Several antimicrobial stewardship strategies are aimed at improving the quality
of antibiotic use, including the provision of guidelines for optimal antibiotic selection, de-escalation of therapy, reduction of prolonged duration of therapy, and conversion of antibiotic treatment from an intravenous to an oral route.1
However, with the pressing global threat of antimicrobial resistance, consideration of the highest-yield activities that maximally reduce the quantity
of antibiotic exposure is of critical significance. For example, reducing duration of therapy or using a narrower-spectrum antibiotic will reduce the risk of antibiotic resistance, Clostridioides difficile
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,2
cellulitis mimics such as stasis dermatitis,4
and aspiration pneumonitis.5
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)6
and viral upper respiratory tract infection (URTI).7
Antimicrobial stewardship leaders have described these conditions as antibiotic never events (ANEs).8
The term never events
was introduced in 2001 to describe severe medical errors that should never occur and are largely preventable.9
Experts have suggested that the field of antimicrobial stewardship borrows this terminology and uses the term antibiotic never events
to address the appropriateness 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.
TWO KEY ANEs: ASB AND VIRAL URTI
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—overwhelming evidence shows that treating ASB with antibiotics is not beneficial 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.10
Viral Upper Respiratory Tract Infections
In outpatient settings, a large proportion of patients with acute upper respiratory tract infections receive antibiotic prescriptions 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.11
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 are12,13
- Fear of harm: Concerns about antibiotic under-treatment harms (recurrence, increased severity) often trump those of overtreatment (adverse effects, antibiotic resistance, C difficile infection).
- Externalized responsibility: Prescribers may believe the harms of antibiotic therapy are more likely caused by other clinicians in other settings, distant from their own.
- Balancing of risks: Immediate risk to the patient is weighted heavily over less tangible delayed risks to the patient and the population.
- Diagnostic uncertainty: Clinicians will err on the side of caution by prescribing antibiotics in uncertain situations, thereby reducing cognitive effort associated with differential diagnoses.
- Perceived demand: 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.14
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.15
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 behavioral 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.16
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.17
Two recent randomized, controlled trials in outpatient settings have found that providing social normative feedback on antibiotic prescribing resulted in a significant decrease in prescribing.18,19
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.20
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.21
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 demonstrated 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.22
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, resident 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.23
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) discontinuing the use of dipsticks for UTI diagnosis, (3) obtaining a urine culture only when residents have signs and symptoms of UTI, (4) obtaining a culture with proper technique to avoid contamination, and (5) recommending antibiotics only when clinical criteria are met. This program decidedly 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 antibiotic use.24
Preventing unnecessary antibiotic treatment before it starts is a vital component of antimicrobial stewardship initiatives. 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 comparison, 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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