Novel Strategies for Reducing Unnecessary Antibiotic Use Christine E. Kistler, MD, MASc Associate Professor Department of Family Medicine University of North Carolina at Chapel Hill

Conflicts of Interest I have no financial conflicts of interest to disclose.

How do people make decisions? People are predictably irrational. The basic wiring of our brains makes us return to the same mistakes again and again. This work has been enunciated by Kahneman and Tversky, Dan Ariely, and others. People are susceptible to natural decision-making bias and the use of heuristics, through a dual process of decision-making Tversky and Kahneman. Judgment under Uncertainty: Heuristics and Biases. Science. 1974 Ariely, D. Predictably Irrational. Harper Collins. 2008

How are antibiotic prescribing decisions made? Factors Influencing Antibiotic Prescribing Decisions Clinical Situation Prescribing Decision Patients and Families Nursing Homes and Staff Health Care Providers This model summarizes the three factors, and suggests more a reciprocal relationship

How individual nurses and providers make antibiotic prescribing decisions? Nursing Home Characteristics: overall rates of prescribing, types of nurses, providers and patients, residents with dementia     Intuitive Thinking- quick judgments based on implicit beliefs or cognitive biases; influenced by heuristics such as attribute substitution for clinical symptoms of infection- increased during time pressures and unfamiliarity Nurse and Provider Usual Care Antibiotic-related decisions not based on evidence Evaluation of information to initiate a call/ antibiotic Preference Construction- “What matters most about this decision?” Decision to call provider/ decision to prescribe Clinical event requiring an antibiotic-related decision Rates of appropriate antibiotic prescribing and rates of sepsis and hospitalization   This model summarizes the three factors, and suggests more a reciprocal relationship Enhanced Decision- Making Deliberative Thinking- slow, analytical judgments that explicitly weigh options, e.g., perceived balance of likelihood of an infection versus other source of symptoms; may include emotional or cognitive values but weighed against the evidence for an active infection. Evidence-based antibiotic prescribing DUAL PROCESS THEORY OF DECISION MAKING

Stumbling Blocks Complexity Stumbling Blocks Clinical picture doesn’t fit pattern Lack of full information Social and emotional pressures Cognitive Stumbling Blocks Premature closure of clinical reasoning Misattribution bias Risk aversion Islam R, et al. BMC Med Info & Dec Mak 2015

Current Research We conducted several chart-based studies of nursing home infections as part of a larger dissemination trial of an antibiotic stewardship project in 31 nursing homes in North Carolina. We randomly sampled charts and abstracted relevant data. Urinary tract infection (UTI) study: 260 participants with antibiotic prescriptions for UTI Respiratory study: 226 participants with chest radiographs Skin and soft tissue infection (SSTI) study: 161 participants with antibiotic prescriptions for SSTI Kistler CE J Am Geriatr Soc. 2017 Brown M J Am Med Dir Assoc 2016 Feldstein D J Am Dir Assoc. 2017

Urinary Tract Infections Common heuristics and stumbling blocks: Anchoring bias: “Any symptom” can indicate a UTI Choice-supportive bias: Initial use of broad spectrum antibiotics (typically fluoroquinolone) and no narrowing or discontinuation of antibiotics in the face of cultures Confirmation bias: +LE must be an infection Context effect: Overlying long-prescribing duration Of 260 cases, 60% had documented signs/ symptoms of the presenting illness and 15% met the Loeb criteria. Acute mental status change was the most commonly documented sign/symptom (24%). Kistler CE, et al. J Am Geriatr Soc. 2017

Urinary Tract Infections Enhanced Decision Making Techniques: Use a structured evaluation and know prescribing criteria: SBAR, etc. Watchful waiting and periodic re-evaluation (once cultures result): await culture results and de- prescribe Use guidelines and first line agents: TMP/SMX, Nitrofurantoin, Fosfomycin, or pivmecillinam (and NOT fluoroquniolones) Only prescribe for 3-5 days Kistler CE, et al. J Am Geriatr Soc. 2017

Respiratory Tract Infections Common heuristics and stumbling blocks: Illusion of validity: symptoms/signs of cough and upper respiratory infections often seen as part of pneumonia Probability neglect: discount the prevalence of other common chest conditions: COPD, arthritis, CHF Loss aversion in the face of uncertain radiographic findings 118 (52%) identified a very low likelihood of pneumonia, 67 (30%) indicated that pneumonia was present or highly likely, and the remaining 41 (18%) used a variety of terms to describe uncertainty regarding the presence of pneumonia. NH medical providers tended to treat ambiguous chest x-ray reports similarly to positive x-ray reports, prescribing antibiotic therapy to 71% of patients with ambiguous reports and 78% of positive reports. Also notable is that 40 (34%) of the 118 patients with a very low likelihood of pneumonia based on chest x-ray results were prescribed antibiotics, the majority of whom failed to meet criteria for a clinical diagnosis of pneumonia or chronic obstructive pulmonary disease exacerbation. Of our 226 study cases, only 19 had a temperature greater than 37.9°C (100.0°F), and only six had a respiratory rate greater than 25 breaths per minute, yet 121 received antibiotics Brown M, et al. J Am Med Dir Assoc 2016

