TY - JOUR
AU - Traynor,, Kate
AB - Efforts to reduce unnecessary antimicrobial use in outpatient settings can lead to awkward conversations with patients about why they shouldn’t use up a medication that they’ve already paid for. “If you give someone a prescription and you call them and say, ‘I know you just bought 20 tablets and you’ve only taken 2, but I’m telling you I don’t want you to take the other 18,’ that’s hard,” said Elizabeth Dodds-Ashley, clinical pharmacist with the Duke Antibiotic Stewardship Outreach Network and associate professor in medicine at Duke University Medical Center in Durham, North Carolina. Such a recommendation could arise if culture results indicate the therapy is not needed but the patient has already been to a pharmacy to pick up their prescribed course of antimicrobial therapy. Dodds-Ashley pointed out that this situation doesn’t occur in inpatient settings. “In the hospital … if I stop an antibiotic today, that patient … won’t be paying for tomorrow’s dose, because we won’t dispense it,” she said. Dodds-Ashley’s insights followed the July 26 publication in BMJ of a hotly debated commentary arguing that prescribers should not routinely instruct patients to complete their full course of antibiotics, because the practice contributes to unnecessary overuse and drives antimicrobial resistance. The article’s authors are mostly concerned about “collateral” resistance developing in bacteria that are present in the patient but aren’t causing the infection for which treatment is sought. “Completing the course goes against one of the most fundamental and widespread medication beliefs people have, which is that we should take as little medication as necessary,” the article states. Possible alternatives to instructing patients to “complete the course” could include discontinuation of the antimicrobial when patients feel better or when their fever is gone, according to the BMJ article. But the United Kingdom–based authors acknowledged that new research is needed to develop sound messages for patients about the appropriate duration of therapy. The Centers for Disease Control and Prevention (CDC) has stated that antimicrobial misuse in outpatient settings is common and involves inappropriate antimicrobial selection and prescriptions for antimicrobials in the absence of infection. Factors that contribute to this misuse, according to CDC, include clinicians’ failure to order laboratory tests to confirm the presence of an infection and pressure from patients to prescribe an antibiotic for viral illnesses. Dodds-Ashley acknowledged that in primary care settings, it’s much faster to send a patient home with a prescription for an antimicrobial than to explain to the patient why the medication is unnecessary. “The challenge, and the key to success, is making the right thing the easy thing to do,” she said. Dodds-Ashley said she doesn’t think clinicians, when they prescribe antimicrobials, are inclined to discard the complete-the-course instruction. “It’s still the common mantra, and it’s still on the auxiliary label” that many pharmacies affix to medication containers, she said. But she said there are ways for clinicians to appropriately shorten antimicrobial courses. “I think the first big step … is to start asking yourself, ‘Would a shorter course be just as good and not cause any harm?’” she said. She said antimicrobial prescriptions are typically written for 7, 10, or 14 days of therapy on the basis of data from traditional efficacy studies of the drugs. But there’s evidence that in some cases, such as uncomplicated urinary tract infection in women, 3–5 days of antimicrobial therapy is adequate. “It depends on the drug and where the infection is,” she said. But at primary care clinics that have adopted electronic prescribing systems, she said, the technology may default to 7- or 10-day antimicrobial courses. “Computer systems for prescribing are usually [configured] for provider convenience,” she said. “One thing that I am a huge proponent of … is not having a quantity or days’ supply for antibiotics, and making providers input that every time.” Dodds-Ashley said this would reinforce to clinicians that they need to consider the duration of therapy each time they prescribe an antimicrobial. “I don’t think it should be [done] on autopilot. I think it’s something that should require careful thought for each patient,” she said. She said big changes in outpatient antimicrobial use would likely require “creative solutions,” possibly including payment models that eliminate multiple copayments for patients if they are given a short antimicrobial course and require additional doses. Another possibility could be a payment system that supports pharmacists’ efforts to assess patients’ response to antimicrobial therapy and determine when they should stop taking the medications. “Wouldn’t it be nice … if we could come up with some sort of model where patients could stop by the pharmacy for an assessment of whether their antibiotics are still needed?” Dodds-Ashley asked. Copyright © 2017 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
TI - Antimicrobial stewardship faces hurdles in primary care
JF - American Journal of Health-System Pharmacy
DO - 10.2146/news170063
DA - 2017-10-01
UR - https://www.deepdyve.com/lp/oxford-university-press/antimicrobial-stewardship-faces-hurdles-in-primary-care-2BkTrh3NUx
SP - 1516
VL - 74
IS - 19
DP - DeepDyve
ER -