COMMENTARY

How Can We Turn the Tide Against Inappropriate Antibiotic Prescriptions?

What Providers, Policy-Makers, and Patients Need to Know

Brad Spellberg, MD; John G. Bartlett, MD; David N. Gilbert, MD

Disclosures

August 18, 2014

In This Article

Overuse Them, and Lose Them

In 1945, Alexander Fleming (Figure), the discoverer of penicillin, warned the public that doctors were abusing penicillin by using it in patients who did not need it. He said, "In such cases, the thoughtless person playing with penicillin is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism. I hope this evil can be averted."[1]

Figure. Alexander Fleming. Image from Wikimedia Commons.

Fleming knew that antibiotics were different from all other types of drugs: They are the only drugs that undergo transmissible loss of efficacy over time. The more we use them, the more we lose them. In contrast to other drugs, antibiotics are a public trust. Every individual's use of antibiotics affects the efficacy of antibiotics for everyone else.

So why have we been unable to stop rampant overuse and abuse of these drugs? Why do physicians and other providers overprescribe them, and why do patients continue to ask for an antibiotic prescription? Why do educational campaigns not work? Why have we failed to heed 7 decades of very loud and generally agreed-upon public warnings, dating back to Fleming himself?

A recent survey conducted by Medscape (Too Many Antibiotics! Patients and Prescribers Speak Up) sheds considerable light on these questions.More than 1100 patients and nearly 800 providers (including physicians, nurse practitioners, and physician assistants) responded to the survey. The providers generally confirmed that they regularly prescribe antibiotics when they are not absolutely certain that antibiotics are necessary. This was true across all specialties surveyed.

When providers were asked why they prescribed antibiotics even when they were not certain the antibiotics were necessary, answers included the following:

Prescriptions were written when the providers were "certain enough" that antibiotics were needed (53%);

Discomfort with the possibility that an infection could be bacterial (42%);

The patient is ill, and the lab work will take too long (31%);

The infection did not appear to be viral or fungal (30%);

The patient did not want or could not afford a test (19%); and

Malpractice concerns (15%).

The critical commonality of all of these answers is that what really drives inappropriate prescriptions is fear -- fear of the unknown, or fear of being wrong.

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