2018-19 TOW #14: Antibiotics in primary care

School is in full swing, and we have already had the first cold of the season at our house. As we gear up for flu vaccines in preparation for viral season, it’s time to think about antibiotic use and stewardship in primary care setting. Our amazing general pediatrics and hospital medicine chair, Dr. Rita Mangione-Smith MD MPH, has been a lead researcher in informing this topic.

Materials for this week:

Take-home points:

  1. How often are antibiotics prescribed in outpt settings? More than 1 in 5 ambulatory visits for children results in antibiotic prescription. Studies have shown up to 1/3 of patients diagnosed with a common cold receive an antibiotic prescription. This increases up to 60% among patients presenting with bronchitis and other viral illnesses.
  2. What are some harms of antibiotic use from both an individual and a community-based standpoint? Individual harm includes diarrhea, upset stomach, adverse drug reactions, higher rates of resistant bacteria, and disruption of the gut microbiome. From a society standpoint, unnecessary antibiotic use contributes to excess health care costs and promotes antibiotic resistance.
  3. What situations trigger physicians to prescribe antibiotics for respiratory infections? Dr. Mangione-Smith and team found physicians were more likely to prescribe antibiotics for children with a cold if 1) they perceived the parent or patient expects it, 2) there is parental anxiety about the child’s illness before the visit, 3) they reported wheezing or rhonchi on exam, and 4) parents had very low SES (perhaps MDs may mistakenly believe it is faster to give ABX than explain what to do instead). Other studies have also found we prescribe more in visits that occur later in the day (consistent with decision fatigue).
  4. What are the principles of responsible antibiotic prescribing? 1) Determine the likelihood of a bacterial infection-use diagnostic criteria and guidelines, as well as tests to determine pre-test probability when possible, such as Centor criteria for sore throat and strep infection, and clear clinical findings for acute otitis media; 2) Weigh benefits and risks of ABX treatment to determine whether they should be given, and 3) Use judicious prescribing strategies (i.e., the most narrow-spectrum and effective antibiotic for the appropriate duration – this might include a watch and wait approach, if appropriate).
  5. What methods can we use to counsel family members about antibiotics? As per Dr. Mangione-Smith’s research, we are likely to get more questioning of the treatment if we specifically say “antibiotics are not needed” when we summarize the treatment plan, rather than focusing on positive, supportive treatment that parents can implement. When parents suggest a “candidate diagnosis” that might require antibiotics, like ear infection, sinusitis, or pneumonia, we should explain how we will determine the diagnosis based on the exam. Other strategies we can use: align with parents on goals of helping the child get well as quickly and safely as possible, legitimize symptoms and concerns for bringing the child in, and address parent anxiety and effort. Addressing specific ways to manage symptoms (analgesics, elevated head of bed, steam/ warm baths, honey for cough, etc.) is helpful. I’ve also taken to highlighting the benefit of building the immune system in young ages, as this potentially helps lower risk of autoimmune diseases later.

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