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Late-career physicians more likely to prescribe prolonged antibiotic courses

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January 8, 2019

More than one-third of the antibiotic courses prescribed by family physicians during a year-long study in Ontario, Canada, were for durations that exceeded 8 days, and researchers found that late-career physicians were more likely to prescribe prolonged courses of antibiotic treatment than their counterparts.

Writing in Clinical Infectious Diseases, Cesar I. Fernandez-Lazaro, PharmD, PhD, MPH, visiting research fellow at Public Health Ontario and an adjunct professor at the University of Salamanca, Spain, and colleagues noted that antimicrobial stewardship programs have aimed to reduce antimicrobial resistance by “optimizing antibiotic use,” including using them for the appropriate duration.

According to Fernandez-Lazaro and colleagues, most antibiotic prescriptions are written in the outpatient setting, and family physicians prescribe the highest volume, making them a potential target for antimicrobial stewardship activities.

“Promoting shorter courses of antibiotics is a potential stewardship strategy that is likely safe and acceptable to physicians, and reduces selective pressure by limiting the exposure time to antibiotics,” they wrote. “Understanding patterns of variability in prescribed antibiotic durations will support the utility of an intervention and help define subgroups of physicians that are most in need of practice improvement.”

Study findings published last year in Open Forum Infectious Diseases showed that physicians who are male, older than age 40 years, located in the southern United States and part of a small practice prescribe more antibiotics compared with their peers by specialty. A more recent study published in BMC Family Practice found that when both the patient and doctor are women, antibiotic prescribing decreases.

Between March 1, 2016, and Feb. 28, 2017, Fernandez-Lazaro and colleagues conducted a retrospective cohort analysis of family physicians in Ontario, Canada. More than 8 days of therapy was considered a prolonged course of antibiotics and the primary outcome was the proportion of prescriptions for prolonged antibiotic courses.

The study included 10,616 family physicians who prescribed a total of 5.6 million antibiotic courses. According to Fernandez-Lazaro and colleagues, the proportion of prolonged antibiotic courses was substantially varied among physicians. They found that a greater use of prolonged antibiotic courses was significantly associated with physicians in a later stage of their career, in rural locations and at larger pediatric practices. Furthermore, when compared with early-career physicians, late-career (adjusted OR = 1.48; 95% CI, 1.38-1.58) and mid-career (aOR = 1.25; 95% CI, 1.16-1.34) physicians were more likely to prescribe prolonged courses, they reported.

The most common treatment length selected by physicians during the study period was 7 to 8 days, and 35.4% of courses exceeded 8 days, according to the findings.

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“Future research should evaluate the optimal community-based interventions to improve prescribing behaviors,” Fernandez-Lazaro and colleagues wrote.

In a related editorial, Brad Spellberg, MD, chief medical officer at the Los Angeles County-University of Southern California Medical Center and professor of clinical medicine and associate dean for clinical affairs at USC’s Keck School of Medicine, and Noah Wald-Dicker, MD, clinical instructor of medicine at USC’s Keck School of Medicine, said that when it comes to antibiotic therapy, physicians should “adopt the mantra” that “shorter is better.”

In a previously published study, Spellberg and colleagues reported that an “expected practice” intervention focused on shorter antibiotic courses substantially reduced antibiotic therapy duration at a downtown Los Angeles hospital with no change in mortality.

In the editorial, Spellberg and Wald-Dicker suggested it is “time to retire Constantine unit-based antibiotic durations.”

“The modern week has 7 days in it because the Roman Emperor Constantine the Great said so in 321 CE,” they wrote. “Had Constantine chosen a 4-day week, providers would likely routinely prescribe 4-8 day courses of therapy.”

They said educating clinicians about appropriate antibiotic prescribing is important, but so is addressing the fear that drives poor prescribing habits. – by Marley Ghizzone

Disclosures : Spellberg reports consulting for Acurx Pharmaceuticals, Alexion Pharmaceuticals, Paratek Pharmaceuticals, Shionogi, Synthetic Biologics and TheoremDx in the past 12 months, and owning equity in BioAIM Scientific, Exbaq, Motif Bio, MycoMed and Synthetic Biologics. The authors of the study and Wald-Dicker report no relevant financial disclosures.

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