Kevin Schwartz, MD, MSc, FRCPC

Several antimicrobial stewardship strategies are aimed at improving the 

of antibiotic use, including the provision of guidelines for optimal antibiotic selection, de-escalation of therapy, reduc&shy;tion of prolonged duration of therapy, and conversion of antibiotic treat&shy;ment from an intravenous to an oral route.

However, with the pressing global threat of antimicro&shy;bial resistance, consideration of the highest-yield activ&shy;ities that maximally reduce the 

of antibiotic exposure is of critical significance. For example, reducing duration of therapy or using a narrower-spectrum anti&shy;biotic will reduce the risk of antibiotic resistance, 

infection, and adverse effects, but if the patient has a noninfectious condition, the highest-yield approach to reducing collateral damage is avoiding antibiotic use in the first place. When no benefit of antibiotic use exists, any harm is unnecessary and avoidable.

Antimicrobial stewards will recognize the multitude of noninfectious conditions that often receive unnecessary antibiotics, including blood culture contamination,

 cellulitis mimics such as stasis dermatitis,

However, more than 90% of antibiotics are used outside hospitals, with 2 of the most common reasons for unnecessary antibiotic use being asymptomatic bacteriuria (ASB)

 and viral upper respiratory tract infection (URTI).

Antimicrobial stewardship leaders have described these conditions as antibiotic never events (ANEs).

was introduced in 2001 to describe severe medical errors that should never occur and are largely preventable.

Experts have suggested that the field of antimicrobial stewardship borrows this terminology and uses the term 

to address the appro&shy;priateness of antibiotic prescribing. We aim to review these 2 key ANEs, describe challenges, and list key strategies that clinicians can employ to prevent unnecessary antimicrobial exposure for their patients.

ASB is the presence of bacteria in the urine without signs or symptoms attributable to urinary tract infection (UTI). The prevalence of ASB can be as high as 15% to 50% in older adults and as high as 100% in those with chronic indwelling urinary catheters. Aside from treatment for 2 populations— patients who are pregnant and those undergoing urological procedures expected to cause mucosal trauma&mdash;overwhelming evidence shows that treating ASB with antibiotics is not bene&shy;ficial and can lead to harm, including increased risk of adverse effects and antimicrobial resistance. Positive urine cultures are often unjustly deemed to be indicative of UTIs in patients with nonspecific symptoms (eg, delirium or foul-smelling or cloudy urine) and, as such, are identified as major targets for antimicrobial stewardship programs in long-term care and acute care to reduce unnecessary antibiotic use.

Viral Upper Respiratory Tract Infections 

In outpatient settings, a large proportion of patients with acute upper respiratory tract infections receive antibiotic prescrip&shy;tions despite their likely viral etiology. Sinusitis, bronchitis, and acute pharyngitis are typically viral infections and are 3 of the main reasons for antibiotic misuse in primary care. In fact, up to half of antibiotic prescriptions for upper respiratory tract infections have been determined to be unnecessary.

REASONS FOR UNNECESSARY ANTIBIOTICS AND STRATEGIES TO PREVENT THEIR USE 

Antibiotic prescription decisions are complex. In addition to lack of knowledge or awareness of evidence, some other factors commonly cited as reasons for antibiotic overuse are

Concerns about antibiotic under-treatment harms (recurrence, increased severity) often trump those of overtreatment (adverse effects, antibiotic resistance, 

Prescribers may believe the harms of antibiotic therapy are more likely caused by other clinicians in other settings, distant from their own.

Immediate risk to the patient is weighted heavily over less tangible delayed risks to the patient and the population.

Clinicians will err on the side of caution by prescribing antibiotics in uncertain situations, thereby reducing cognitive effort associated with differential diagnoses.

Pressure from patients and family may be real or perceived, and the concern that non-prescribing can reduce patient satisfaction.

Strategies to prevent unnecessary use should take into account the known barriers associated with overuse behavior. The drivers of unnecessary antibiotic use are frequently emotionally salient to both the patient and prescriber. Antimicrobial stewardship strategies, on the other hand, are inherently less emotionally salient.

 Therefore, strategies must use the principles of behavioral science by addressing the emotional aspect of prescribing, the environmental context in which prescribing decisions are made, and factors related to prescribers’ capability, opportunity, and motivation to change their behavior.

 For these reasons, education alone is typically insufficient to improve antibiotic prescribing.

The following are a few well-supported strategies to prevent antibiotic never events.

Audit and feedback with peer comparison have been shown to be more effective than traditional approaches for behav&shy;ioral change. They can be helpful for reducing prescribing variability and targeting outlier prescribers by illustrating the difference in their antibiotic prescribing practice compared with that of their peers.

