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 Antibiotic Stewardship Still a Challenge in Outpatient Settings

​Despite efforts on the part of long term practitioners and facilities to reduce the inappropriate or unnecessary use of antibiotics, a new study finds that these drugs continue to be prescribed at alarming rates in outpatient settings.

According to an article in the current issue of Infection Control & Hospital Epidemiology, researchers found that antibiotic prescribing rates in these settings did not drop between 2013 and 2015 and, in some cases, actually went up.

During the study period, approximately 98 million outpatient antibiotic prescriptions were filled by 39 million insurance beneficiaries. The most commonly prescribed antibiotics were azithromycin, amoxicillin, amoxicillin/clavulanate, ciprofloxacin, and cephalexin.

There isn’t a single or simple reason for this. Even with national efforts to reduce antibiotic use by the Centers for Medicare & Medicaid Services, Centers for Disease Control and Prevention (CDC), and other national organizations, there are still prescribers who write scripts for these drugs and still patients who demand them.

Once considered a sort of “wonder drug,” patients went to the doctor for everything from a cold to bronchitis to a sore throat. “It’s challenging. People are used to getting antibiotics. It’s hard to expect them to go ‘cold turkey,’” says Patricia Kaldy, MD, FAAFP, an urgent care physician in Concord, N.C.

When someone comes in with a respiratory infection, she says, she knows that a discussion about antibiotics is likely. “We have handouts about these medications—when they’re indicated and when they’re not, as well as the dangers of antibiotic resistance. So, hopefully, patients understand before they even see me that they won’t be getting a prescription for one of these drugs.” However, she says that she still has patients who demand them.

In these situations, even if the physician tries to reason with the patient and ultimately refuses to write the prescription, this isn’t necessarily the end of the story. “If they really want antibiotics, they will find another practitioner who will give them the prescription,” Kaldy says. This continues to be a challenge, she admits.

It doesn’t help when people see ads or news stories that appear to support antibiotics. Kaldy says, “Recently, local media outlets ran a story promoting Tamiflu, and patients are influenced by these kinds of things. Then they come in, and we have to try to help sort out the facts from the misconceptions and myths.”

She is optimistic, however. “I am seeing more consumer-oriented magazines and TV shows promoting antibiotic stewardship.” She encourages experts on the topic to offer themselves as guests on news and talk shows to further get out the word.

Educational materials from reliable sources are helpful. For instance, CDC has numerous resources, including many materials related to its “Be Antibiotics Aware” national campaign. CDC also published “The Core Elements of Antibiotic Stewardship for Nursing Homes” (www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html).

Wayne Saltsman, MD, PhD, a Massachusetts-based physician specializing in geriatrics and long term care, observes that the ABIM Foundation’s Choosing Wisely program (www.choosingwisely.org/), which encourages appropriate antibiotic use, is helpful.  Additionally, he notes that there are many useful tools and resources that are aligned with federal Quality Assurance and Performance Improvement (QAPI) program.

For instance, the Agency for Healthcare Research and Quality has an online “Nursing Home Antimicrobial Steward Guide” (www.ahrq.gov/nhguide/index.html) that includes toolkits on starting and maintaining an antibiotic stewardship program.

These tools, combined with open, caring one-on-one conversations, can make a difference. Saltsman recalls a situation where a patient and his family were insistent on a prescription for antibiotics for a urinary tract problem.

“I initiated a face-to-face meeting with the patient and his family to discuss why I was not going to prescribe an antibiotic for a urine test that I did not believe showed evidence of an infection,” he says. “I had actually called the primary provider beforehand to have his support. It was a difficult conversation, but transparency and the willingness to educate and listen were keys to success.” Ultimately, he adds, the patient did fine without antibiotics.

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