Reduction of Unnecessary Antimicrobials

The Consensus Group identified inappropriate prescribing to be the major influence on developing resistance and increasing costs, and called for antibiotic therapy to be limited to infections in which bacteria are the predominant cause. While this principle certainly seems self-evident, it is one to which adherence seems very difficult. The reasons for over-prescribing antibiotics are multifactorial. Patients may consult clinicians, expecting an antibiotic to be prescribed for an acute respiratory infection for which the etiology is most likely viral; as a result, clinicians may feel pressured to write antibiotic prescriptions to satisfy patients and to maintain good doctor-patient relationships. Receiving an antibiotic reinforces the patients' perception that antibiotics are warranted in similar situations. Thus, patients may continue to consult clinicians each time similar symptoms occur, expecting that antibiotics are again needed. Clinicians also may prescribe antibiotics as a rapid means of treating patients' symptoms rather than taking the time to educate patients that antibiotics are not always necessary, especially if a viral infection is suspected. However, clinicians should recognize that patient satisfaction is not compromised by the absence of an antibiotic prescription, provided patients understand the reasons. Hamm et al. demonstrated that patient satisfaction was influenced by patient perceptions that the clinician spent enough time discussing the illness and by patient knowledge about the treatment choice (28). Moreover, clinicians may prescribe antibiotics as part of a defensive approach to avoid the potential sequelae of not prescribing for patients with bacterial infection.

Unfortunately, most patients and many clinicians view "unnecessary" antibiotic prescribing as at worst a neutral intervention (i.e., cannot harm, but may help). It is imperative patients understand this is not the case. In fact, the unnecessary use of antibacterials has several possible harmful effects in addition to selection of resistance, such as increased cost and exposure to unnecessary adverse reactions. Decreasing excess antibiotic use is an important strategy for combating the increase in community-acquired antibiotic-resistant infections. Several studies have documented a benefit of combining physician intervention and patient education that has resulted in decreased use of antimicrobials and reduction of resistance (Table 1) (29-34).

Correct diagnosis to differentiate viral from bacterial infection is a key to limiting unnecessary antimicrobials. Unfortunately, there is a lack of rapidly available, cost-effective diagnostic tests, which reliably differentiate self-limiting, viral from bacterial infection. However, practice guidelines can offer pragmatic criteria for better antimicrobial usage. For example, restriction of antibiotic therapy in otitis media to those children with acute bacterial disease and avoidance in otitis media with effusion could reduce unnecessary use by two-thirds (35). The Consensus Group concluded that antibiotics that maximize bacterial eradication improve both short- and long-term clinical outcomes, reduce overall costs— particularly those relating to treatment failure and consequent hospital admis-sion—and assist in the minimization of resistance emergence and dissemination. They believe that a radical re-evaluation of RTI therapy, incorporating these principles, is long overdue, to guide the decisions of both individuals and formulary and guideline committees more accurately.

In addition to reducing antimicrobial usage, more effective use of pneumo-coccal vaccines offers promise to decreasing the burden of this pathogen and resistance in both pediatric and adult populations. Preliminary data indicate significant reductions in hospitalization and mortality from use of these vaccines, suggesting an associated reduced necessity of prescribing (36). However, of primary importance is the continued promotion of principles of judicious antibiotic when they are warranted.

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