Resistance Factor: Physicians Change Prescribing Practices as Antimicrobial-Resistant Bacteria Spread

In the past decade, bacteria have become more resistant to antibiotic treatment, causing the Centers for Disease Control and Prevention (CDC) to name antimicrobial resistant bacteria as one of its top concerns. (1) Methicillin-resistant Staphylococcus aureus (MSRA) currently plagues hospitals. (2) Cases of community associated MRSA (CA-MRSA) have emerged in areas of close contact, including correctional facilities, child care centers, and gyms. (3) MRSA infections led to four pediatric deaths in Minnesota and North Dakota. (4)

Even more ominous, since 1997 there have been 16 recorded cases in the United States of antibiotic resistance to Vancomycin — the antibiotic of last resort. (5) Fortunately, both Vancomycin-resistant Staphylococcus aureus (VRSA) and Vancomycin-intermediate Staphylococcus aureus (VISA) have so far been susceptible to other FDA-approved drugs. (6) The emergence of a bacterium resistant to all existing antibiotics may be inevitable.

CAUSE AND EFFECT

When penicillin was first mass-produced in the 1940s, antibiotics were perceived as an "almost magical medicine, capable of curing almost any disease." (7) Instead, the result has been described as "The use and misuse of large quantities of antibiotics are the driving force behind the worldwide resistance phenomenon." (7)

Antibiotic over prescription and inappropriate prescription remain a problem. Between 20% and 50% of antibiotic prescriptions in community settings are believed to be unnecessary. (8) Though a 1999 study showed that antibiotics were unnecessary to treat upper respiratory infections (URI), the medications were still prescribed for more than 40% of the URIs in the United States. (9)

Nevertheless, a more positive trend is emerging. A study published in the Journal of General Internal Medicine showed that between 1995 and 2002, "there was a significant decline in the proportion of outpatient visits that resulted in antibiotics prescribed for U.S. adults." The study also showed that the decline was in proportion to prescriptions written for acute respiratory infection which are "overwhelmingly viral in origin and do not respond to antibiotic therapy." (10)

Along with the decline in the number of antibiotic prescriptions comes a new challenge for physicians — changing their patients' overconfidence in the power of antibiotics. Often patients expect, even demand, antibiotics. Many patients come to health care offices assuming that antibiotics will cure any ailment.

Patients' persistence often gets them the antibiotics that they want. According to a study published in Pediatrics, physicians are 30% to 45% more likely to prescribe antibiotics if they perceive patients want them. In the same study, 71% of family physicians and 53% of pediatricians said they would immediately prescribe antibiotics for an infant exhibiting symptoms of a URI for only one day. For older children, 50% of the family physicians and 24% of pediatricians would prescribe antibiotics. (11)

Patient expectations may also account for the reason that antibiotics are prescribed for viral infections. Researchers found that nearly one-third of patients diagnosed with a cold receive antibiotics. (12)

"Patients want antibiotics and physicians continue to prescribe them in situations where antibiotics may be withheld for many reasons. The act of prescribing an antibiotic has social and medical implications. From the patient's point of view, the prescribing of an antibiotic validates that the patient does have an illness, that a diagnosis has been made and that the illness is amenable to treatment. The fact that there is a 'cure' for their problem reassures them that the illness is not serious." (13)

While physicians may try to resist patients' demands for antibiotics, there are several reasons they may prescribe them anyway. Physicians must weigh a number of factors when diagnosing an infection. They may fear the infection will turn out to be bacterial, and prescribe an antibiotic for peace of mind. If the infection turns out to be bacterial, the prescription was appropriate. If not, the physician can then diagnose the problem having ruled out a bacterial infection. (14) Physicians may also fear a lawsuit if a misdiagnosed viral infection turns out to be disastrous bacterial infection. In the patient's eyes, a simple antibiotic prescription may have avoided an uncomfortable and costly illness. (14)

GUIDELINES TO PREVENT BACTERIAL RESISTANCE

The CDC has implemented guidelines to prevent resistance to antibiotics and change patient attitudes. It has undertaken the task of advising local and state health agencies, health care facilities, and laboratories on identifying resistant bacteria and educating patients on risks. (15) In this effort, the CDC has promoted programs that encourage the appropriate use of antibiotics. One program, the Campaign to Prevent Antimicrobial Resistance, centers on four strategies physicians can use.

1. "Prevent infections. Encourage your staff and patients to receive regular influenza and pneumococcal vaccinations. Prevent the conditions that lead to infection. Use IV devices only when essential and with minimal exposure.
2. Diagnose and treat infections effectively. Consult infectious disease experts for complicated infections and potential outbreaks.
3. Use antibiotics wisely. Know when to say "no" to patients. Stop antibiotic treatment when cultures are negative and infection is unlikely.
4. Prevent the transmission of infections. Isolate the pathogen and break the chain of contagion. Cover your mouth when you cough or sneeze. Insist your employees do the same. Promote wellness among your staff. Insist they stay home when they are sick." (15)