Respiratory Tract Infections Enhanced Decision Making Techniques: Use a structured evaluation and know when to prescribe and when not to: a head cold or chest cold do not need antibiotics COPD is best treated with steroids CHF is best treated with diuretics Deprescribe in the face of a low-risk chest x-ray Be tolerant of ambiguity and don’t over-value technology vital signs and physical exam have been shown to be 95% sensitive in diagnosing pneumonia, so in the setting of normal vitals and physical exam, neither an x-ray nor an antibiotic should be necessary if close follow-up is available.   Brown M, et al. J Am Med Dir Assoc 2016

Skin and Soft Tissue Infections Common heuristics and stumbling blocks: Misattribution of signs/symptoms: redness and ulcers Sunk Cost Commitment: Use broad-spectrum antibiotics where narrow-spectrum may suffice, e.g. doxycline (and NOT cephalosporin), aka, an assumption of MRSA Our results indicate considerable nonadherence to guidelines regarding the type, route, and duration of antibiotic therapy. Cellulitis was treated most often with doxycycline rather than the recommended first-line penicillin-based therapies,14 ;  19 as the most common etiology of cellulitis in the community and in NHs is Streptococcus, not Staphylococcus. 19 ;  20 Other agents approved as first-line therapy in penicillin-allergic patients, such as clindamycin,14 were also prescribed less often than doxycycline for cellulitis. Further, the duration of therapy tended to be longer than recommended. Mild cellulitis, defined as erythema, warmth, and swelling, without fever or other signs of a systemic infection, should be treated with 5 days of antibiotics14; however, in our data, the mean treatment course for cellulitis was 9.3 days, despite the fact that only one patient had a documented fever, which potentially indicated a more severe infection. Feldstein D, et al. J Am Dir Assoc. 2017

Skin and Soft Tissue Infections Enhanced Decision Making Techniques: Mark the wound and follow over time Treat superficial infections (e.g. impetigo, mild wound infections) with topical antibiotics Treat small abscesses with I&D (though recent NEJM showed benefit with oral abx treatment) Treat for only 5-7 days and know your antibiogram : consider Cephalexin or Penicillin, or Clindamycin No wonder they are considered “missing in action” Feldstein D, et al. J Am Dir Assoc. 2017

Conclusions: Improve Your Decision-Making Know the evidence-based signs and symptoms of infections: Fever is 1.2°F above baseline (usually around 99 °F -99.5 °F) Avoid premature closure of the diagnostic and treatment pathways: use all options Use watchful waiting and re-evaluation Prescribe first-line agents and the lowest appropriate duration Sloane PD, et al. N C Med J. 2016 Sloane PD, et al. J Am Geriatr Soc. 2014

Implications We are only human! We need help overcoming our own natural bias. De-biasing techniques and systems-based interventions can help!

Downloadable Condition-Specific SBARS

Promoting Wise Antibiotic Use in Nursing Homes https://nursinghomeinfections.unc.edu/ Promoting Wise Antibiotic Use in Nursing Homes Home Medical Providers Nurses Nursing Assistants Residents and Families Contact Us Why is this important? Facts about Antibiotic Overuse in Nursing Homes Adverse effects such as clostridium difficile infection are increasing. Between 25-75% prescriptions do not meet clinical guidelines. Few new antibiotics are being developed; so we need to preserve what we have. Health and well-being of nursing home residents is the goal of care. Inappropriate overuse of antibiotics leads to serious complications. We need to change our thinking from “just in case” to “only when needed” What you can do Nurses  Click here to complete our 10-module antibiotic stewardship training course and obtain up to 2 hours of CE credit. Medical providers Click here to download our ”Infection Management in Nursing Homes” audiocasts, available for CME credit. Residents and Families Click here to download our educational brochure and fact sheet about antibiotic use in nursing homes.

Thanks to the UNC Department of Family Medicine and our IMAS team: Thank You! Thanks to the UNC Department of Family Medicine and our IMAS team: Sheryl Zimmerman, PhD Phil Sloane, MD, MPH Mallory Brown, MD Diane Feldstein, MD Kimberly Ward, BA David Reed, PhD David Weber, MD Kezia Scales, PhD And all of our nursing homes and medical providers!