Prescribing antibiotics appropriately
Appropriate prescription of antibiotics is a realistic goal that practicing NPs and PAs can strive for to help control rising AMR rates. In turn, appropriate antibiotic prescribing can reduce morbidity, mortality and health-related costs. Here are 10 principles that I share with my students and strive to employ in my own clinical practice (also summarized in Table 1):
- Obtain an accurate diagnosis. Appropriate antibiotic prescribing begins with an accurate diagnosis. Inaccurate diagnoses lead to unnecessary antibiotic prescribing or to use of the wrong antibiotic. Take an honest look at your diagnostic skills. When was the last time you reviewed the differential diagnoses for sore throat, cough or purulent nasal discharge? Where are you getting your diagnostic information? Are you using outdated sources? To guide your diagnosis, use current, research-based evidence, such as Up-To-Date, or a recent (i.e., published within the past five years) clinical guideline from a reputable professional organization (e.g., CDC, American Academy of Pediatrics, American College of Physicians, Infectious Diseases Society of America [IDSA]). Remember that diagnostic decision-making should utilize a process that considers the wide spectrum of applicable differential diagnoses for the chief concern and carefully considers and rules out life-threatening conditions.
- Know the likely etiology. Once you’ve established an accurate diagnosis of infection, you need to consider the likely etiology or etiologies responsible for the infection and treat accordingly. At times, this can be determined through C&S. When C&S is not possible or practical, you’ll need to rely on empirical data. The Sanford Guide to Antimicrobial Therapy12 is an excellent resource that provides typical and atypical etiologies for most infectious diseases. The guide is updated annually and is available in a variety of print and electronic forms.
- Assess for related health history that could alter the patient’s etiology. Always consider and assess for other health and social history factors that could alter the etiology of the infection, such as drug and alcohol use, recent antibiotic use, recent hospitalizations, occupational history and national or international travel to areas where certain diseases are endemic. For example, patients who work in inpatient, residential or endoscopy laboratories may be more likely to have a resistant infection.
- Obtain and use local antibiotic resistance data. Make a point to regularly obtain and review antibiotic sensitivity data from your local laboratory or inpatient facility. Similarly, consider contacting your state health department to determine if your state participates in a microbiological surveillance program from which you can access data. These data can be especially valuable if you need to select an antibiotic empirically. For example, if more than 20% of the E. coli strains in your community are resistant to SMX/TMP, then SMX/TMP should not be your first-line choice for simple UTI.12
- Use current, evidence-based prescribing information. In the same way that being up to date on diagnostic data is important, it is critical to base antibiotic prescribing on the most current, evidence-based information. These resources will guide your initial choice and dose of antibiotics, as well as duration of treatment. They also can provide guidance regarding the decision for place of treatment (i.e., inpatient or outpatient) or the need for referral to an infectious disease expert. Some good examples include The Sanford Guide, Prescriber’s Letter, the CDC’s Morbidity and Mortality Weekly Report (MMWR), and clinical guidelines from the IDSA. Information regarding the diagnosis and treatment of infectious diseases can change rapidly, so consider subscribing to an automatic, electronic daily update service, such as Journal Watch or Physician’s First Watch.
- Have a backup plan. As you develop an initial treatment plan for your patient’s infection, think about your next course of action should the patient’s infection worsen or not respond to initial treatment or if the patient develops an allergy or intolerance to the antibiotic. Consider whether your plan will include rethinking the initial diagnosis, obtaining a C&S, changing antibiotics or consulting with an infectious disease specialist. No matter how experienced or astute a clinician you are, initial treatment plans will fail from time to time, and backup planning will likely save you precious time in the long run.
- Educate your patients. Well-informed patients are more likely to adhere to the recommended treatment regimen and to seek assistance if anything goes awry (i.e., symptoms are worsening, signs of allergy develop). Carefully explain your diagnostic reasoning and treatment recommendations, as well as what to watch for and what to do in the event that problems arise. Patients often do not remember details from office visits, so your best course of action is to put all important information in writing. A number of electronic programs (including some electronic medical record systems) have patient information templates for various conditions. Be sure to read these templates (and revise them as needed) before distributing them to patients.
- Understand that antibiotic prescribing does not necessarily lead to patient satisfaction. Clinicians frequently prescribe antibiotics for viral ARIs because they believe that doing so will lead to patient satisfaction. The psychology between antibiotic prescribing and patient satisfaction is complex and beyond the scope of this article. However, a growing body of literature indicates that patients and parents (even those who specifically ask for antibiotics) are satisfied when they feel that the clinician has listened to them and they have received honest, nonpatronizing information, regardless of whether they receive a prescription for an antibiotic.27-29
- Use meticulous hand hygiene. Although hand hygiene is not an antibiotic prescribing principle, all the previously noted prescribing measures amount to little if clinicians are not routinely engaging in effective hand hygiene. Poor hand hygiene by health care workers (HCWs) is a major source of disease transmission and has greatly contributed to the rise in AMR.14 A recent analysis of multiple studies of HCWs’ adherence to hand hygiene procedures indicated that on average, HCWs adhere to recommended hand hygiene procedures only 38.7% of the time.30 With the advent of alcohol-based hand sanitizers, hand hygiene is quicker, more accessible, and less irritating than ever before. See Table 2 for a brief summary of current, evidence-based hand hygiene recommendations.
- Hold your peers to these same principles. Antibiotics have significant societal and global implications,32 and every prescribing clinician needs to be aware of how his or her antibiotic prescribing habits contribute to AMR. Table 3 provides a list of electronic AMR resources that may help doubting colleagues.