According to an article published in the American Family Physician, education is crucial to changing patient attitudes. The authors recommend that physicians take time to, "explain when antibiotic use is appropriate and when it is not." (8) The Alliance for the Prudent Use of Antibiotics states that it may only take "two or three minutes" to educate a patient on why antibiotics are or are not an appropriate therapeutic option. (16)

Recent studies show that the amount of time spent educating patients, and not necessarily the receipt of an antibiotic prescription, correlate with patient satisfaction. "One survey indicated that while 65 percent of patients expected to receive an antibiotic for treatment of a URI, there was no correlation between patient satisfaction and receipt of an antibiotic prescription. Instead, patient satisfaction correlated highest with the quality of the physician-patient interaction. Results from focus groups indicate that patients would be satisfied if an antibiotic was not prescribed as long as the physician explained the reasons for this decision." (13)

Resources are available to help physicians educate patients. The CDC offers brochures that, in clear language, explain to patients the difference between viruses and bacteria and why antibiotics are not effective against viral infections. Most importantly, they explain that the misuse of antibiotics can endanger the patient and others in the community. Brochures and other materials are available at the CDC Get Smart web site. Physicians can also order fact sheets, laminated cards, notepads, and posters from the CDC web site, www.cdc.gov.

At the 1999 Summit of Antimicrobial Resistance, researchers developed a plan to educate physicians and the public about antibiotic-resistant bacteria. For physicians, they recommend:

• "Do not accommodate patients' or parents' demands for unneeded antibiotics.
• Clarify to patients and parents that antibiotics put them at risk for a multi-resistant bacterium.
• Educate patients and parents on the prudent use of antibiotics, including the importance of completing the full course of prescribed antibiotics.
• Educate patients and parents on preventative measures such as vaccines, frequent hand washing, and proper hygiene.
• Make use of all diagnostic methods to identify the proper pathogen." (16)

The CDC also offers guidelines for the appropriate use of antibiotics in adults. The American College of Physicians follows the CDC guidelines, described below.

Upper respiratory infections

1. "The diagnosis of nonspecific upper respiratory tract infections or acute rhinopharyngitis should be used to denote acute infection that is typically viral in origin, and in which sinus, pharyngeal, and lower airway symptoms, although frequently present, are not prominent.
2. Antibiotic treatment of nonspecific URI in adults does not enhance illness resolution or prevent complications, and is therefore not recommended.
3. Purulent secretions in the nares and throat (commonly reported and seen in patients with an uncomplicated, upper respiratory tract infection) neither predict bacterial infection nor benefit from antibiotic treatment.
4. Throat cultures are not recommended for the routine primary evaluation of adults with pharyngitis, nor for the confirmation of negative rapid antigen tests. Throat cultures may be indicated as part of investigations of outbreaks of GABHS [Group A beta hemolytic streptococcus] disease, for monitoring the development and spread of antibiotic resistance, or when pathogens such as gonococcus are being considered.
5. The preferred antibiotic for treatment of acute GABHS pharyngitis is penicillin, or erythromycin for a penicillin-allergic patient." (17)

Bronchitis

1. "The evaluation of adults with an acute cough illness, or with presumptive diagnosis of uncomplicated acute bronchitis, should focus on ruling out pneumonia. In the healthy, non-elderly adult, pneumonia is uncommon in the absence of vital sign abnormalities or asymmetrical lung sounds, and chest radiography is usually not indicated. In patients with cough lasting 3 weeks or longer, chest radiography is warranted in the absence of other known causes.
2. Routine antibiotic treatment of uncomplicated bronchitis is not recommended, regardless of duration of cough. In the unusual circumstance when pertussis infection is suspected, a diagnostic test should be performed and antimicrobial therapy initiated.
3. Patient satisfaction with care for acute bronchitis is most dependent on the doctor-patient communication rather than on whether or not an antibiotic is prescribed." (17)

PEDIATRIC PATIENTS

The most common reason for prescribing antibiotics in children is acute otitis media (AOM). (18) To prevent the over-prescription of antibiotics in children, the American Academy of Pediatrics (AAP) has published the following guidelines for AOM:

1. "careful diagnosis;
2. use of narrow-spectrum antimicrobial agents; and
3. the initial observation of nonsevere cases of acute otitis media in selected children, including children up to 2 years old with mild ear pain, without high fever, and for whom the physician believes that prompt follow-up is assured should symptoms worsen." (18)

A watchful waiting policy for AOM has been adopted by the AAP and the American Academy of Family Physicians (AAFP). (19) Watchful waiting involves deferring antibiotic treatment for up to 72 hours. During this time, analgesics are prescribed. If the infection is not bacterial, the patient's condition will likely improve on its own. If the patient's condition persists or worsens, the physician can prescribe antibiotics. (18) The AAP and AAFP guidelines are described below.

