Q&A: Interventions to improve outpatient antibiotic prescribing

Katherine Fleming-Dutra, MD
Katherine Fleming-Dutra

There is a growing body of literature regarding interventions to improve antibiotic use and prescribing in health care settings.

In a review published in The BMJ, Katherine Fleming-Dutra, MD, deputy director of the CDC’s Office of Antibiotic Stewardship, and colleagues summarized drivers behind inappropriate prescribing in the outpatient setting and assessed interventions to improve antibiotic use in this setting.

Inappropriate antibiotic use is widespread and contributes to the growing rise of antibiotic resistance, which causes approximately 23,000 deaths annually in the United States, according to the CDC. Antimicrobial stewardship programs and other interventions can improve antibiotic use, and infectious diseases experts are seen as a critical resource for sparing these life-saving drugs.

Infectious Disease News spoke with Fleming-Dutra about the review and what it showed. – by Marley Ghizzone

What was the motivation behind this review?

At least 30% of outpatient antibiotic prescriptions written in doctors’ offices and emergency departments in the U.S. are unnecessary, and even when antibiotics are necessary, antibiotic selection and duration are often inappropriate. Using antibiotics only when needed, and using the right drug, dose and duration at the right time is a matter of patient safety. There has been growing awareness of the importance of improving antibiotic use in the outpatient setting. In 2016, CDC published the Core Elements of Outpatient Antibiotic Stewardship, which provide a framework for implementing stewardship interventions in outpatient settings. The motivation for this review was to summarize recent evidence regarding the drivers of inappropriate outpatient antibiotic prescribing and interventions to improve antibiotic use in outpatient settings.

Where does unnecessary overprescribing occur the most frequently?

In the U.S., all outpatient settings and regions have opportunities to improve antibiotic prescribing. Antibiotic prescribing rates are higher in the South compared with other regions, although reasons for these geographic differences are still not fully understood. Additionally, outpatient antibiotic prescribing rates for children have been declining, but rates among adults have not changed. Although there is additional work to do to improve antibiotic use among children, we need to make sure that efforts to improve antibiotic use are reaching adult patients and clinicians who care for adults.

What are the psychosocial factors that influence antibiotic prescribing?

Social and emotional factors, including lack of self-awareness or accountability, fear of complications, perceived patient expectations for antibiotics, time constraints, habit and fatigue, often drive inappropriate antibiotic prescribing. Thus, interventions that address these drivers of inappropriate use are often the most effective.

What are some interventions that have improved antibiotic prescribing?

Many interventions have been shown to improve antibiotic use. The effects of behavioral-science-based interventions, such as commitment posters, peer comparison, accountable justification and communication training are especially promising.

Commitment posters are posters hung in exam rooms with a commitment from the clinician to patients pledging to use antibiotics appropriately and nudge clinicians to prescribe antibiotics appropriately.

In peer comparison interventions, data on a clinician’s antibiotic prescribing are fed back to them and are accompanied by a comparison between their antibiotic prescribing patterns and the patterns of their peers.

Accountable justification interventions require clinicians to enter a text justification for prescribing an antibiotic for a condition for which antibiotics are not indicated.

Communication skills training empowers clinicians to communicate effectively with patients when antibiotics are not needed in a way that maintains patient satisfaction.

The effect of outpatient antibiotic stewardship interventions may be greater when multiple, complementary intervention strategies are used.

What is the take - home message for clinicians?

Inappropriate antibiotic use puts your patients at unnecessary risk. Social and emotional factors, such as concern for patient satisfaction or fear of misdiagnosis, may drive clinicians to prescribe antibiotics inappropriately. Being aware of these often unconscious social and emotional factors and implementing interventions that address these drivers of inappropriate use can help us all improve antibiotic use and keep patients safe.

References:

CDC. Antibiotic prescribing and use in doctor’s offices. https://www.cdc.gov/antibiotic-use/community/programs-measurement/measuring-antibiotic-prescribing.html. Accessed November 13, 2018.

CDC. Antibiotic/antimicrobial resistance (AR / AMR). https://www.cdc.gov/drugresistance/about.html. Accessed November 13, 2018.

CDC. Antibiotic prescribing and use in hospitals and long-term care. https://www.cdc.gov/antibiotic-use/healthcare/evidence.html. Accessed November 13, 2018.

King LM, et al. BMJ. 2018;doi:10.1136/bmj.k3047.

Disclosure: Fleming-Dutra reports no relevant financial disclosures.

