William M. Geisler, MD, MPH
Assistant Professor of Medicine
Department of Medicine, Division of Infectious Diseases
The University of Alabama at Birmingham
Birmingham, Alabama

In accordance with the Accreditation Council for Continuing Medical Education Standards for Commercial Support, Dr. Geisler discloses honorarium from Pfizer, Inc. and Ortho-McNeil.

The University of Alabama School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The University of Alabama School of Medicine designates this educational activity for a maximum of 0.25 Category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the activity.

The boards of nursing in many states, including Alabama, recognize Category 1 continuing medical education courses as acceptable activities for the renewal of license to practice nursing.

Prescribing Practices

In 2001, the Centers for Disease Control and Prevention (CDC), the American Academy of Family Physicians, the American College of Physicians/American Society of Internal Medicine, and the Infectious Diseases Society of America published guidelines for appropriate antibiotic use, focusing on reducing prescriptions, especially for URTI symptoms and otitis media. Nearly 5 years later, antibiotic overprescription, while decreasing, still occurs. Although physicians may hesitate to prescribe unwarranted antibiotics, patients often demand a prescription.

However, based on studies evaluated for the 2001 guidelines, fears of increased return visits and patient dissatisfaction seem unfounded. The authors found quality of clinician-patient interaction rather than receipt of an antibiotic was the most important determinant of patient satisfaction. Similarly, medicolegal concerns have not increased with decreases in antibiotic prescriptions, although caution is urged when dealing with respiratory illnesses in elderly or immunocompromised patients.

Geisler notes the impact of prescribing patterns based on perceptions rather than evidence-based guidelines still reverberates throughout communities. "Resistance to Streptococcus pneumoniae (pneumococcus) has significantly increased in the last decade. In the 1980s, penicillin was the drug of choice, but now cases of multidrug resistant pneumococcal infections are common, and the potential exists for resistance to cephalosporins, tetracyclines, amoxicillin/clavulanate, macrolides, and even flouroquinolones, which were one of the few oral antibiotics available to treat multidrug-resistant pneumococcus in the 1990s."

Currently, about 40% of pneumococcal infections in the United States and >15% in Canada are resistant to penicillins — once considered first-line therapy for infections due to these bacteria (N Engl J Med. 1999;341:233-239).

"Studies show elevated fluoroquinolone resistance in Canada and Southeast Asia following increases in prescriptions in those regions, and early evidence suggests fluoroquinolone resistance is rising in some areas of the United States as well," he says.

In a study of nearly 2000 adults seen by physicians for URTI symptoms, broad-spectrum agents were selected for 54% of patients, including those presenting with the common cold or nonspecific URTIs, acute bronchitis, and otitis media. Physician specialty and geographic region predicted selection of broad-spectrum agents (JAMA. 2003;289:719-725), with subspecialists prescribing more broad-spectrum drugs and much higher resistance rates in the Southeast and Northeast compared with the West.

"Compared with a family practice physician, an internist or infectious disease specialist may be more likely to prescribe a broad-spectrum antibiotic for URTI," Geisler says. "If a clinician prescribes an antibiotic for URTI, it should be based on practice guidelines when available, and therapy should be initiated with a narrow-spectrum drug when possible."

Emerging studies suggest a link between antibiotic use in ambulatory patients and resistance in hospital populations. "In particular, fluoroquinolones can impact bacteria in the gut. Thus, higher rates of fluoroquinolone use in community and hospital settings may increase the proportion of hospital-acquired infections due to more resistant bacteria and may increase morbidity, and possibly mortality, if such infections cannot be treated early with effective antibiotics," he says. Clinicians often believe that as single providers, they have little impact on their community, but, he adds, one physician's prescribing practices can make a dramatic difference.

"One of the biggest reproducible themes from current antibiotic resistance research is that patients who have taken antibiotics within 3 months have a markedly increased risk for nonresponse to that same antibiotic, which appears to set the stage for multidrug-resistant pathogens that require expensive medications and can lead to the need for hospitalization in some patients," he says.

A recent British study found patients with acute uncomplicated lower respiratory tract infections who were given antibiotics had little difference in symptom relief compared with patients who did not receive antibiotics. Immediate antibiotic prescribing was likely to decrease the number of patients who returned for cough within one month, but the number was marginal compared with delaying antibiotic prescriptions. Study authors noted the next challenge for physicians is determining which groups are at risk for adverse outcomes and who might selectively benefit from immediate antibiotic use (JAMA. 2005;293:3029-3035).

In older patients, renal function and ability to metabolize drugs may differ and risks for adverse events increase. Some older adults have difficulty remembering drug interactions between their regular medicines and antibiotics and have trouble keeping track of dosing schedules.

Among children, acute otitis media is the most frequent reason pediatricians prescribe antibiotics. Yet, recent guidelines suggest watchful waiting and pain relief for ear infections may be more effective, as many ear infections resolve on their own. A survey of more than 2000 parents who used watchful waiting for children aged 2 years or older with nonsevere ear pain and no high fever revealed 34% were satisfied. There was greater acceptance among parents with more education, a greater understanding of antibiotics, or those who felt included in the medical decision (Peds. 2005;115:1455-1465).

"If a physician takes time to explain why no antibiotic is needed, patients are typically satisfied, but physicians in busier practices have less time for education," Geisler says. Patient education is not always customized toward a level of patient understanding and much misinformation exists.

"Informational handouts from CDC and specialty societies are available, but by the time patients visit the physician, symptoms or fears have urged them to action, which many patients interpret as the need for a prescription," he says. "Inquiring if there is a special reason a patient wants an antibiotic for what is most likely a viral illness is perfectly valid. Saying no, but leaving the door open to prescribe an antibiotic later by having the patient call back to report worsening symptoms, is also justified."

To support judicious use of antibiotics, the CDC and Public Health Foundation offer patient education materials, including a "viral prescription pad" that has been used successfully by pediatricians and is adaptable to patients of any age. Physicians write names of recommended over-the-counter medications or other instructions and patients leave the office with "prescription" in hand. Physicians can view a complete list of antibiotic educational materials and order bulk forms at www.cdc.gov/drugresistance/community/orderform.htm.

As newer drug classes evolve, such as the ketolides for macrolide-resistant respiratory tract pathogens, Geisler urges judicious use. "Antibiotic use is not without potential harm to patients or communities. Benefits should be justified and risks assessed before prescribing."

CDC is also collaborating with primary care specialty societies to provide evidence-based guidelines specifically targeting bronchitis and other nonspecific URTIs that are typically of viral origin.

"We are trying to prevent overprescription of antibiotics, especially broad-spectrum agents, to prevent allergic reactions and adverse effects, such as drug hepatotoxicity, rashes, and gastrointestinal distress. Ultimately, antibiotic prescribing limitations will limit resistance, prevent or reduce side effects, and minimize health care costs that impact us all."

For more information:

Dr. William Geisler
1-800-UAB-MIST
mist@uabmc.edu

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