1. "Accurately diagnose AOM and differentiate it from otitis media with effusion (OME), which requires different management.
2. Relieve pain, especially in the first 24 hours, with ibuprofen or acetaminophen.
3. Minimize antibiotic side effects by giving parents of select children the option of fighting the infection on their own for 48-72 hours, then starting antibiotics if they do not improve.
4. Prescribe initial antibiotics for children who are likely to benefit the most from treatment.
5. Encourage families to prevent AOM by reducing risk factors. For babies and infants these include breastfeeding for at least six months, avoiding 'bottle propping,' and eliminating exposure to passive tobacco smoke.
6. If antibiotic treatment is agreed upon, amoxicillin is recommended for most children." (19)

As a follow up to the recommendation for AOM, the AAFP, AAP, and the American Academy of Otolaryngology published recommendations for otitis media with effusion (OME). OME is also a common diagnosis in children, with 2 million cases in the U.S. per year. (20) The guidelines state:

• "Physicians should manage children with OME who are not at risk with 'watchful waiting' for at least three months before recommending other treatment.
• Antibiotics and corticosteroids are not recommended for routine management of OME." (20)

LOOKING AHEAD

Adherence to guidelines for the prudent use of antibiotics has proven to be effective. A Finnish study published in the New England Journal of Medicine demonstrated that erythromycin resistance among group A streptococcidecreased from 16.5 to 8.6 percent over four years during implementation of national guidelines to limit the use of erythromycin. (21) "Other studies in the United States show that decreased use of antibiotics for prophylaxis and treatment correlated with decreasing rates of colonization with resistant organisms." (13)

SOURCES

1. Centers for Disease Control and Prevention. Get Smart: Know When Antibiotics Work. Available at www.cdc.gov/drugresistance/community/ anitbiotic-resistance.htm. Accessed December 28, 2006.
2. Enright MC, Robinson DA, Randle G, Feil E, Grundmann H, Spratt BG. The evolutionary history of methicillin-resistant Staphylococcus aureus (MRSA). Proceedings of the National Academy of Sciences of the United States of America. May 28, 2002. 99;11:7687-7692.
3. Gorwitz RJ, Jernigan DB, Powers JH, Jernigan JA. Strategies for Clinical Management of MRSA in the Community. March 2006. Available at www.cdc.gov. Accessed June 12, 2006.
4. Four Pediatric Deaths from CA—MSRA S. Aureus. - Minnesota and North Dakota, 1997-99. MMWR. August 20, 1999. 48;32:707-710.
5. Staphylococcus aureus Resistant to Vancomycin — United States, 2002. MMWR. July 5, 2002. 51;26:565-567.
6. Centers for Disease Control and Prevention. Frequently Asked Question About VISA/VRSA. Available at www.cdc.gov/ncidod/dhqp/ar_visavrsa_FAQ.html. Accessed June 12, 2006.
7. Radyowijati A, Haak H. Determinants of Antimicrobial Use in the Developing World. Child Health Research Project Special Report. February 2002. 5;1.
8. Hooton TH, Levy SB. Antimicrobial Resistance: A plan of action for community practice. Am Fam Physician. March 15, 2001. 63;6:1087-1097.
9. Rutschmann OT. Antibiotics for Upper Respiratory Tract Infections in Ambulatory Practice in the United States, 1997-1999: Does Physician Specialty Matter? J Am Board Fam Med. May-June 2004. 17;3:196-200.
10. Roumie CL. Trends in Antibiotic Prescribing for Adults in the United States — 1995 to 2002. J Gen Intern Med. August 2005. 20;8:697-702.
11. Mangione-Smith R, McGlynn EA, Elliott MN, Krogstad P. The Relationship Between Perceived Parental Expectations and Pediatrician Antimicrobial Prescribing Behavior. Pediatrics April 1999. 103;4:711-718.
12. Colgan R, Powers JH. Appropriate Antimicrobial Prescribing: Approaches that Limit Antibiotic Resistance. Am Fam Physician. September 15, 2001. 64;6:999-1006.
13. Wheeler JG, Fair M, Simpson PM, Rowlands LA, Aitken ME, Jacobs RF. Impact of a Waiting Room Videotape Message on Parent Attitudes Toward Pediatric Antibiotic Use. Pediatrics. September 2001. 108;3:591-596.
14. CDC. Campaign to Prevent Antimicrobial Resistance in Healthcare Settings. Available at www.cdc.gov/drugresistance/healthcare/overview. htm. Accessed June 12, 2006.
15. Center for Disease Control and Prevention. Adult Appropriate Antibiotic Use Summary. Available at www.cdc.gov/drugresistance/community/healthcare_provider.htm#1. Accessed December 29, 2006.
16. Finkelstein JA, Stille CJ, Rifas-Shirman SL, Goldmann D. Watchful Waiting for Otitis Media: Are parents and physicians ready? Pediatrics. June 2005. 115;6:1466-1473.
17. American Academy of Pediatrics and American Academy of Family Physicians. Question and Answers on Acute Otitis Media. Available at www.aap.org/advocacy/releases/aomqa.htm. Accessed December 29, 2006.
18. American Academy of Family Physicians. New Guidelines Say 'Watchful Waiting' is Best Approach to Fluid in the Middle Ear. Available at www.aafp.org/online/en/home/press/aafpnewsreleases/may04/ middleear.html. Accessed December 29, 2006.
19. Seppala H, et al. The Effect of Changes in the Consumption of Macrolide Antibiotics on Erythromycin Resistance in Group A Streptococci in Finland. N Engl J Med. Aug 14, 1997. 337;7:491-492.