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Antibiotic Resistance – The Problem and Solution

August 21, 2018

Written by Clay Smith

Spoon Feed
Most doctors and clinicians think someone else is the problem when it comes to antibiotic resistance and stewardship.  We are the problem.  And we are the solution.

Why does this matter?
Each year, 23,000 patients die in the US from resistant bacteria.  The outpatient setting is the largest driver of total antibiotic use.  A recent JAMA article found 30% of outpatient antibiotic use was inappropriate. Attention to shrewd, appropriate antibiotic use in the outpatient setting is key to patient safety and prolonging the usefulness of current drugs.

The clock is ticking…
What are the key tenets of stewardship?

  • Use only when necessary, i.e. bacterial.
  • Use the right drug, as narrow as possible, as brief as possible.

Who is prescribing?

  • “41% of all outpatient antibiotic prescriptions were written by family practice doctors, pediatricians, and internal medicine physicians.‍”
  • NPs and PAs are in second place.
  • The southern region of the U.S. is the worst.

What drugs are being used?

  • The top three drug classes were pencillins, macrolides, and cephalosporins.

What is driving prescribing?

  • Patient satisfaction and expectations may drive prescribing, although this may be a perceived expectation and not real.
  • Time pressure and diagnostic uncertainty play a role.
  • Finally, clinicians think others are causing the problem, not themselves.

How do we address this?  The CDC recommends commitment, action, tracking, and education.

  • Commitment – Public commitment letters signed by physicians and displayed in the exam room decreased prescribing by 20%.
  • Action – Written justification for prescribing is an example.
  • Tracking/Reporting – Provider antibiotic use and feedback is key to understanding prescribing patterns.  Health care systems and insurers can provide incentives for appropriate prescribing and targeted outreach to high prescribers.
  • Education – Patient and provider education is a must. 

Outpatient Antibiotic Use and the Need for Increased Antibiotic Stewardship Efforts.  Pediatrics. 2018 Jun;141(6). pii: e20174124. doi: 10.1542/peds.2017-4124.
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Another Spoonful
The CDC has excellent information and resources for outpatient antibiotic stewardship.

Reviewed by Thomas Davis

What are your thoughts?