The World Health Organization, the Centers for Disease Control and Prevention (CDC) and hundreds of organizations including federal agencies, corporations, professional societies and health advocacies are collectively observing Antibiotic Awareness Week from November 13 to November 19, 2017. Their purpose is to draw attention to the threat of antibiotic resistance and the importance of appropriate antibiotic prescribing and use. These efforts could not come at a better time.
There is an epidemic of antibiotic over-prescribing. For example, Z-Packs became popular because they only take a few days to finish. As a result, they became one of the most over-prescribed drugs in the U.S.A. and amoxicillin, another antibiotic, is too frequently prescribed for children to treat everything from ear infections to strep throat.
It is estimated that antibiotic resistance caused by inappropriate or unnecessary use adds more than $20 Billion in excess direct healthcare costs annually in the U.S. plus an additional $35 Billion, or more, per year from lost productivity. In terms of human cost, the CDC estimates that more than 2 million people are infected annually with antibiotic-resistant bacteria and at least 23,000 people die each year as a direct result of these infections. Many more die from related complications.
Antibiotics are medicines designed to kill bacteria. Unfortunately, since their introduction in 1928, they have been prescribed for a wide variety of illnesses and diseases (sometimes caused by a virus), that, by definition, do not respond to antibiotics. In fact, one study showed that roughly 25 percent of antibiotic prescriptions are useless since the infection stems from a virus. Alexander Fleming, who discovered penicillin, saw the potential for this problem when he reportedly warned that doctors were using the drug in patients who really did not need it.
And the more antibiotics are used, the more bacteria figure out ways to resist them. The result is that the antibiotics no longer work. Compounding the problem is that new antibiotics take years to develop and most of these tend to be IV-based. While effective, this newer class requires either outpatient and sometimes inpatient hospital visits to administer. This, in turn, creates additional costs which may or may not be fully reimbursed by private and government insurers.
While some of the resistance can be attributed to rampant use of antibiotics in the meat industry, most of it comes from the over-prescribing of antibiotics by well-meaning physicians. A recent survey confirmed many physicians regularly prescribe antibiotics when they are not absolutely certain that antibiotics are necessary. When it’s not clear whether the issue stems from a virus or bacteria defensive prescribing comes in to play. The doctors know that if the infection is bacterial, antibiotics will work, and if the bacterial infection is left untreated, the patient may be harmed. It’s kind of a “rather be safe than sorry” approach.
Caregivers and patients themselves contribute to the overuse of antibiotics by having unrealistic expectations about what antibiotics can and cannot do as well as insisting that their doctors “give me something,” even if that “something” may not work. In fact, it is estimated that doctors write about 100 million antibiotic prescriptions a year for conditions that antibiotics cannot treat. A big part of this is because more than a third of Americans still believe antibiotics, if not a cure-all, are effective against viral infections.
Education and Partnership are the Solution
The public health risks related to the inappropriate and/or over-prescribing antibiotics have been known for some time as have various attempts to address them. In fact, the U.S. Government developed and published a national action plan for combating antibiotic-resistant bacteria. Other governments around the world, healthcare providers and professional associations have also studied and researched possible solutions. Some have had promising results while others have not.
A critical element of any program to reduce the incidence of antibiotic-resistant bacteria must begin with what helped create the problem in the first place – namely over-prescribing and inappropriate prescribing of antibiotics. Several strategies have proven successful in reducing the number of antibiotic prescriptions written by individual physicians with the most promising being those that engage both health care providers and patients and their families. By doing so, both the “supply” and the “demand” are simultaneously addressed. This approach has shown to continue to produce benefits even when ongoing outreach or program activities have ended.
The cornerstone of these programs is, not surprisingly, education. Education is key to fostering the attitude and behavior changes that will most likely turn the antibiotic tide. Patients and families need to understand and accept that antibiotics are not appropriate for every situation and that when it comes to this class of medication “more is not better.” They also need to learn how to be educated health care consumers and to not be afraid to challenge their healthcare providers on antibiotic use. Consumers need to partner with physicians both on determining the best course of treatment, which may or not include antibiotics, and identifying the root cause of their illnesses.
For their part, physicians and other health care providers need be up-to-date on the latest developments on combating antibiotic-resistant bacteria, the most appropriate treatment protocols and alternative treatments. They also need to be better prepared to handle and manage their patients who may insist on getting a prescription for antibiotics even then they won’t be successful at treating their illness (especially if it is the common cold).
The other half of the equation is changing prescribing habits. Several health care systems have experimented with incentive and feedback systems, but most have proven too costly and not very effective. What has proven effective, however, are programs that help health care providers and patients alike make public commitments to reducing antibiotic use. One such program involved placing posters in exam rooms during the flu season. Supported by the NIH, the simple, low-cost posters featured a commitment letter along with healthcare provider photos and signatures. The letter addressed how antibiotics could sometimes do more harm than good and was written in easy-to-understand language instead of “doctor speak” and mentioned each provider’s commitment to appropriate use of antibiotics. This simple program resulted in nearly 20 percent fewer inappropriate antibiotic prescriptions.
Another innovative, low-cost program researched at the University of Southern California used the idea of a giving physicians a “nudge” to help reduce unnecessary antibiotic prescriptions. One of the nudges updated the participating physicians on how they were doing compared to their peers when it came to prescribing unneeded or inappropriate antibiotics. The other required them to report the reason for prescribing antibiotics in a patient’s record. These two “nudges” prevented on average one inappropriate prescription for every eight patients seen.
And yet another combined a comprehensive education program for doctors with educational materials for the caregivers of children. Over the course of nine months, this one-two punch succeeded in reducing the antibiotic prescription rate from 82 percent to 40 percent.
The financial and human costs of the current epidemic of inappropriate and unnecessary prescribing of antibiotics demands the kinds of contemplated by participants of the Antibiotic Awareness Week. Anything less could take us back to a time before antibiotics – a time when a paper cut could be a death sentence.