Promoting Judicious Antibiotic Use in the Community

NameOrganizationDate

Overview

Discuss antibiotic resistance in the United States Summarize recent national policy developments Describe the Get Smart: Know When Antibiotics Work

program Discuss factors and challenges contributing to inappropriate

antibiotic prescribing Review current guideline recommendations for

management of common outpatient infections Describe new frontiers for characterizing antibiotic

prescribing

Antibiotic Resistance: A Growing Threat

Associated with higher costs, poor health outcomes, more toxic treatment

Requires prolonged and costlier treatments, resulting in greater morbidity and mortality

Over half of outpatient antibiotic prescribing is unnecessary or inappropriate

There’s more to the story

Antibiotics are responsible for almost 1 out of every 5 visits to emergency departments for drug-related adverse events (142,000 visits annually).

Antibiotics are the most common cause of drug-related emergency department visits for children.

Shehab, et al. Clin Infect Dis. 2008 Sep 15;47(6):735-43

Unintended consequences of antibiotic use: Clostridium difficile

Wendt, J. M., et al. (2014). Pediatrics 133(4): 651-658. Khanna, S., et al. (2012). Am J Gastroenterol 107(1): 89-95.

C difficile infections (CDIs) are frequently community- acquired, accounting for approximately 77% of CDI cases in children and 41% of CDI in adults

A National Strategy for Combating Antibiotic Resistant Bacteria

Presidential Committee of Advisors for Science and Technology (PCAST) Report on Antibiotic Resistance

National Strategy Goal #1: Slow the Development of Resistant Bacteria and Prevent the Spread of Resistant Infection

"National Strategy for Combating Antibiotic Resistant Bacteria." Retrieved September 18, 2014, from

http://www.whitehouse.gov/sites/default/files/docs/carb_national_strategy.pdf.

“Strengthen educational programs such as Get Smart: Know When Antibiotic Work which inform [providers]… and the public about good antibiotic stewardship”

Actions to address the threat of antibiotic resistance

Improving Antibiotic Use in the Community

Goals• Decrease unnecessary antibiotic use in the community• Reduce the spread of antibiotic resistanceObjectives• Promote appropriate antibiotic prescribing • Decrease consumer demand for antibiotics• Promote adherence to prescribed therapies Focus• Common infections in ambulatory care settings, especially

acute respiratory tract infections

Get Smart General Patient Communication Educational Tools

Get Smart Provider Tools

Guide for symptomatic treatment

Symptomatic prescribing pad

Continuing education opportunities

Patient education handouts

Medical school curriculum

Clinical practice guidelines

“Get Smart” web page for Providershttp://www.cdc.gov/getsmart/community/for-hcp/outpatient-hc

p/index.html

Antibiotic Prescriptions per 1000 Persons of All Ages By State, 2010

Hicks LA et al. N Engl J Med 2013;368:1461-1462

Lowest prescribing rate (529/1000)

Highest prescribing rate (1237/1000)

Characterizing Injudicious Antibiotic Prescribing

Antibiotic Overuse

Inappropriate Antibiotic Selection

SinusitisPharyngitisAcute BronchitisUrinary Tract InfectionsCommon ColdAcute Otitis Media

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Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09

Antibiotics were prescribed during 101 million ambulatory visits annually, representing 10% of all visits

Antibiotics were most commonly prescribed for Respiratory conditions (41% of antibiotics prescribed) Skin/mucosal conditions (18%) Urinary tract infections (9%)

Among visits for conditions in which an antibiotic is rarely indicated, over half were prescribed an antibiotic

Even when indicated, the wrong antibiotic was frequently prescribed Broad-spectrum agents were prescribed during 61% of visits in which

antibiotics were prescribed

Shapiro, D. J., et al. (2014). J Antimicrob Chemother 69(1): 234-240.

Drivers ofInappropriate Antibiotic Use:

Patient perspective• Want symptoms resolved quickly• Want clear explanations, even when

there is no “cure”• May harbor misconceptions about

when antibiotics work• Cycle of expectations – previous

experiences influence current behaviors

Clinician perspective• Perceived patient expectations • Concern for misdiagnoses and

potential negative consequences• Time pressure• Cycle of broad-spectrum prescribing

– concern for resistance leads to broad-spectrum use

Barden at al. Clin Pediatr 1998 Nov;37(11):665-71Finkelstein et al. Clin Pediatr 2013 Oct 17.Sanchez, G. V., et al. (2014). "Effects of knowledge, attitudes, and practices of primary care providers on antibiotic selection, United States." Emerg Infect Dis 20(12): 2041-2047.

