In their article in this issue of American Family Physician, Hooten and Levy1 point out that drug-resistant microorganisms are a growing global problem. Use of antimicrobial agents creates an environment open to the development of resistance, placing both general populations and individual patients at risk. Antibiotic resistance has been shown to be proportional to the volume of antibiotic consumption; reduction in resistance requires a proportional reduction in consumption.2 Consequently, judicious use of antibiotics must be part of the solution to the problem of drug resistance. Otherwise, the current concern about a “post-antimicrobial era,” in which antimicrobial agents will no longer be effective, may become a reality.
Recently, the U.S. Food and Drug Administration proposed that all antibiotics dispensed in the United States contain warning labels encouraging physicians to prescribe antibiotics only when clinically necessary and to talk with patients about taking the medication exactly as directed.3 As an example, although evidence documents the lack of benefit and possible harm of antibiotic therapy for the treatment of many respiratory tract infections, antibiotics continue to be prescribed for these primarily viral conditions.4,5
The overall goal of reducing antibiotic prescriptions should be to minimize antibiotic resistance while appropriately delivering quality health care. Effective strategies to accomplish this goal must be identified, and all health care groups must promote and participate in efforts to reduce antibiotic resistance. Education is integral to Hooton and Levy's1 plan to reduce antibiotic resistance.
Overuse of antibiotics may relate to misinformation or misunderstanding about which infections benefit from the use of an antibiotic. For example, most patients understand that antibiotics are not needed for colds. But when they find they have discolored, rather than clear, nasal discharge with symptoms of a cold, the vast majority of them think an antibiotic is necessary treatment.6 Where did they learn this? This misinformation may have come from physicians and pharmacists who, when presented with the same description of signs and symptoms, also thought antibiotic therapy was necessary.7,8 Knowing not to use antibiotics to treat viral infections is not the only thing that matters—knowing what is a viral infection is also important.
Currently, in the United States, access to antibiotics is more restricted than it is in many other countries. In many countries, antibiotics are legally available without a prescription or existing regulations are not uniformly enforced. Studies indicate that in countries with little regulation of antibiotics, substantial misuse occurs. People in these countries frequently self-diagnose their ailments and buy antibiotics in quantities too small to kill all bacteria but large enough to promote resistance.9–14 In a town on the U.S. side of the U.S.–Mexico border, 75 percent of those questioned had purchased antibiotics in Mexico without a prescription.10
It is likely that the use of antibiotics without a prescription mirrors cultural systems of self-diagnosis and self-management. In a study15 of Bronx residents, 26 percent reported using nonprescribed antibiotics for upper respiratory tract infections in the past year. Thirty-one percent of the persons in this study believed that antibiotics should be available on an over-the-counter basis. Depending on their birthplace or the birthplace of their mother, persons were divided into three groups that reflected control of antibiotic access in the different countries. Those from countries where antibiotics are available without a prescription were more likely than those from countries with some regulations or the U.S. group to report using antibiotics that were not prescribed by a physician to treat a cough or a cold (40 percent versus 30 percent versus 20 percent, respectively; P < 0.05).
It is clear that education is warranted, but many of the general passive educational interventions employed up to this point have yielded disappointing results. An exception was shown in the results of a study16 conducted in a closed setting in which education was provided by physicians' immediate supervisors. Widespread dissemination of practice guidelines is not an effective means of changing practice.17 Even government-sponsored or third-party feedback on prescribing patterns has not been shown to have an impact on the antibiotic prescribing habits of generalist physicians.18,19
In contrast, the use of administrative or financial controls has been successful in limiting antibiotic use and decreasing resistance. Antibiotic control policies are usually institutional interventions that create barriers to inappropriate practices and limit prescriber autonomy. Administrative interventions may also come from governmental agencies, which enforce specific practices through laws, regulations or recommendations.
Inpatient antibiotic control programs have been successful and contain mechanisms such as automatic therapy stop dates. Other programs require clinical justification for the specific antibiotic order before it can be dispensed by the pharmacy. In a 1996 survey,20 81 percent of university-affiliated teaching institutions were shown to have used antibiotic restriction policies and 56 percent to have used official recommendations to guide antibiotic use.
Restricting the use of specific antibiotics and antibiotic classes has been effective in altering patterns of resistance in individual institutions. In a hospital with significant rates of cephalosporin-resistant Klebsiella pneumoniae, an antibiotic control policy was developed that, in general, excluded the use of cephalosporins without prior approval from an infectious disease expert.21 In one year, ceftazidime-resistant Klebsiella was reduced by 36 percent in nosocomial infections.
In Finland, a national initiative22 restricted the use of erythromycin and other macrolide antibiotics in the treatment of respiratory and skin infections in outpatients in an effort to combat erythromycin resistance among group A streptococci. This initiative led to a decline in the use of macrolide antibiotics from 2.4 defined daily doses per 1,000 in 1991 to 1.38 defined daily doses per 1,000 in 1992. In return, a decrease in the frequency of erythromycin resistance was noted, from 16.5 percent in 1992 to 8.6 percent in 1996.
Currently, the biggest risk factor for the development of drug resistance in the United States is that patients continue to consult a physician for help with a viral infection. Because of the limited success of most guidelines and educational interventions coupled with the increasing levels of antibiotic resistance, extraordinary strategies may be required to prevent antibiotic resistance. We must find a way to educate patients about when it is necessary to see a physician for upper respiratory symptoms, keep ourselves from prescribing antibiotics or change the way these medications are used. The choice from the physicians' perspective is clear. If we fail to reduce injudicious antibiotic use ourselves, someone else will find a way to do it for us.