1. Antibiotic Stewardship
LeAnn Holmes

2. Balancing best practice and patient satisfaction
Clinical Pathways
Patient Education
The truth about patient satisfaction
URI etiology
Negative effects of antibiotics – resistance and side effects
Negotiation Strategies
Patient education
Symptom management
Reassurance
Manage expectations
f/u plan
Delayed RX
Giving In
Holding Firm

3. Clinical Pathways Acute bronchitis Acute rhinosinusitis
Jenkins et al., American Journal of Medicine, 2013

4. Are patients really only satisfied with an antibiotic prescription?
Patient Satisfaction
Are patients really only satisfied with an antibiotic prescription?

5. The Truth About Patient Satisfaction
Several studies show that patient satisfaction with the care received for respiratory ailments is more closely related to how much time a provider spends explaining the illness, rather than simply writing a prescription for an antibiotic.
Hamm, Hicks & Bemben, Journal of Family Practice, 1996; McFarlane et al., British Medical Journal, 1997; Mainous et al., Journal of Family Practice, 1997

6. The Truth About Patient Satisfaction
There was no change in patient satisfaction or the number of return office visits in a primary care practice where antibiotic prescribing for uncomplicated acute bronchitis had been reduced by 50 percent through provider and patient educational intervention
Gonzales, et al., Effective Clinical Practice, 2001

7. Acute Bronchitis and Rhinosinusitis
How often are bacteria involved?

8. Acute bronchitis and rhinosinusitis - etiology
American College of Physicians and CDC both state unequivocally that pertussis is the only indication for antibacterial agents in the treatment of acute bronchitis
Bacterial sinusitis also occurs uncommonly, in only 0.5 to 2 percent of cases, usually as a complication of viral sinusitis
UpToDate, 2013
Clinical guidelines do not support antibiotic treatment of otherwise healthy adults with acute bronchitis due to the viral origin of acute bronchitis.
Antibiotics are prescribed far too often for sinus infections: only 2 to 10 percent are caused by bacteria, requiring treatment with antibiotics
IDSA Guidelines, 2012

9. Antibiotic Overuse Outcomes
Is there really any harm from giving antibiotics for viral URIs?

10. Antibiotic Resistance
Antibiotic resistance has been called one of the world’s most pressing public health problems.
The number of bacteria resistant to antibiotics has increased in the last decade.
Misuse of antibiotics jeopardizes the usefulness of essential drugs. Decreasing inappropriate antibiotic use is the best way to control resistance.
CDC, 2013

11. Antibiotic Resistance
New resistance mechanisms have emerged, making the latest generation of antibiotics virtually ineffective
Antibiotic resistance has become a serious problem for treatment of gonorrhoea (caused by Neisseria gonorrhoeae), involving even "last-line" oral cephalosporins, and is increasing in prevalence worldwide
Extensively drug-resistant TB (XDR-TB, defined as MDR-TB plus resistance to any fluoroquinolone and any second-line injectable drug) has been identified in 84 countries globally.
Antimicrobial resistance threatens a return to the pre- antibiotic era
World Health Organization, 2013

13. Antibiotic Scarcity
Antibiotics are the most important tool we have to combat life-threatening bacterial diseases.
New and safe antibiotics are not easy to discover and develop.
Since it will be many years before new antibiotics are available to treat some resistant infections, we need to improve the use of antibiotics that are currently available.

14. Outpatient Antibiotic Use
Each year, tens of millions of antibiotics are prescribed unnecessarily for viral upper-respiratory infections.
Antibiotics were prescribed in 68% of acute respiratory tract visits – and of those, 80% were unnecessary according to CDC guidelines.
Antibiotic use in primary care is associated with antibiotic resistance at the individual patient level.
The presence of antibiotic-resistant bacteria is greatest during the month following a patient’s antibiotic use and may persist for up to 12 months.

16. Antibiotic Side Effects
Adverse events from antibiotics cause an estimated 142,000 emergency department visits per year in the United States, according to a study published in the September 15, 2008 issue of Clinical Infectious Diseases.

17. Antibiotic Side Effects
Rash
Diarrhea
Abdominal pain
Yeast infections
Taste alterations
Photosensitivity
Headache
Allergic Reactions
Serum Sickness
Liver toxicity
Renal toxicity
Ototoxicity
C. difficile

18. Negotiation Strategies
Patient Education, Symptom Management, Reassurance, Managing Expectations, F/U plan, Delayed RX

19. Patient Education Viral etiology of most sinusitis and all bronchitis
Virus = antibiotic ineffectiveness
Antibiotic won’t lessen duration of symptoms, severity of symptoms, or contagiousness
Antibiotics have side effects
Overuse of antibiotics leads to antibiotic resistance

20. Patient Education
Would you take blood pressure medicine if you didn’t have high blood pressure?
What if taking blood pressure medicine now when you don’t have high blood pressure would mean that it might not work for you in the future if you did develop high blood pressure?

21. Symptom Management Recommend symptomatic relief.
Often, patients request an antibiotic because they think it will help them feel better.
Rest
Fluids
Humidifier
OTC medications

22. Reassurance
Explain to the patient what to expect over the next few days. This can help them feel reassured and empowered. For example, explain that a cough may persist for several days.
Share normal findings as you go through your exam. For example, let patients know that their lungs sound clear, or that you aren't seeing inflammation in their ear. This reassures the patient or parent that the illness may not be as severe as they thought and may make them more open to the idea that they don't need an antibiotic.

23. Managing Expectations
Antibiotics taken for viral infections will not:
Cure the infection
Keep others from catching the illness
Improve symptoms

24. F/U plan
Give patients a plan of action in case symptoms do change or become more severe -- including that you will reevaluate their situation and prescribe antibiotics if it becomes medically appropriate

25. Delayed RX
Recommend that patients wait hours before filling prescription
Offer to call in RX if patient phones back with continued symptoms

26. Five Ways Patients Pressure Providers for RX
Candidate diagnosis
Implied candidate diagnosis
Portraying severity of illness
Appealing to life-world circumstances
Previous use of antibiotics
Scott et al., The Journal of Family Practice, 2001

27. Practice!

28. Patient Scenarios Candidate diagnosis
“I’m sure I have bronchitis. I have been coughing for a week.”

29. Patient Scenarios Implied candidate diagnosis
“My throat hurts, it’s red and it has white spots”

30. Patient Scenarios Portraying severity of illness
“I just can’t shake it. I feel like the back of my throat has raw hamburger hanging in it. This has lasted 4 days and it has been getting worse today.”

31. Patient Scenario Appealing to life-world circumstance
“I have a cough and congestion for the last 4 days and I don’t have time to be sick right now, I have finals.”

32. Patient Scenario Previous positive experience with antibiotics
“I had sinus congestion and pain last month, the symptoms got better after a course of antibiotics but now they are back again.”

33. Holding Firm

34. CDC Commentary “Don’t Give in and Give Those Antibiotics”
CDC Video

35. Giving In

36. Appropriate Antibiotic Prescribing
Follow clinical pathways for appropriate antibiotic choice and duration
Patient education
Taking RX correctly
Side effects
F/U if not improving

37. Questions