Abstract & Commentary
Synopsis: Interferons to reduce inappropriate antibiotic prescribing are effective.
Source: Emmer CL, Besser RE. Combating antimicrobial resistance: Intervention programs to promote appropriate antibiotic use. Infect Med. 2002;19(4):160-173.
Antimicrobial resistance is still a major health threat and one which is only likely to worsen. Streptococcus pneumoniae is the leading cause of bacterial meningitis and bacteremia and is also the most common cause of community-acquired bacterial pneumonia and otitis media. It is also the bacterium undergoing the most rapid increase in resistance. Pneumococcal resistance has already effected the ability to treat common infections such as otitis media, sinusitis, and pneumonia and it is felt that the overuse of antibiotics for upper respiratory tract infections strongly contributes to this resistance. In fact, one study1 reviewed this prescribing of antibiotics for these conditions and determined that if antibiotics were prescribed appropriately, the number of prescriptions would be reduced by more than 40%.
Physicians believe they over-prescribe because of patient and parent expectations, although studies have shown that this perception is often inaccurate.2,3 In one of the studies,2 parents indicated they would be satisfied with the medical visit if physicians spent more time explaining the illness and treatment choices, rather than receiving a prescription. The obvious problem is the time pressure inherent in outpatient practices where more and more patients are seen in a fixed amount of time.
This has received the attention of the CDC and other groups, resulting in a widespread campaign to reduce the spread of resistance, improve physician-prescribing practices, and modify patient behavior. Their campaign is targeting 4 major areas:
- Characterizing current practices;
- Developing strategies and materials that will lead to changes in risk behaviors related to antimicrobial use;
- Forming partnerships to combine resources with those of collaborating organizations;
- Implementing and evaluation intervention programs.
One of the successful programs mentioned in this article was a large-scale intervention in rural Alaskan villages that was designed to reduce inappropriate prescribing for respiratory infections and thereby reduce penicillin-resistant S pneumoniae carriage.4 The program resulted in a 22% decrease in antibiotic prescriptions for children younger than 5 years of age and a 23% decrease in the number of visits for respiratory illnesses.
Another program was initiated at the Kaiser Permanente HMO in the Denver-Boulder area.5 This was a prospective, nonrandomized, controlled trial with 3 intervention groups. The full intervention group received household and office-based educational materials, brochures, kitchen magnets, and hands-on education. A partial intervention group received only office-based educational materials and the control group provided care without any supplied materials.
Only the full intervention group showed a decline in prescriptions for acute bronchitis, with a decrease of approximately 40%. Emmer and Besser emphasized the obvious need to market such programs at everyone in the chain to ensure effectiveness.
The third program was conducted with HMOs in Boston and Seattle and targeted pediatric respiratory infections.6 Similar to the Kaiser Permanente study, both physicians and patients were targeted with educational intervention. The rate of prescribing was reduced by 16% in this program.
The CDC is funding numerous research projects to determine the effect of interventions that promote appropriate antibiotic use. In 2001, they distributed federal funds to 19 sites and, over the next year, hope to have programs in every state. Table 1 and Table 2 are part of their recommendations for appropriate treatment. A number of useful practice tips were also included with this article and are shown in Table 3.
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Comment by Thomas G. Schleis, MS, RPh
The need to reduce antimicrobial resistance is well accepted within the infectious diseases community. Implementation of appropriate and successful programs to accomplish this has been a much more difficult challenge. While this article focuses primarily on inappropriate prescribing, the problem of increasing antimicrobial resistance is much broader and includes the need to ensure quality infection control policies for hospitals, clinics, and physician offices as well as programs designed to promote and monitor patient compliance. It is unfortunate that these other areas are not part of the CDC initiative. Additionally, while it is expected that drug resistance would be reduced by a reduction in inappropriate prescribing, the 3 studies that were described in this article did not look at the effect interventions had on antimicrobial resistance. This will be critical in future studies to determine the true effect of such programs in reducing antimicrobial resistance.
It was interesting to note that patients do not expect to receive a prescription as often as we may think they do. We all know of patients that will start on antibiotics at the first sign of a cold, but it would appear that they are in the minority. It may be possible that the higher costs for many antimicrobials and increased co-pays with most prescription plans are playing a role here as well. Taking all of that into account, clinician and patient education should have a much higher likelihood of success at this point in time.
What must not be forgotten are the other contributing causes of antimicrobial resistance. The use of inappropriate agents, poor infection control programs, patient non-compliance, formulary restriction, and other practices has been shown to foster antimicrobial resistance. Simply reducing the number of prescriptions will not be enough to solve this problem.
Dr. Schleis, Director of Pharmacy Services, Infections Limited Tacoma, WA, is Associate Editor of Infectious Disease Alert.
References
1. McCaig LF, Hughes JM. Trends in antimicrobial drug prescribing among office-based physicians in the United States. JAMA. 1995;273:214-219.
2. Barden LS, Dowell SF, Schwartz B, Lackey C. Current attitudes regarding use of antimicrobial agents: Results from physician’s and parents’ focus group discussions. Clin Pediatr. 1999;103:711-718.
3. Bauchner H, Pelton S, Klein J. Parents, physicians and antibiotic use. Pediatrics. 1999;103:395-401.
4. Petersen K, et al. Provider and community education decreases antimicrobial use and carriage of penicillin-resistant Streptococcus pneumoniae. In: Program and abstracts of the 37th Annual Meeting of the Infectious Diseases Society of America; November 18-21, 1999; Philadelphia. Abstract 62.
5. Gonzales R, et al. Decreasing antibiotic use in ambulatory practice: Impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. JAMA. 1999;281:1512-1519.
6. Finkelstein J, et al. Reducing antibiotic use by children: A randomized trial in 12 practices. Pediatrics. 2001;108:1-7.
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