Both are increasingly concerned with antibiotic overuse and resistance

The perception that broad-spectrum antibiotics are easier to prescribe drives injudicious antibiotic selection:

“[Broad-spectrum antibiotics] take the thinking out of it for me so that I am not trying to figure out what the organism is and [which] particular antibiotic treats the organism.”

Insight From In-Depth Interviews with Primary Care Providers

Sanchez, G. V., et al. (2014). "Effects of knowledge, attitudes, and practices of primary care providers on antibiotic selection, United States." Emerg Infect Dis 20(12): 2041-2047.

Patient satisfaction drives antibiotic overuse:

“We as doctors are business people. We’re no different than running a shoe store. If somebody comes in and wants black shoes, you don’t sell them white shoes. And if you do, they get upset.

…patients in general don’t understand that concept of not taking [an antibiotic] if you don’t need it… [and] if you don’t give it to them, they don’t come back to you.”

Sanchez et al. Emerg Infect Dis. 2014.

Insight From In-Depth Interviews with Primary Care Providers

More than 80% of patients diagnosed as having acute sinusitis are prescribed an antibiotic

Nearly 50% of patients diagnosed as having acute sinusitis received either a macrolide or a quinolone,

Fewer than 20% received amoxicillin, the recommended first-line treatment (at the time)

Ahovuo-Saloranta, A., et al. (2014). Cochrane Database Syst Rev 2: CD000243.Fairlie et al. (2012). Arch Intern Med. 172(19):1513-1514.

Acute Bacterial Rhinosinusitis

“Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual and general population levels”

-2014 Cochrane Review, “Antibiotics for Acute Sinusitis in Adults”

Acute Bacterial Rhinosinusitis

Diagnose bacterial sinusitis based on symptoms that are: Severe (>3-4 days) such as fever ≥39°C (102°F) and purulent nasal

discharge or facial pain; Persistent (>10 days) without improvement, such as nasal discharge or

daytime cough; or Worsening (3-4 days) such as worsening or new onset fever, daytime

cough, or nasal discharge after initial improvement of a viral upper respiratory infections (URI) lasting 5-6 days.

“The prevalence of a bacterial infection during acute rhinosinusitis is estimated to be 2%–10%, … viral causes account for 90%–98%”

-2012 IDSA Guidelines for Acute Bacterial Rhinosinusitis

Chow, A. W., et al. (2012). Clin Infect Dis 54(8): e72-e112.

Acute Bacterial Rhinosinusitis In patients who meet diagnostic criteria:

Routine sinus radiographs are not recommended 2015 guidelines from the American Academy of Otolaryngology-Head

and Neck Surgeons (AAO-HNS) recommend watchful waiting for uncomplicated cases (of acute uncomplicated bacterial rhinosinusitis)

Antibiotic selection: Amoxicillin/clavulanate is the recommended first-line therapy For penicillin-allergic patients, doxycycline or a respiratory

fluoroquinolone (levofloxacin or moxifloxacin) are recommended as alternative agents

Chow, A. W., et al. (2012). Clin Infect Dis 54(8): e72-e112. Rosenfeld, R. M., et al. (2015). "Clinical practice guideline (update): adult sinusitis." Otolaryngol Head Neck Surg 152(2 Suppl): S1-S39.

Macrolides such as azithromycin are not recommended due to high levels of Streptococcus pneumoniae antibiotic resistance (~30%)

Barnett, M. L. and J. A. Linder (2014). JAMA Intern Med 174(1): 138-140.

GAS prevalence in adults

Group A Streptococcal Pharyngitis

Group A Streptococcal Pharyngitis

The Centor criteria (no cough, cervical lymphadenopathy, tonsillar exudate, fever) It is a screening tool to determine who should receive a RADT Presence of all criteria has a positive predictive value of only 40-60%

Antibiotic treatment is NOT recommended for patients with negative RADT results

Amoxicillin and penicillin V remain first-line therapy for confirmed Group A streptococcal (GAS) cases

GAS resistance to macrolides is increasingly common

“Clinical features alone do not reliably discriminate between GAS and viral pharyngitis…”

-2012 IDSA Guidelines for GAS Pharyngitis

Shulman, S. T., et al. (2012). Clin Infect Dis 55(10): 1279-1282.Roggen, I., et al. (2013). BMJ Open 3(4).

