Q J Med 1999; 92: 287-292
© 1999 Association of Physicians
Commentary |
Antibiotic prescribing—are there lessons for physicians?
From The Infection and Immunodeficiency Unit, and 1 Medicines Monitoring Unit, Ninewells Hospital, Dundee, UK
Dr D. Nathwani, Infection and Immunodeficiency Unit, Kings Cross Hospital, Clepington Road, Dundee DD3 8EA
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Introduction |
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 Top Introduction How then should we...How can sepsis recognition...How can we improve...How can these strategies...What is the evidence...References |
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In 1968, L.P. Garrod wrote `no one recently qualified, even with the liveliest imagination, can picture the ravages of bacterial infection which continued until more than 30 years ago'. Since then, although many new antimicrobials have been developed, we are once again warned of an imminent `post antibiotic era' as a consequence of the rapid emergence of resistant bacteria. This problem has recently culminated in the publication of an excellent report from the House of Lords Select Committee on Science and Technology on `Resistance to Antibiotics and the other antimicrobial agents'.1 The subsequent plethora of editorials2,3 in the medical press and `sensationalist' coverage in the media has brought this important subject to the attention of the non-specialist medical community as well as the public domain. This increased concern has culminated in the British Medical Journal devoting a whole issue to this subject (Br Med J 1998; 317) and the occurrence of an important meeting on this subject of medical officers from throughout Europe in Copenhagen, September 1998.
The failure to implement basic infection control practices, the excessive use of antimicrobials in veteriniary practice, and the excessive and inappropriate use of antimicrobials are the principle causes of the emergence and dissemination of resistant organisms.3–6 In this article, we concentrate on the prescribing of antibiotics, primarily in hospital, and their role in controlling the emergence and spread of resistance. Antibiotics remain the single most abused privilege doctors have.7 Those of us practising infection have known for many years the hazards of uncontrolled and inappropriate antibiotic prescribing. In general practice, where the bulk of antibiotic prescribing occurs (80% of all human antibiotic prescribing occurs in the community; 80% of these prescriptions are for respiratory tract infections), there are apparently wide variations in practice; for example between 5 and 50% of all antibiotic prescriptions are considered inappropriate.1,3 On the other hand, the Association of Medical Microbiology believe that 80% of antimicrobial prescribing in primary care in the UK appears to be `justified'.1 This clearly illustrates lack of clarity to what constitutes `inappropriate prescribing' and the lack of good data linking prescribing to outcome such as resistance and adverse reactions in the community.8 The drive in the community towards implementation of evidence based protocols for prescribing antibiotics,9 developing surveillance of antibiotic prescribing data and resistance,8,10 and producing a cultural change in the medical profession and public about antibiotic prescribing through continued education and feedback, is a welcome goal. The value of these integrated strategies have been the subject of an excellent editorial.11 In reality, these worthy goals are only likely to reach fruition if they are recognized by key decision-makers, patient groups advocating greater awareness, and government, as a priority area. One wonders how they will fare when competing for government resources with current priorities such as cancer, ischaemic heart and vascular diseases. However, there appears to be some light at the end of the tunnel, as a recent quote form Department of Health paper outlining research strategy for the NHS stated that `the threat from infectious diseases continues to be real, and will remain a priority. Research on topics such as vaccine preventable diseases, Hepatitis C and antibiotic resistant organisms and their control would be welcomed; however work on HIV/AIDS will no longer be accorded the same priority.'
Although in hospitals the volume of the drug prescribed is less (20% of all prescribed antibiotics), and the control supposedly tighter, there is clear evidence of inadequate case record documentation when prescribing antibiotics12,13 and inappropriate prescribing of antibiotics for prophylaxis14 and treatment.15–18 In addition, much of the antibiotics prescribed in hospital are parenteral and thereby more expensive.19 The principal reasons identified for inappropriate prescribing are insufficient training in infectious diseases and antibiotic treatment, difficulty of selecting appropriate anti-infective drugs empirically, insufficient use of microbiological information, need for self-assurance, and the fear of litigation.20 In the UK, the change in junior doctor working practices and a move away from a `team structure of delivering care' has exacerbated the long-standing problem that a bulk of the prescribing is done by those who have the least experience in doing so. However, there are some data to suggest that senior non-specialist clinicians are also poorly informed about antibiotic prescribing.21,22 The four particular areas of suboptimal prescribing remain: inadequate recognition of sepsis, leading to prescription of unecessary drugs; inappropriate route of antibiotic (the preference for the parenteral route); the choice of antibiotic; the dose and protracted duration of antibiotics.23–26 Recently, the use of low or suboptimal doses and long duration of treatment have clearly been shown to increase the risk of selecting resistance.27 The consequences of this are increased morbidity and mortality, and rising health-care costs from prolonged hospital stay and the need for more expensive drugs.28,29 Since a high proportion of antibiotic prescribing occurs in general medical wards30 (up to 15% of all our acute general medical admission receive antibiotics on admission), this article concentrates on how physicians in conjunction with infection specialists can optimize the quality of antibiotic prescribing so as to realise the desired endpoints of reduction in resistance, reduction in drug-related adverse reactions, improved patient morbidity and mortality and cost-effectiveness. This philosophy can be applied to other clinical areas in the hospital, for example, surgery and ITU.
