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Antibiotic Overuse: Clinicians Are the Solution

Appeals to use antibiotics wisely are as old as penicillin itself. The potential for antibiotic abuse was recognized even during the early era of the wonder drugs (1). A 1956 U.K. study of patients with acute chest infections found that 82% received antibiotics (2), and in 1962, an expert panel concluded that there was no evidence that antibiotics were beneficial for colds or other upper respiratory viral infections (3). Now, more than 5 decades later, an unacceptably high proportion of patients with viral respiratory infections still receive antibiotics. In their article, Silverman and colleagues (4) report that among a low-risk cohort of 185 014 elderly Canadian patients seen by 8990 primary care providers for acute upper respiratory infections, 46% were prescribed antimicrobials. Further, most prescriptions were for broad-spectrum agents (macrolides, cephalosporins, and fluoroquinolones), which are not recommended as first-line antimicrobial therapy for any of the respiratory infections studied (5). The remarkable durability of guideline-discordant management of these infections highlights the intransigence of clinical practice as well as the allure of antibiotics to clinicians and patients. Antibiotic prescribing seems to be more refractory to evidence-based medicine efforts than other low-value treatments, and the question is why. Antibiotic resistance has often been explained as a tragedy of the commons, which occurs when a shared goodin this case, antibiotic effectivenessis at risk for depletion due to excessive consumption (6). Policies to preserve the resource for the sustained benefit of the population are needed, but for antibiotics this approach has historically been preempted. During the early decades of antibiotic development, differences in regulations across countries contributed to divergences in practice. Scandinavian countries incorporated a need-based criterion into the approval process for novel antimicrobial agents, which slowed the pace of adoption of new classes of drugs (7). In contrast, in the United States stricter regulation of the antibiotic marketplace conflicted with physician and industry autonomy. Our chief moral duty as clinicians is to our individual patients, in defense of physicians who seem to disregard the commons. However, clinicians and patients may be underestimating the individual harms and overestimating the benefits of antibiotics. Although the effects of antibiotics on the host's microbiota are often invisible, evidence that the impact is more deleterious than previously suspected is accumulating (8). Such findings may eventually change our attitude toward individual antibiotic risk to a greater degree than the threat of resistant infections alone. Using antibiotics only when needed is in the best interest of our patients as well as our communities. The safety and feasibility of judicious antibiotic prescribing is manifest by clinicians who already follow this approach. Just as countries vary widely in their prescribing rates, some physicians prescribe antibiotics for viral respiratory infections much less frequently than others, even within the same setting (9). Silverman and colleauges' study is important because it examines the clinician factors that correlate with prescribing patterns and generates several important hypotheses regarding drivers of overuse. Patients were more likely to receive antibiotics from mid- or late-career physicians, those with high patient volumes, and those who trained outside of Canada or the United States. Which of these factors could be targets of interventions to promote sustainable change warrants further exploration. Long-standing habits are hard to break. Analogous to birth cohort effects, training cohorts may exhibit stable similarities in social practice norms, which are affected by cultural attitudes toward antibiotic benefits versus harms, patientclinician communication, or perceived expectations, and may result in different thresholds for antibiotic use. Learned practices that are shared, especially between attending physicians and trainees, resist change even when there is no evidence to support the practice. However, physicians are also influenced by their contemporary social networksthe system and social context within which they practice, including the attitudes and behaviors of their surrounding colleagues (10). These networks can be a powerful motivator for change. Putting it together, accurate weighing of the true risks and benefits of antibiotic prescribing will help to make prudent use more justifiable on a rational level. However, physicians also need to feel that judicious prescribing is the right thing to do on an emotional or intuitive level, which often requires social cues and accountability. Interventions must also be designed with the reality of time pressure in mind, and caution must be taken with procedures that require an expenditure of time or cognitive resources. The correlation in Silverman and coworkers' study between high patient volume and antibiotic prescribing is consistent with the notion that physicians seeing patients with acute respiratory infections are practicing under extremely busy circumstances, which often require rapid decision making and intuition as opposed to deliberate, rational thought. Thus, we should be optimistic that the current state of affairs is amenable to large-scale improvement. Durable reductions in antibiotic prescribing have been observed in countries where rigorous local and national campaigns were launched. In the United States, we have substantially decreased antibiotic use in young children. Outpatient stewardship is an expanding feature of antibiotic stewardship programs associated with health systems, which heretofore focused on the inpatient setting. Further research will improve our understanding of the cognitive and motivational processes that drive clinical behaviors and how clinicians share information, attitudes, and practice norms to shape prescribing patterns. Studies of behavioral interventions that target modifiable risk factors, can be integrated into clinician workflow, and promote sustainable change are needed. The tipping point to a culture of judicious antibiotic use is within reach, with clinicians at the forefront of change. Preservation of the benefits of the wonder drugs depends on us.