Prescribing for acute bronchitis in ambulatory care, 1996-2010

Barnett et al. JAMA. 2014; 311(19):2020-22.

Bottom line: No improvement and getting worse!

Acute Uncomplicated Bronchitis

Cough is the most common symptom for which adult patients visit their primary care provider Acute bronchitis is the most common diagnosis in these patients

Pneumonia is rare among healthy non-elderly adults in the absence of abnormal vital signs or asymmetric lung sounds (focal consolidation, egophony, rales, fremitus etc.) Heart rate ≥ 100 beats/min, Respiratory rate ≥ 24 breaths/min Oral temperature ≥ 38 °C

Colored sputum does NOT indicate bacterial infection

Gonzales R, Bartlett JG, Besser RE, et al. Ann Intern Med. 2001;134(6):521–9.

Evaluation of acute bronchitis in otherwise healthy adults should focus on ruling out pneumonia

Aggregate antibiogram surveillance of outpatient urinary E. coli, United States

Figure. Cumulative changes in E. coli antibiotic resistance, 2000-2010

Sanchez GV, et al. (2012). Antimicrob Agents Chemother. Apr;56(4):2181-3.

Acute Uncomplicated Cystitis

Increased use of 2nd-line broad-spectrum agents leads to resistance and difficult-to-treat infections

Nitrofurantoin, fosfomycin, and TMP/SMX remain 1st-line therapy Nitrofurantoin retains good antimicrobial activity against E. coli, including

multidrug resistant strains Nitrites and leukocyte esterase are the most accurate indicators of

acute uncomplicated cystitis

“[Ciprofloxacin has] a propensity for collateral damage and… should be considered [an] alternative antimicrobial for acute cystitis” -2011 IDSA Guidelines for UTIs

Gupta, K., et al. (2011).Clin Infect Dis 52(5): e103-120.Colgan R, Williams M (2011). Am Fam Physician. 84(7):771-6.

Interventions to improve outpatient prescribing

Print materials alone have little impact on prescribing Audit and feedback of current practice has been

successful Academic detailing, opinion leader education effective Clinical decision support promising Other options:

Delayed prescribing practices Poster interventions involving public commitment to prescribe

judiciously

Arnold et al. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD003539.Forrest et al. Pediatrics 2013 Apr;131(4):e1071-81.Little et al. Lancet 2013 Oct 5;382(9899):1175-82.Meeker et al. JAMA Intern Med. 2014;174(3):425-31.

Interventions to improve outpatient prescribing

Several proven interventions, but the next step is to: Identify how to maximize the effect size Explore which combinations work best Examine how to scale-up interventions (e.g. health

systems, state-level interventions, etc.) Assess sustainability

CDC to develop guidance for outpatient antibiotic stewardship

Arnold et al. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD003539Forrest et al. Pediatrics 2013 Apr;131(4):e1071-81Little et al. Lancet 2013 Oct 5;382(9899):1175-1182

New frontiers for characterizing antibiotic prescribing

Assessing prescribing among different provider types, medical specialties, and practice settings Physician assistants, nurse practitioners, dermatologists, dentists,

emergency medicine, etc. Outpatient Parenteral Antibiotic Therapy (OPAT) Telehealth and telemedicine Retail clinics and urgent care

CDC National “Get Smart Week”

• November 16-22, 2015• Share brochures/flyers/via social media with

colleagues and patients• More details to come from the New York “Get

Smart (Know When Antibiotics Work) Campaign”

Summary

Antibiotic resistance is a serious threat to public health Get Smart: Know When Antibiotics Work promotes judicious

antibiotic prescribing among outpatients Antibiotics are most commonly prescribed inappropriately for

respiratory infections Diagnostic criteria established by guidelines should be used to

determine whether an antibiotic is needed Choosing the right drug for the right bug is critical; macrolides and

fluoroquinolones are often overprescribed

Questions?