room talk, according to the survey.

Overall, the findings suggest a prescribing landscape with positives as well as negatives. Almost all patients surveyed are at least aware of antibiotic resistance, and close to 90% say they understand that antibiotics are useless for some infections. When patients ask for a prescription — roughly 1 in 4 do this — and a clinician says no, they generally accept the decision. Meanwhile, 95% of clinicians prescribe antibiotics even when they are not absolutely sure they are needed. It's sometimes understandable, especially in light of slow-poke lab tests. However, the belief among some clinicians that antibiotics won't hurt "is an indication that we've got some educating to do," said Daniel McQuillen, MD, a past chairman of the Clinical Affairs Committee of the Infectious Diseases Society of America and current president of the Massachusetts Infectious Diseases Society. Better patient education about antibiotics, added Dr. McQuillen, could reduce the number of misguided demands for the drugs. With only about 1 in 2 patients reporting that they've had an antibiotic talk with their clinician, "there's room for improvement," he said.

And improvement can't come too soon. At least 2 million people get infected with antibiotic-resistant bacteria each year, resulting in at least 23,000 deaths, according to the Centers for Disease Control and Prevention (CDC). The World Health Organization calls antibiotic resistance "an increasingly serious threat to global public health that requires action across all government sectors and society."

The Myth of the Harmless Antibiotic

WebMD/Medscape surveyed both consumers and clinicians to better understand how prescribing practices contribute to the problem. The consumer portion was completed on the WebMD Web site earlier this month by 1174 individuals, largely older, white, and female. To get the professional side, WebMD reached out to active users of Medscape and received email responses from 796 clinicians: 407 physicians, 200 nurse practitioners (NPs), and 189 physician assistants (PAs).

Although the vast majority of clinicians say they order antibiotics even when they have their doubts, only 12% do it most of the time. As a whole, these clinicians are uncertain prescribers about 21.5% of the time, with hardly any difference between physicians (20.2%) and NPs (20.3%). PAs are significantly higher at 25.3%.

For 53% of clinicians who prescribe antibiotics without absolute clinical certainty, being "certain enough" of the diagnosis is reason enough to put in the order. Forty-two percent say they are uncomfortable not treating a possible bacterial infection, and 31% say that the lab work to identify the bug may take too long to help an ill patient.

Other reasons exist for prescribing what are called empirical antibiotics, but the one most worrisome to infectious disease experts is the notion that the antibiotic "won't hurt if not needed."

"It's important for providers to know that prescribing antibiotics when they are not needed can cause patients harm," said Lauri Hicks, DO, medical director of the CDC's program to promote smart antibiotic prescribing, in an email interview with Medscape Medical News. "They put them at harm for allergic reactions, antibiotic resistant infections, and deadly diarrhea caused by the bacteria [Clostridium] difficile."

The diarrhea scenario sometimes occurs when a clinician immediately orders an antibiotic for a suspected case of acute bacterial rhinosinusitis, said Dr. McQuillen. By way of collateral damage, the antibiotic will knock out most of the bacteria in the gastrointestinal tract, but usually not C difficile, which mushrooms out of control and leads to diarrhea "which is almost like cholera," Dr. McQuillen told Medscape Medical News.

Patients seen at an early stage of an upper respiratory tract infection typically turn out to have a virus, said Dr. McQuillen. While such viral infectious often resolve in several days without medication, bacterial infections tend to persist and worsen. Accordingly, many physicians write postdated prescriptions for antibiotics in case the culprit is a bacterium, instructing the patient to fill it in 3 or 4 days if their symptoms intensify.

In the WebMD/Medscape survey, 49% of clinicians say they occasionally write such postdated prescriptions, and another 4% say they did it most of the time. In contrast, 47% report never writing postdated scripts, reflecting the prescribing community's mixed feelings about the practice.

"The rationale is sound, but whether it's effective, nobody knows," said infectious disease expert Brad Spellberg, MD, a recently appointed professor of medicine at the Keck School of Medicine of the University of Southern California in Los Angeles. "It's a clinician trying to make the best of the bad situation."

One potential problem with postdated antibiotic prescriptions, according to Dr. Spellberg and others, is that the patient may get them filled immediately and start treatment right then, contrary to the instructions. However, only 2% of patients with these prescriptions jump the gun like this, according to the WebMD/Medscape survey.

There's an even riskier possibility, though, with postdated prescriptions: errant self-diagnosis. Someone who initially presents with a respiratory infection, for example, may develop pneumonia but delay seeing a clinician because he or she misreads the problem and resorts to the postdated prescription, said Russell Steele, MD, head of pediatric infectious diseases at the Ochsner Health Center for Children in New Orleans, Louisiana.

"This is what happens," Dr. Steele told Medscape Medical News, "when patients treat themselves."

Clinicians Want Better Patient Ed Material, Better Tests

Clinicians have solutions for the pitfalls of antibiotic prescribing, and they shared them in the WebMD/Medscape survey.

Improved patient education materials (58%) top the list of answers chosen by clinicians who answered the question of what would make them a "better antimicrobial steward." A close second (54%) is better diagnostic tests to determine the cause of the infection.

Other solutions identified by clinicians include more readily available information on local patterns of antibiotic resistance (47%), more time to talk to patients and get needed tests done (37%), clearer clinical guidelines (36%), and advice on how to talk to patients who expect antibiotics.

Add life-long antibiotic training for clinicians to the list, said Dr. Steele. He pointed to a survey of house officers showing that interns and residents judiciously prescribe antibiotics in their academic medical center, "but once they're out in practice, they start sliding, and use antibiotics indiscriminately."

"Education wears off in 5 years," explained Dr. Steele. "Doctors need reminders."

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