Lindee Abe, APRN
Antimicrobial stewardship is a term I have heard used more and more in my career. There are now programs that specifically address antibiotic overuse and misuse. As healthcare professionals, we are part of the solution to reduce antibiotic overuse and misuse to also decrease antibiotic resistance.
In the United States, 41,900 deaths were caused by antimicrobial-resistant infections in 2019. While antibiotic resistance is a global problem, according to the World Health Organization, this highlights that it is also a problem in the United States. We must all work to decrease inappropriate antibiotic prescribing and also reduce the number of antimicrobial-resistant organisms.
The Evidence
Two studies specifically highlighted that the practice setting of urgent care was found to have a higher rate of inappropriate antibiotic prescriptions. Incze et al. and Palms et al. found that 30 to 45% of antibiotic prescriptions were inappropriate for the diagnosis in the urgent care setting. That means one-third to one-half of the antibiotic prescriptions aren’t necessary. Specifically, most inappropriate antibiotic prescriptions are for upper respiratory illnesses. A few years ago, one urgent care I worked in had antibiotic prescriptions to diagnose upper respiratory illness as a target for our bonuses. We were graded on how many antibiotics were written for the diagnosis of upper respiratory infections, with the goal being zero. This did increase providers’ awareness initially, but then we started to notice some providers would find alternative diagnoses that would not flag the chart review for appropriateness of antibiotics, like sinusitis or bronchitis.
Reducing Iatrogenic Disease with Stewardship
The primary reason for improving our prescribing practices is to reduce the amount of antimicrobial resistance and improve patient outcomes. The World Health Organization also has an annual conference in November to address antimicrobial resistance. Adverse reactions of antimicrobials include hypersensitivity reactions, gastrointestinal disturbances, and also Clostridium difficile. There is also the risk of antimicrobial resistance already seen in pneumonia, tuberculosis, gonorrhea, and salmonella. If we are left unable to treat these infections due to resistance, they can result in higher morbidity and mortality rates.
Reducing Unnecessary Antibiotic Treatment
This reference slide is taken from our Clinical Toolkit – Click here to learn more about CME from Provider Practice Essentials
One area of focus is several common diagnoses associated with antibiotics that may not require antibiotics for treatment. The first condition is sinusitis. Most immunocompetent patients will improve within two weeks without antibiotics (as much as 70-80%). For this reason, it is recommended that patients be observed for an initial seven-day period to see if they improve without antibiotic treatment. If the patient fails to improve during that time or has worsening symptoms, starting the patient on antibiotics is appropriate.
Otitis media is another area where antibiotics are frequently prescribed, but there have been some changes regarding when to start antibiotics. Children and adults can be observed for 48-72 hours to see if otitis media improves without antibiotics. If there is no improvement at 48- 72 hours, antibiotics can be initiated. Several criteria would also exclude a patient from observation and warrant using antibiotics upon diagnosis: age < 6 months, toxic appearance, immunocompromised, and also craniofacial abnormalities (e.g., cleft palate).
Acute bronchitis is another diagnosis I have noticed antibiotics prescribed to treat. When I first started practicing, it was fairly common for azithromycin to be prescribed to treat bronchitis. However, it is now recommended not to treat bronchitis with antibiotics because it most frequently has a viral etiology.
Managing Patient Expectations
Even when we know prescribing antibiotics is not indicated for a patient, it is hard to say no to patients when they are adamant that they need an antibiotic. The key is to make an appropriate medical decision and have the patient understand and accept that position. I have found that listening to the patient and acknowledging that even if it is a viral illness, I still understand that they are miserable. Therefore, I also try to give patients a realistic time frame (e.g., most viral illnesses last 5-7 days) so that they can have a time frame of the illness in mind. Frequently, patients present several days into their illness, and if they know they only have a day or two left before improving, they can handle the symptoms better. I also discuss over-the-counter treatments that can be effective and write them down specifically on the discharge instructions.
Several resources are available to help communicate when antibiotics aren’t necessary and keep the conversation with the patient positive. The Centers for Disease Control has a handout that can be placed in patient rooms to address when a disease is likely due to a virus or bacteria. This can help patients to understand why certain diagnoses do not require the use of antibiotics. The Center for Disease Control also has patient handouts that can be printed on topics like why antibiotics aren’t always needed, treatment for the common cold, and bronchitis. The handouts are available in English and also Spanish. I like to print these out during cold and flu season to have at the desk to give to patients with their discharge instructions.
Summary
Antimicrobial resistance is a growing problem worldwide. As healthcare professionals, we can change the number of antimicrobial-resistant organisms through appropriate antibiotic prescribing. Refraining from using antibiotics unless clinically indicated helps our patients and addresses the global disease burden.
References:
File TM. Acute bronchitis in adults. Post TW, ed. UpToDate. UpToDate Inc. Accessed October 19, 2023. https://www.uptodate.com/contents/acute-bronchitis-in-adults
Gillies, Burgner, D. P., Ivancic, L., Nassar, N., Miller, J. E., Sullivan, S. G., Todd, I. M. F., Pearson, S., Schaffer, A. L., & Zoega, H. (2022). Changes in antibiotic prescribing following COVID‐19 restrictions: Lessons for post‐pandemic antibiotic stewardship. British Journal of Clinical Pharmacology, 88(3), 1143–1151. https://doi.org/10.1111/bcp.15000
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Institute for Health Metrics and Evaluation. (n.d.). The burden of antimicrobial resistance (AMR) in the United States of America. https://www.healthdata.org
Mohsen, S., Dickinson, J. A., & Somayaji, R. (2020). Update on the adverse effects of antimicrobial therapies in community practice. Canadian family physician Medecin de famille canadien, 66(9), 651–659.
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Simeoni, Saragosa, M., Laur, C., Desveaux, L., Schwartz, K., & Ivers, N. (2022). Coping with “the grey area” of antibiotic prescribing: a theory-informed qualitative study exploring family physician perspectives on antibiotic prescribing. BMC Family Practice, 23(1), 1– 188. https://doi.org/10.1186/s12875-022-01806-8
Tonazzi, Prenovost, L., & Scheuermann, S. (2022). Delayed antibiotic prescribing to reduce antibiotic use: an urgent care practice change. BMJ Open Quality, 11(1), 1-5. https://doi.org/10.1136/bmjoq-2021-001513
World Health Organization. (n.d.). World AMR Awareness Week. https://www.who.int/campaigns/world-amr-awareness-week/2023
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