 Peer comparison uses behavioral strategies of persuasive communication and social normative feedback that have been shown to nudge prescribers to prescribe fewer antibiotics without causing harm.

 Two recent randomized, controlled trials in outpa&shy;tient settings have found that providing social normative feedback on antibiotic prescribing resulted in a significant decrease in prescribing.

For those looking to implement audit and feedback, Brehaut and colleagues presented 15 practical strategies to improve impact, including frequency of feedback provision, choice of comparators, and use of actionable messaging.

Shared decision making involves conversations between the prescriber and the patient. It is facilitated by eliciting patient expectations and providing information on the benefits and risks of therapy and their expected frequency of occurrence. This approach has been shown to reduce inappropriate antibiotic prescribing for URTIs while maintaining patient satisfaction.

 Various decision aids and infographics are available to support this process.

Given the frequently cited concern that patients and family members demand antibiotics for indications that do not require them (eg, ASB or viral URTIs), clinicians can follow additional techniques to address these challenging issues. Research on communication strategies has demon&shy;strated the effectiveness of providing a positive treatment recommendation (“You can take a spoonful of honey to ease your sore throat and prevent cough”), as well as a negative treatment recommendation (“This infection is likely caused by a virus, so you shouldn’t take antibiotics because they won’t help”). This communication strategy results in shorter clinical visits, a lower likelihood of receiving an antibiotic prescription, and high family satisfaction.

Tools such as viral prescribing pads that replace antibiotic prescriptions can be helpful in employing these negative and positive recommendations, thus ensuring patients feel satisfied despite not receiving an antibiotic. Likewise, resi&shy;dent and family letter templates can help to ensure that caregivers are aware of the harms of treating ASB with antibiotics and the contingency plans to improve patients’ symptoms (eg, increased fluid intake, increased frequency of monitoring).

A comprehensive program implemented in 10 long-term care homes in Ontario, Canada, used a multimodal approach to successfully prevent unnecessary urine culturing.

 The program incorporated key strategies for developing new policies and procedures, appointing local champions, providing education to staff and families, coaching, and process surveillance that were tailored to known challenges to reducing urine culturing. In addition to these strategies, formation of an implementation team and buy-in from staff and prescribers were noted to be key success factors. Five practice changes were employed: (1) discontinuing routine urine screening, (2) discontin&shy;uing the use of dipsticks for UTI diagnosis, (3) obtaining a urine culture only when residents have signs and symp&shy;toms of UTI, (4) obtaining a culture with proper technique to avoid contamination, and (5) recommending antibiotics only when clinical criteria are met. This program decid&shy;edly aimed at urine culturing to prevent the downstream consequences of reacting to a positive urine culture.23 The multimodal strategy was associated with a 28% reduction in urine culturing and a 40% reduction in urinary anti&shy;biotic use.

Preventing unnecessary antibiotic treatment before it starts is a vital component of antimicrobial stewardship initia&shy;tives. Key high-yield opportunities include the prevention of antimicrobial never events, such as antibacterial treatment of viral URTIs and ASB. The drivers for antibiotic overuse are multifactorial, so solutions may need to be multifaceted to address known barriers to behavioral change. Effective evidence-based antimicrobial stewardship strategies to prevent unnecessary antibiotic use include peer compar&shy;ison, patient communication strategies, and multifaceted educational and organizational initiatives.

Langford is a pharmacist consultant in the Antimicrobial Stewardship Program at Public Health Ontario in Canada. He is also the lead antimicrobial stewardship pharmacist at St. Joseph’s Health Centre Toronto in Canada, where he helped build a stewardship program. His research interests include the implementation and evaluation of antibiotic stewardship initiatives in all health care sectors. *He is an active member of the Society for Infectious Diseases Pharmacists. 

Lo is an antimicrobial stewardship pharmacist at Sunnybrook Health Sciences Centre in Toronto, Canada, and a pharmacist consultant with the Antimicrobial Stewardship Program at Public Health Ontario. Her practice and research interests include interprofessional education, knowledge translation, and health care technology. 

Schwartz is a pediatrician and infectious disease specialist at St. Joseph’s Health Centre Toronto, as well as an academic infection control and antimicrobial stewardship physician at Public Health Ontario. He is an assistant professor at the Dalla Lana School of Public Health at the University of Toronto and an adjunct scientist at ICES in Canada. His research interests include vaccine-preventable diseases and antimicrobial stewardship.

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By stopping unnecessary antibiotics before they start, clinicians can avoid unnecessary harm to the patient and the population. 

Kevin Schwartz, MD, MSc, FRCPC

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