Edward A Belongiaa Rita Mangione Smithb Mary Jo Knoblocha

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aMarshfield Clinic Research Foundation, Marshfield, Wise., and bDepartment of Pediatrics, University of Washington, Seattle, Wash., USA

Abstract

Acute respiratory tract infections account for the majority of outpatient antimicrobial use, and physicians continue to prescribe these drugs inappropriately for cough, cold and flu symptoms despite lack of efficacy for viral illness. There have been modest reductions in antimicrobial prescribing for respiratory illness in recent years, but inappropriate use of broad-spectrum antimicrobials has increased. Multiple factors contribute to excessive and inappropriate antimicrobial prescribing, including patient expectations, time pressure and diagnostic uncertainty. Physicians perceive that patients will be more satisfied with an antimicrobial prescription, despite evidence that satisfaction with the physician and the office visit is largely determined by other factors. Market forces also contribute to excessive antimicrobial use in primary care.

Changing physician behavior is challenging, and traditional approaches, such as continuing medical education conferences and materials, have little impact. Evidence suggests that multifac-eted interventions are more effective than single interventions, particularly if they involve personal or small group educational sessions ('academic detailing'). In general, it appears to be easier to influence decisions regarding the type of antimicrobial and duration of treatment as opposed to withholding antimicrobials entirely. Focusing patient communication on symptom alleviation can reduce patient opposition to non-antibiotic treatment recommendations and improve satisfaction. A contingency plan is helpful for patients who question non-antimicrobial treatment plans.

Appropriate antimicrobial use is increasingly viewed as a quality improvement issue, and performance measures have been established for pediatric upper respiratory infection and adult bronchitis. There is growing interest in pay for performance, but little is known regarding the relationship between physician reimbursement and appropriate antimicrobial prescribing. Clinical decision support tools are also promising but require further investigation. Over the next decade, we must acquire a better understanding of macro-level factors that contribute to inappropriate antimicrobial use, including social/cultural health beliefs and practices, physician reimbursement practices, pharmaceutical marketing, and organizational policies regarding return-to-work or child care following illness. Health care systems, pharmaceutical companies, medical schools, residency programs and managed care organizations must all take responsibility and work col-laboratively to produce lasting change in antimicrobial prescribing habits.

Copyright © 2010 S. Karger AG, Basel

In 1995, the writer Nicholas Wade predicted the day when the best medical advice would be: '(1) Don't get sick; (2) if you do, don't go to the hospital, and (3) if you must go to the hospital, don't take antibiotics.' [1]. The same advice is appropriate today for patients seen in the outpatient setting for acute respiratory illness. Multiple studies have demonstrated a strong and consistent link between antimicrobial use and the development of resistance at individual and population levels [2-7]. However, it is less clear how a reduction in outpatient antimicrobial use will affect the occurrence of resistant infections. The population dynamics of antimicrobial resistance are complex and poorly understood, but models of chromosomal or plasmid-mediated resistance in commensal flora suggest that resistance may persist as long as antimicrobial-resistant bacteria exist and individuals continue to receive antimicrobial treatment [8, 9]. The complete withdrawal of antimicrobial exposure might yield dramatic reductions in resistance over a period of years, but such a goal is not justifiable (or ethical) because there will always be patients with legitimate need for therapy. Despite these uncertainties, judicious use of antimicrobials may at least slow the spread of resistant pathogens, improve the quality of health care and help prevent adverse events.

Acute respiratory tract infections (ARIs) account for the majority of outpatient antimicrobial use, and many physicians prescribe these drugs inappropriately for cough, cold and flu symptoms despite their proven lack of efficacy for viral illness. A report by the Institute of Medicine in 1998 addressed this problem, noting that physicians and patients have not received adequate information about the appropriate use of antimicrobials and the risks of excessive use [10]. Multiple factors contribute to excessive and inappropriate antimicrobial prescribing for acute respiratory illness. Physicians and patients have different perceptions about antimicrobial use, and patient expectations influence physician prescribing behavior [11, 12]. It appears to be easier to influence decisions regarding antimicrobial selection and treatment duration than to persuade physicians to withhold antimicrobials entirely. Writing a prescription is a strategy to quickly end an office visit, an outcome that is important in an era of increasing patient volume and declining reimbursement. However, evidence indicates that the time savings are minimal, and that pediatric visits may even take longer when antimicrobials are prescribed [13-15]. Physicians perceive that patients will be more satisfied with an antimicrobial prescription, despite evidence that patient satisfaction is largely determined by factors other than receipt of an antimicrobial [16-18]. Diagnostic uncertainty also contributes to the pressure for antimicrobial use, since many ARIs are diagnosed and managed without laboratory confirmation, and the clinical manifestations of bacterial and viral infections often overlap. For example, duration of illness is often used as a surrogate marker for bacterial sinusitis, and adult guidelines support treatment of rhinosinusitis symptoms lasting more than 7 days with maxillary pain or tenderness [19]. Rhinovirus infections last a median of 9-11 days [20], and many patients receive antimicrobials unnecessarily based on the 7-day threshold.

Many physicians in outpatient practice have limited experience with severe manifestations of antimicrobial resistance, and may perceive the threat to be low [21]. These physicians may consider the balance between public health and individual patient care to be weighted more toward provision of antimicrobials for patients with an ARI, even when they recognize that the expected benefit is low. Past experience reinforces this behavior because many older practitioners acquired their antimicrobial prescribing habits during an era when resistance appeared to be a problem only in the hospital setting. Physician focus groups held by the Centers for Disease Control and Prevention (CDC) revealed the overarching sentiment that antimicrobial resistance was more of a national problem than a local problem [22]. Patient expectations (real or perceived) also tend to reinforce this behavior. Education is lacking among patients and the public, and there is little understanding of the difference between viral and bacterial infections [23-26].

Market forces also contribute to excessive antimicrobial use. Direct-to-consumer advertising is designed to promote antimicrobial selection based on taste, dosing interval and other factors unrelated to clinical efficacy. Pharmaceutical drug detailing emphasizes newer, broad-spectrum antimicrobials over generic, narrow-spectrum agents, and clinicians receive conflicting messages from marketing materials and practice guidelines [27].

Over the past decade, a variety of programs have been implemented at national, state and local levels to improve outpatient antimicrobial prescribing. Some have focused on educating or motivating clinicians to reduce antimicrobial use, others have focused on patient and public education, and several have developed multi-faceted interventions that target clinicians, patients and the general public. Which of these approaches is most effective, and what can we recommend to the leaders of health care organizations and policy makers concerned about quality of care and rising health care costs? In this chapter, we discuss the impact of interventions to improve outpatient antimicrobial prescribing, identify gaps in knowledge, and suggest approaches for clinicians and health care organizations who want an evidence-based approach to appropriate antimicrobial use.

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