Physicians key to slowing the rise of antibiotic resistance

Washington -- It's not that the warnings about antimicrobial resistance are new. Consider this admonition from Sir Alexander Fleming in his 1945 Nobel lecture: "It's not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body."

Despite this cautionary advice given decades ago and the mounting evidence that microbes are indeed becoming resistant to even the latest antibiotics, physicians are still prescribing these agents in circumstances for which they are of no use. And many patients continue to seek these drugs believing that they are the long-sought cure for the common cold.

The increase in the number of pathogens that are proving stronger than any of the more than 100 antibiotics in a physician's toolbox are fueling fears that the amazing public health advance that was begun with the discovery of penicillin will ultimately be defeated.

But perhaps office-based physicians can at least help slow the rise of these resistant bugs, suggested Jeffrey Linder, MD, MPH , an internist at Brigham and Women's Hospital in Boston. He spoke at a conference on antimicrobial resistance held June 25-27 in Bethesda, Md., sponsored by the National Foundation for Infectious Diseases.

Acute respiratory infections are the most common reason for millions of ambulatory care visits. In about 50% to 75% of cases, antibiotics are prescribed -- many inappropriately, said Dr. Linder.

Why are doctors doing this?

He explored a number of possibilities including diagnostic uncertainty -- perhaps physicians are unsure of the patient's illness. Is it bronchitis, pneumonia or something else?

Or maybe it's for patient satisfaction. Patients may expect that antibiotics will be prescribed and the physician doesn't want to disappoint them.

How about time efficiency? It's faster to write the script than it is to explain the difference between a virus and a bacterium. The physician's desire to do something is also a factor.

Although each reason likely comes into play, physicians should forget about trying to meet patient expectations for an antibiotic because research is showing not all patients harbor this desire, said Dr. Linder. A summary of research on patients' wishes for an antibiotic found that 39% expect a prescription, which is a fair number, but not all.

Thwarting the impulse to prescribe

What else can be done to stem the tide of inappropriate prescribing? Patient education about the downside of the practice was somewhat effective, according to research findings, Dr. Linder said. And physician education has been shown to be a little more effective. One study showed that doctors prescribed fewer antibiotics if they were observed by others, he added.

Sometimes, however, even well-orchestrated education efforts don't result in sharp declines in prescribing rates. A study published in 2002 found that an all-out education push on the harms of inappropriate antibiotic use that targeted physicians, parents and hospitals in Knoxville, Tenn., resulted in a relatively modest 11% overall reduction in prescribing to children.

Paper or computer-based systems that guide decision-making have been shown to be effective. A 2005 study of primary care physicians in rural Utah found the use of clinical decision support systems reduced prescribing rates and improved their appropriateness.

Partners HealthCare System, a network of physicians and hospitals in Boston to which Dr. Linder belongs, is trying a new clinical support system to help physicians in the network appropriately treat acute respiratory infections. The Acute Respiratory Infection (ARI) Smart Form helps guide a physician toward the proper diagnosis and then to the question of whether to prescribe. The form was designed to "make doing the right thing as easy as possible," said Dr. Linder.

Cultural attitudes matter

But doing the right thing is harder when patients take matters into their own hands. Cultures play a large role in the demand for antibiotics, said Kitty Corbett, PhD, MPH, a medical anthropologist on the health sciences faculty at Simon Fraser University in Burnaby, British Columbia, Canada.

"We need to address consumer expectations," she noted. The burden of disease almost doesn't matter, she said. For example, an international study found that at the first signs of a cold, the French want an antibiotic while the Dutch will tough it out.

Research from the University of Colorado in Denver revealed 20% of U.S. Latinos self-medicate, Dr. Corbett said. The percentage rises to 60% to 70% among Mexicans, particularly those who speak only Spanish. This group obtains antibiotics in their native country where pharmacy regulations are loose and prescriptions aren't always necessary.

Penicillin is often the antibiotic of choice among this group, Dr. Corbett added. When asked about penicillin the research subjects said, "We can't get penicillin from just anybody, and so we bring it from [Mexico]."

Since that's an idea that makes infectious diseases experts apoplectic, what should patients be told when they are fighting a cold?

Returning to the prescient Nobel winner Dr. Fleming, David G. White, PhD, director of the Food and Drug Administration's National Antimicrobial Resistance Monitoring System, quoted, "A good gulp of whiskey at bedtime -- it's not very scientific, but it helps."