1. 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

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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 °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

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

16. Downloadable Condition-Specific SBARS

17. Promoting Wise Antibiotic Use in Nursing Homes
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.

18. 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!