Educating Patients on Unnecessary Antibiotics

Personalizing Potential Harm Aids Patient Understanding

Benjamin J. Miller, BS; Kathryn A. Carson, ScM; Sara Keller, MD, MPH, MSPH


J Am Board Fam Med. 2020;33(6):969-977. 

In This Article

Abstract and Introduction


Introduction: Antibiotic resistance is a public health emergency fueled by inappropriate antibiotic use. Public education campaigns often focus on global antibiotic resistance or societal harm of antibiotic misuse. There has been little research into what messages have the greatest impact on patient preferences for nonindicated antibiotics in ambulatory clinics.

Methods: We administered a survey at a primary care clinic in Baltimore, MD. A total of 250 participants rated 18 statements about potential harm from antibiotics on how each statement changed their likelihood to request antibiotics for an upper respiratory tract infection. Statements focused on potential harm either to the individual, to contacts of the individual, to society, and related or not to antibiotic resistance. Initial and final likelihood of requesting antibiotics was measured, and the impact of the statements in each category were compared using general linear models and Wilcoxon rank sum or Kruskal-Wallis tests.

Results: All statements decreased patient likelihood to request antibiotics. Statements about harm to the individual or contacts of the individual decreased participant likelihood to request antibiotics significantly more than statements about societal harm of antibiotic misuse. Statements not discussing antibiotic resistance decreased participant likelihood of requesting antibiotics significantly more than statements discussing antibiotic resistance. Overall likelihood to request antibiotics decreased after the survey by 2.2 points on an 11-point Likert scale (P < .001).

Conclusion: When dissuading patients from requesting nonindicated antibiotics, providers and public health campaigns should focus on potential harm of nonindicated antibiotics to the individual rather than societal harm or antibiotic resistance


While progress has been made in antibiotic stewardship, antibiotic resistance is increasing at an alarming rate. Antibiotic-resistant organisms cause more than 2.8 million infections and 35,000 deaths per year in the United States.[1] In 2015, approximately 47 million antibiotic courses were prescribed for infections not needing antibiotics.[1]

Many interventions aimed at improving antibiotic use in ambulatory settings have focused on clinician behavior. However, clinicians cite perceived patient desire for antibiotics, impact of patient satisfaction scores, time demands, or lack of patient understanding about negative impacts of harmful antibiotic use as several reasons they may prescribe antibiotics for conditions where they are not indicated, such as for upper respiratory infections (URIs).[2,3] Studies have shown that when physicians perceive that patients expect antibiotics, the physician is 10 times more likely to prescribe an antibiotic.[2,4]

To decrease unnecessary antibiotic prescriptions, clinicians may benefit from an improved understanding of how to communicate with patients about antibiotics. Patients may not appreciate the negative impact of taking nonindicated antibiotics,[3] and it is unclear what information clinicians could provide to patients that has the greatest impact on patient desire for antibiotics. There is limited data on the effectiveness of specific language meant to dissuade patients' desire and requests for antibiotics for nonindicated conditions. While public health campaigns have often focused on global antibiotic resistance, little research has directly compared this approach with more personal messaging.[5,6]

The purpose of this study was to determine which statements most deter requests for antibiotics for nonindicated conditions by effectively communicating the risks associated with antibiotics. We hypothesized that statements about potential harm to the individual patient or contacts of the individual patient from unnecessary antibiotics would decrease participant desire for antibiotics more than statements about societal harm from nonindicated antibiotics.