Katherine Fleming-Dutra, MD
Katherine Fleming-Dutra

There is a growing body of literature regarding interventions to improve antibiotic use and prescribing in health care settings.

In a review published in The BMJ, Katherine Fleming-Dutra, MD, deputy director of the CDC’s Office of Antibiotic Stewardship, and colleagues summarized drivers behind inappropriate prescribing in the outpatient setting and assessed interventions to improve antibiotic use in this setting.

Inappropriate antibiotic use is widespread and contributes to the growing rise of antibiotic resistance, which causes approximately 23,000 deaths annually in the United States, according to the CDC. Antimicrobial stewardship programs and other interventions can improve antibiotic use, and infectious diseases experts are seen as a critical resource for sparing these life-saving drugs.

Infectious Disease News spoke with Fleming-Dutra about the review and what it showed. – by Marley Ghizzone

What was the motivation behind this review?

At least 30% of outpatient antibiotic prescriptions written in doctors’ offices and emergency departments in the U.S. are unnecessary, and even when antibiotics are necessary, antibiotic selection and duration are often inappropriate. Using antibiotics only when needed, and using the right drug, dose and duration at the right time is a matter of patient safety. There has been growing awareness of the importance of improving antibiotic use in the outpatient setting. In 2016, CDC published the Core Elements of Outpatient Antibiotic Stewardship, which provide a framework for implementing stewardship interventions in outpatient settings. The motivation for this review was to summarize recent evidence regarding the drivers of inappropriate outpatient antibiotic prescribing and interventions to improve antibiotic use in outpatient settings.

Where does unnecessary overprescribing occur the most frequently?

In the U.S., all outpatient settings and regions have opportunities to improve antibiotic prescribing. Antibiotic prescribing rates are higher in the South compared with other regions, although reasons for these geographic differences are still not fully understood. Additionally, outpatient antibiotic prescribing rates for children have been declining, but rates among adults have not changed. Although there is additional work to do to improve antibiotic use among children, we need to make sure that efforts to improve antibiotic use are reaching adult patients and clinicians who care for adults.

What are the psychosocial factors that influence antibiotic prescribing?

Social and emotional factors, including lack of self-awareness or accountability, fear of complications, perceived patient expectations for antibiotics, time constraints, habit and fatigue, often drive inappropriate antibiotic prescribing. Thus, interventions that address these drivers of inappropriate use are often the most effective.

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What are some interventions that have improved antibiotic prescribing?

Many interventions have been shown to improve antibiotic use. The effects of behavioral-science-based interventions, such as commitment posters, peer comparison, accountable justification and communication training are especially promising.

Commitment posters are posters hung in exam rooms with a commitment from the clinician to patients pledging to use antibiotics appropriately and nudge clinicians to prescribe antibiotics appropriately.

In peer comparison interventions, data on a clinician’s antibiotic prescribing are fed back to them and are accompanied by a comparison between their antibiotic prescribing patterns and the patterns of their peers.

Accountable justification interventions require clinicians to enter a text justification for prescribing an antibiotic for a condition for which antibiotics are not indicated.

Communication skills training empowers clinicians to communicate effectively with patients when antibiotics are not needed in a way that maintains patient satisfaction.

The effect of outpatient antibiotic stewardship interventions may be greater when multiple, complementary intervention strategies are used.

What is the take - home message for clinicians?

Inappropriate antibiotic use puts your patients at unnecessary risk. Social and emotional factors, such as concern for patient satisfaction or fear of misdiagnosis, may drive clinicians to prescribe antibiotics inappropriately. Being aware of these often unconscious social and emotional factors and implementing interventions that address these drivers of inappropriate use can help us all improve antibiotic use and keep patients safe.

References:

CDC. Antibiotic prescribing and use in doctor’s offices. https://www.cdc.gov/antibiotic-use/community/programs-measurement/measuring-antibiotic-prescribing.html. Accessed November 13, 2018.

CDC. Antibiotic/antimicrobial resistance (AR / AMR). https://www.cdc.gov/drugresistance/about.html. Accessed November 13, 2018.

CDC. Antibiotic prescribing and use in hospitals and long-term care. https://www.cdc.gov/antibiotic-use/healthcare/evidence.html. Accessed November 13, 2018.

King LM, et al. BMJ. 2018;doi:10.1136/bmj.k3047.

Disclosure: Fleming-Dutra reports no relevant financial disclosures.