Antibiotics can also precipitate minor to severe adverse events and other unintended consequences that compromise patient safety. They can cause side effects, such as rashes and antibiotic-associated diarrhea, as well as severe allergic reactions, including a life-threatening condition known as anaphylaxis.
One in a thousand antibiotic prescriptions leads to an emergency department visit for an adverse event—totaling 142,000 ER visits per year for antibiotic-associated adverse events. Among children, antibiotics are the most common cause of drug-related ER visits.
Emerging evidence points to long-term consequences of antibiotic use, associating them with chronic conditions, such as allergic and autoimmune diseases by disrupting the community of microbes living in and on our bodies and the collective genes and their products.
Another serious unintended consequence of antibiotic use is Clostridium difficile
infections. C. difficile
is a bacterium that can cause potentially life-threatening diarrheal illness. In 2013, the CDC estimated that C. difficile
was responsible for at least 250,000 infections and 14,000 deaths in the United States, leading to approximately $1 billion in medical costs. More recent projections were even higher, citing 453,000 infections and 15,000 deaths annually.
The initial steps to implementing outpatient antibiotic stewardship are identifying opportunities for improvement by pinpointing the high-priority conditions for intervention, in which clinicians are commonly deviating from best practices for prescribing antibiotics. For instance, antibiotics are often overprescribed for acute bronchitis.
It’s also important to identify barriers that lead to deviation from best practices, such as clinician knowledge gaps, perception of patients’ expectations for antibiotics, perceived pressure for practitioners to see them quickly, and concerns about decreased satisfaction with visits when antibiotics are not prescribed.
Setting standards for antibiotic prescribing is essential as well. They can be based on national clinical practice guidelines by professional organizations, such as the American Academy of Pediatrics, the American College of Physicians, or the Infectious Diseases Society of America, to name a few.
“Establishing standards is really the foundation of deciding what is and what is not appropriate antibiotic prescribing,” Dr. Fleming-Dutra said. “Clinicians need to know what they are supposed to be prescribing to be able to make improvements.”
She highlighted four core elements of outpatient antibiotic prescribing: commitment to demonstrating dedication to and accountability for optimizing prescribing and patient safety; action to implement at least one policy or practice to improve prescribing and assess whether it’s working and modify as needed; tracking and reporting prescribing practices and offering regular feedback to clinicians or having them assess their own antibiotic use; and education and expertise to provide educational resources to clinicians and patients.
Even clinicians who are pressed for time can inform patients about appropriate antibiotic use and potential harms, including both common and serious side effects, C. difficile
infection, and antibiotic resistance. Clinicians can provide materials that contain information about potential adverse drug events and symptomatic relief for common infections, Dr. Fleming-Dutra said.
“Patients really want communication whether or not they get an antibiotic,” she added. Many experts would contend that “part of good patient care, regardless of the treatment plan that you’re providing, is “to give those messages in short and succinct ways that don’t add much time to the visit but also help maintain satisfaction.”
Susan Kreimer, MS, is a medical journalist who has written articles about infectious diseases and many other health topics. For two decades, her coverage has informed consumers, physicians, nurses and health system executives. Raised in the Chicago area, she holds a master’s degree in journalism from Columbia University and lives in New York City.
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