Intervention Studies

Since it might be difficult to distinguish between bacterial and viral infections, physicians must be aware of elements that might help them elaborate a presumptive diagnosis and decide which patients might benefit from antibiotic therapy. The knowledge of the natural history of some infectious diseases and whether antibiotics will affect the course of the illness must be reinforced since viral and many common bacterial infections are self-limited and there is no additional benefit from antimicrobial treatment. For example, antibiotic therapy has little effect on the course of acute bronchitis caused by Mycoplasma pneumoniae or Chlamydophila pneumoniae (Gonzales and Sande 2000). Due to the complexity of this problem, the medical community has adopted a number of interventions directed to physicians, nurses, pharmacist, and the public.

In 1995, the CDC launched the Campaign for Appropriate Antibiotic Use in the Community (Emmer and Besser 2002). This campaign targeted the five respiratory conditions that account for more than 75% of all office-based prescriptions for all ages combined: otitis media, sinusitis, pharyngitis, bronchitis, and the common cold. In collaboration with the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians, the CDC developed six principles for appropriate use of antibiotics for pediatric upper respiratory tract infections (Dowell et al. 1998). They also produced health education materials for both parents and providers to promote appropriate use of antibiotics use. The objective of these materials was to stimulate discussion between patients and providers and change the current social perspective toward antibiotic drugs (Table 28.1).

Acute otitis media (AOM) is one of the most common infections for which antibiotics are prescribed in the pediatric population, resulting in more than 20 million antibiotic prescriptions and a cost of more than $3 billion each year (Powers 2007). The prescription rate of antimicrobials for this infection varies between 31% in the Netherlands and 98% in the United States, Australia, and New Zealand (Froom et al. 1990). In 2004, the AAP released its new guidelines

Table 28.1 CDC tips for practicing physicians When parents ask for antibiotics to treat viral infections:

  • Explain that unnecessary use of antibiotics can be harmful
  • Share the facts
  • Build cooperation and trust
  • Encourage active management of the illness
  • Be confident with the recommendation to use alternative treatments

Create an office environment to promote the reduction in antibiotic use: •Talk about antibiotic use at 4- and 12-month-old child visits

  • Start the educational process in the waiting room
  • Involve office personnel in the educational process
  • Use the CDC/AAP pamphlets and principles to support your treatment decisions for the management of OMA including a subset of patients that might be carefully observed with no antimicrobial treatment. All these efforts to improve the clinical practice are obscured by the lack of continuous medical education. It is not unusual that these kinds of guidelines are totally unknown to general physicians, and even to infectious diseases specialists (Ibia et al. 2003).

Vernacchio et al. (2007) compared physicians' practice with the AAP acute otitis media guideline's recommendations among 299 physicians (77% pediatricians). Although the "watch-and-wait" option for low-risk children was considered to be acceptable by 83%, it was only used in 15% of AOM cases during the past 3 months. Parental reluctance was the most common reason for rejecting the observation option. Also, this group found that the antibiotic suggestions for treating OMA are not being followed. Only 57% reported the use of high-dose amoxicillin (80-90 mg/kg daily) for treatment of non-severe AOM, 13% used high-dose amoxicillin plus clavulanate for severe AOM, 43% used high-dose amoxicillin plus clavulanate for patients with AOM who had not responded to initial high-dose amoxicillin, and 17% used intramuscular ceftriaxone for patients who had not responded to high-dose amoxicillin plus clavulanate.

It is important to emphasize that all these educational and intervention strategies must be implemented in different social environments, in both a national and a regional basis. It is important to use local data when developing these programs, since the epidemiologic and social conditions might differ between communities.

Our modern lifestyle has caused that both physicians and patients have less time to discuss important issues, such as the true therapeutic activity of antibiotics, their limitations, and the risks of their inappropriate use. It has been observed that physicians who spend less time with their patients are likely to prescribe more antibiotics than those who spend more time with their patients (Hutchinson and Foley 1999).

On the other hand, several studies have analyzed the correlation between patients' degree of satisfaction and their treatment expectations; the results show that most patients would be satisfied with a non-antibiotic treatment as long as their physician explained thoroughly their diseases, treatment options, and the reasons for the decision to withhold antibiotics (Colgan and Powers 2001; Ong et al. 2007; Barden et al. 1998).

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