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How then should we improve practice in hospital general medical wards? |
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TopIntroductionHow then should we...How can sepsis recognition...How can we improve...How can these strategies...What is the evidence...References |
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Two recent US recommendations31,32 have identified well-thought-out strategies to optimize the prophylactic, empiric and therapeutic use of antimicrobials in hospital, together with suggested measures of outcome and process to be used in audit. These guidelines are based more on expert opinion and on the results of descriptive studies than on controlled trials, which are difficult to design when evaluating such population-based interventions, particularly as the determinants of resistance are specific to the ecosystem of each hospital. Solutions are, therefore, best tailored to local needs. Although these guidelines are welcome and timely, it is unlikely that many UK hospitals have information systems which would allow easy assessment of many of the recommended outcome measures, but the process measures should be achievable without too much difficulty.
Over the last 6 years, we have evolved a number of similar strategies which are more applicable and realistic to undertake in British hospitals. Our experience commends a number of strategies aimed at: (a) reducing unnecessary prescribing, i.e not starting antibiotics at all or stopping them as soon as possible; (b) improving cost-effectiveness of prescribing (e.g. oral therapy in hospital and home iv therapy as an alternative to in-patient iv therapy for suitable patients,33 and (c) ensuring adequate documentation of information related to prescribing, so that meaningful audit can be performed. The strategies outlined below will serve one or more of these aims.
First, improve recognition and assessment of the patient with `sepsis'; this should be linked to adequate case-record documentation of why the prescribing clinician thinks the patient has sepsis, and why an antibiotic should be prescribed. This strategy will aim to reduce or stop commencement of unnecessary antibiotic prescribing and aid audit of antibiotic use.
Second, introduction of evidence-based protocols for the empiric management of sepsis. These protocols should incorporate a multitude of parameters based on local practice and antibiotic sensitivities, and should include whether the infection is deemed to be acquired in the hospital or community setting, the choice, route, dose and duration of antibiotic, the criterion for use of the intravenous route and when the patient can be switched to oral therapy, and how to deal with patients who have `true' (rash, anaphylaxis) penicillin or other drug hypersensitivity.
Third, the continuous and audit and feedback of prescribing at a group or unit level. This aim requires generating a spirit of enthusiastic proactive monitoring of practice supported by appropriate infrastructure (e.g. medical records, secretarial support). This process should not be seen as threatening or labour-intensive, but as a normal part of the clinicians duty. The eventual aim is to bring about an improvement in the relevant outcome indicators summarized earlier. Finally, these strategies are unlikely to work unless their implementation is supported by senior clinicians and hospital leadership (e.g. trust executive boards).34
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How can sepsis recognition and assessment be improved? |
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TopIntroductionHow then should we...How can sepsis recognition...How can we improve...How can these strategies...What is the evidence...References |
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Fever is a frequent finding on all services of a general hospital.35,36 Medical and surgical patients have the highest incidence of fever, estimated to be in the region of 30%.35 In this study, an equivalent percentage of fever was found not to be due to infection. Furthermore, the absence of fever does not exclude infection, as is the case in the elderly, neutropenic or immunocompromised patients.37,38 Clinicians frequently, 40% in one study, order investigations or prescribe antibiotics21 on patients who have no symptoms or signs of infection. This deficiency is further highlighted by a hospital-wide audit12 in Dundee, which revealed that only 30 to 60% of case records had recorded the indication for antibiotic prescribing. Recently, somewhat vague and ambiguous terms such as septiacemia have been replaced by terms for clinical syndromes (SIRS, Sepsis, Severe sepsis or sepsis syndrome, Septic shock) describing a progressive increase in the systemic inflammatory response to infection. The goal of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference39 was to provide clinicians with more precise definitions of the inflammatory response to infection which they may apply at the bedside or in clinical trials, and that has prognostic value.40 Unfortunately, these parameters have limitations in elderly and immunocompromised patients, those with deep-seated cardiovascular infections, and those on drugs such as beta-blockers.40
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How can we improve the use of parenteral antibiotics? |
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TopIntroductionHow then should we...How can sepsis recognition...How can we improve...How can these strategies...What is the evidence...References |
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Studies indicate that about one third of all hospitalized patients receive antimicrobial therapy,41 which accounts for between 3 and 25% of all prescriptions,42 and up to 41% of the drug budget in hospitals.43 In the latter, an increase in mean annual total expenditure of $US300 was noted per occupied bed, primarily due to a combination of antibacterial resistance, increased surgical use and improper use. Many of these drug costs are due to use of expensive broad-spectrum parenteral agents, often inappropriately prescribed in some respect.44,45 For example, in Dundee Teaching Hospitals Trust, over 5000 iv antibiotic injections are administered annually on a 40-bed acute medical or surgical unit;45 86–95% of these patients could have taken oral drugs.46
