July 15, 2022
Antibiotic Aware – Beware of Inappropriate Care
“Data from the National Center for Health Statistics indicate that, in recent years, approximately 75% of all outpatient antimicrobial prescriptions have been issued for 5 conditions – otitis media, sinusitis, bronchitis, pharyngitis and upper respiratory tract infections” – JAMA 1995. (1)
“Among the approximately 100 million antibiotic scripts written every year for acute respiratory tract infections, half are prescribed inappropriately” – Journal of Primary Care Community Health 2020. (2)
“There is never any indication for antibiotic treatment of the common cold…” as indicated in an article from American Family Physician authored in 1998. (3). Still many physicians/providers continue to prescribe antibiotics inappropriately for these past 27 years.
In 2013, the CDC recognized antibiotic resistance as a major threat to the country’s health. The leading cause of these resistant infections is due to the unnecessary prescribing of antibiotics when not medically indicated. Since an estimated 60% of all US antibiotic prescriptions are written and received in the outpatient setting, the outpatient environment is a good place to practice antibiotic stewardship. (4)
Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. There is a clinician checklist for essential elements of an outpatient antibiotic stewardship program, a simple program you can start in your office. The core elements are:
- Commitment – is what transforms actions like utilization of guidelines and provider/patient education into success (a reduction of antibiotics prescribed for acute respiratory illness).
- Action – implement a practice to improve antibiotic prescribing like utilization of an acute respiratory infection protocol.
- Tracking and reporting – review your HEDIS CI measures for avoidance of antibiotic treatment of acute respiratory illness.
- Education – provide educational material to patients regarding the use and misuse of antibiotic medications.
The American College of Physicians (2016) (5) and the CDC (2017) have released new clinical guidelines on antibiotic use in adults with acute respiratory tract infections. The purpose of these guidelines and antibiotic stewardship is to develop a change in the practice pattern – when the history and physical findings suggest an acute respiratory tract infection of a viral etiology, please do not prescribe an antibiotic.
We have enclosed referral material for your review and use:
- An upper respiratory infection treatment protocol example from the Journal of Primary Care Community Health 2020.
- Antibiotic educational material for patients from the CDC and Choosing Wisely.
- American College of Physicians clinical guidelines on antibiotic use in adults with acute respiratory tract illness.
- Development and Implementation of an Upper Respiratory Infection Treatment Protocol in a Primary Care Health Clinic. Journal of Primary Care & Community Health, vol. 11, First Published November 2, 2020. https://journals.sagepub.com/doi/full/10.1177/2150132720966811
2a) Antibiotic Use Questions and Answers from the Centers for Disease Control and
Prevention. https://www.cdc.gov/antibiotic-use/q-a.html
2b) CDC Advises Patients and Their Families to Be Antibiotics Aware https://www.cdc.gov/antibiotic-use/index.html
CDC advises patients and their families to Be Antibiotics Aware
The Centers for Disease Control and Prevention (CDC) is advising patients and their families to use antibiotics only when necessary to further reduce antibiotic resistance, the spread of superbugs, and protect patients from side effects from antibiotics. During U.S. Antibiotic Awareness Week and beyond, CDC promotes Be Antibiotics Aware, an educational effort to raise awareness about the importance of safe antibiotic use. The Be Antibiotics Aware initiative educates the public about when antibiotics are needed, when they are not, how to take antibiotics appropriately, and potential side effects of antibiotics. CDC encourages patients and families to:
- Get the facts about antibiotics. Antibiotics do NOT work on viruses, such as those that cause colds, flu, or COVID-19. When antibiotics aren’t needed, they won’t help you, and the side effects could still cause harm.
- Ask your healthcare professional about the most appropriate treatment for you or your loved ones’ illness. If antibiotics are not needed, ask about the best way to feel better while your body fights off the virus.
- If you need antibiotics, take them exactly as prescribed. Talk with your healthcare professional if you have any questions about your antibiotics.
- Talk with your healthcare professional if you develop any side effects, especially severe diarrhea, since that could be a Clostridioides difficile (or C. diff) infection, which needs to be treated immediately.
- Do your best to stay healthy and keep others healthy by cleaning hands by washing with soap and water for at least 20 seconds or using a hand sanitizer that contains at least 60% alcohol; covering your mouth and nose with a tissue when you cough or sneeze; staying home when sick; and getting recommended vaccines, such as the flu vaccine.
CDC encourages patients and families to use the educational resources and learn more about Be Antibiotics Aware by visiting: https://www.cdc.gov/antibiotic-use/index.html.
2c) Choosing Wisely: Using Choosing Wisely Tools to Empower Patients; pg 25-26. Colds, flu and other respiratory illnesses in adults: When you need antibiotics – and when you don’t. https://www.choosingwisely.org/wp-content/uploads/2017/01/Using-Choosing-Wisely-Tools-to-Empower-Patients.pdf
3) Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention. https://www.acpjournals.org/doi/full/10.7326/M15-1840
Acute respiratory tract infection (ARTI) is the most common reason for antibiotic prescription in adults. Antibiotics are often inappropriately prescribed for patients with ARTI. This article presents best practices for antibiotic use in healthy adults (those without chronic lung disease or immunocompromising conditions) presenting with ARTI.
High-Value Care Advice 1:
Clinicians should not perform testing or initiate antibiotic therapy in patients with bronchitis unless pneumonia is suspected.
High-Value Care Advice 2:
Clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis (for example, persistent fevers, anterior cervical adenitis, and tonsillopharyngeal exudates or other appropriate combination of symptoms) by rapid antigen detection test and/or culture for group A Streptococcus. Clinicians should treat patients with antibiotics only if they have confirmed streptococcal pharyngitis.
High-Value Care Advice 3:
Clinicians should reserve antibiotic treatment for acute rhinosinusitis for patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (>39 °C) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or onset of worsening symptoms following a typical viral illness that lasted 5 days that was initially improving (double sickening).
High-Value Care Advice 4:
Clinicians should not prescribe antibiotics for patients with the common cold.
References:
- Trends in Antimicrobial Drug Prescribing Among Office-based Physicians in the US, JAMA 1995, McCaig LF, Hughes JM.
- Development and Implementation of an Upper Respiratory Infection Treatment Protocol in a Primary Care Health Clinic, Journal of Primary Care Community Health, pub 11/2 2020, Christina Alpin-Snider.
- Appropriate Use of Antibiotics for Upper Respiratory Infections in Children: Part II Cough, Pharyngitis and the Common Cold, American Family Physician, 1998, Scott F. Dowell MD, MPH.
- Improving Antibiotic Prescribing for Acute Respiratory Illnesses, University of St. Augustine, 4/11/2021, Laurinia K. Hunter RN, MSN.
- Appropriate Antibiotic Use for Acute Respiratory Tract Illness in Adults, 2016, Annals of Internal Medicine, Harris AM, High Value Care Task Force of the American College of Physicians and for the CDC.