In the US47 and much of Europe,48 intravenous antibiotics are very much the `standard of care' for managing serious infections in hospitals. In the UK, there is much more of an `oral antibiotic use' culture.48 Despite this, some recent data indicate the preference for the intravenous route or for protracted courses of iv therapy when oral or in some cases no therapy would suffice.49,50 The latter audit50 found that 18% of patients were kept on iv antibiotics when change to oral therapy would have been appropriate. The main reasons for the delay appeared to be a reluctance by junior staff to change to oral therapy before the next consultant ward round or at weekends. Some economic consequences of this were calculated and extrapolated to over a 12-month period. The unnecessary expenditure on medicines for the 6-week period (cost difference between iv and oral doses) was £970, which extrapolates to £8400 in 12 months. One must, however, bear in mind the caveat that oral switch therapy may encourage unnecessary prolongation of treatment since it removes some of the important incentives to review prescribing (cost and inconvenience of iv therapy).45 Nonetheless, financial saving may be the way to a managers heart, and can be used to fund audit which encompasses the first aim. This preference for intravenous use stems from concern over the relative lack of available oral antibiotics with good broad-spectrum cover and bioavailability to ensure efficacy equivalent to their intravenous counterparts. In addition, there have been concerns about poor compliance with oral therapy and the perception amongst physicians that oral therapy is not the best available standard of care, leading to subsequent fear of liability in the event of unsuccessful clinical outcome. However, the last decade has witnessed the availability of improved oral agents that achieve higher or more persistent serum and tissue concentrations than previous drugs, accompanied by a better knowledge of the pharmacodynamics of antimicrobial efficacy, and a realization that they can often be met by oral therapy.47,51
Other potential consequences of such inappropriate treatment include increased exposure to unnecessary adverse reactions, including Clostridium difficile infections, prolonged hospital stay, selection of resistant organism, and increased morbidity.52–54
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How can these strategies be effectively implemented? |
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TopIntroductionHow then should we...How can sepsis recognition...How can we improve...How can these strategies...What is the evidence...References |
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Many different interventions have been used to influence the prescribing behaviour of physicians. A meta-analysis of 26 randomized controlled studies of these interventions confirmed that thoughtful interventions such as formularies and medical management protocols were successful, particularly on a one-to-one basis.55 Wider appreciation of the above definitions of sepsis by integration into various protocols, would ensure early and appropriate assessment and management. If one is going to be able to monitor the impact of such guidelines related to sepsis recognition and antibiotic prescribing, then accurate and complete case-record documentation is a pre-requisite. This could realistically be improved by guidance such as an antibiotic stamp or sticker.13 Furthermore, teaching on antibiotic prescribing, with increasing emphasis on the principles of protocol development and their use, should be an integral part of undergraduate teaching, an area clearly identified by the House of Lords report1 as being currently deficient and in need of action by the General Medical Council, and continuing post-graduate education. For example, in Dundee, we have introduced this teaching in third year and fifth year of the new undergraduate curriculum, the block release teaching during the pre-registration house job, and teaching in sepsis for those taking MRCP and FRCS. The teaching is done in close collaboration with medical microbiology and clinical pharmacy. All this activity is co-ordinated through the Undergraduate Medical Committee, the Antibiotic Sub-committee and Drug and Therapeutics Committees.
Traditionally, and in most UK hospitals, antibiotic control has been through various types of policies or formularies devised by microbiologists in conjunction with clinicians and pharmacists.30 In Dundee, as in the US,31,56 and elsewhere,57 ID physicians working in internal medicine are taking a more proactive role in developing and implementing antibiotic control strategies.
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What is the evidence for the effectiveness of ID physicians in improving the quality and cost-effectiveness of antibiotic prescribing in hospital.? |
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TopIntroductionHow then should we...How can sepsis recognition...How can we improve...How can these strategies...What is the evidence...References |
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This has been the subject of a recent review58 and research.59 The evidence indicates that ID physicians working with a multi-disciplinary teams have a significant effect on improving the quality of antibiotic prescribing and costs.30,56,57,59 Based on this evidence, it is reasonable to state that ID physicians working in internal medicine would be a valuable asset60 to any future senior hospital manager contemplating an appointment in general (internal) medicine. Not only would ID physicians provide expertise in communicable and other infectious diseases, AIDS, management of multi-resistant nosocominal infections, travel medicine and so on, they would help considerably to curb the excesses of irrational antimicrobial prescribing in the hospital. The clinical effectiveness and cost-effectiveness of such internal-medicine-related subspecialists need to be further defined.61 Although we accept that clinical microbiologists62 can have a similar impact, they are not able to provide an integrated clinical service along the lines previously described. However, the actual composition of any team providing advice on antibiotic prescribing is dependent on local practice and resource, but must include an infection specialist (microbiologist or ID physician or both) and a pharmacist. If we are to maintain the efficacy of currently available antimicrobials well into the next millenium and beyond, we urge physicians to support the development and active implementation of strategies aimed at improving the quality of antibiotic prescribing and advocate wider audit of this practice. We recommend that empiric therapy is justified if properly controlled, and the question `Is this antibiotic really necessary' is pertinent to all prescribers.
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References |
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TopIntroductionHow then should we...How can sepsis recognition...How can we improve...How can these strategies...What is the evidence...References |
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