SHARE the Responsibility of Antibiotic Stewardship With Our Patients

March 3, 2021
Audry Hawkins, PharmD

Audry Hawkins is a PGY-2 Infectious Diseases Pharmacy Resident at MUSC Health. She is an active member of multiple organizations and the current resident member of the ACCP ID PRN Executive Committee.

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Bradley Langford, PharmD, BCIDP

Bradley Langford is a Pharmacist Consultant at Public Health Ontario and an Antimicrobial Stewardship Pharmacist at Hotel Dieu Shaver Health and Rehabilitation Centre in Ontario, Canada. Dr. Langford’s practice and research interests include the implementation and evaluation of antimicrobial stewardship initiatives in all healthcare settings.

Strategic Alliance Partners | <b>Society of Infectious Diseases Pharmacists</b>

How pharmacists can use shared decision-making to improve antibiotic use.

According to the US Centers for Disease Control and Prevention (CDC), up to 90 percent of antibiotics prescribed are for patients in the outpatient setting. Outpatient antibiotic prescribing is heavily influenced by social norms and behavioral factors, resulting in a high degree of variability between prescribers as well as a significant volume of inappropriate use.1,2 Fifty percent of outpatient antibiotics are prescribed inappropriately while 30 percent are unnecessary, driving antimicrobial resistance (AMR) and the need for antimicrobial stewardship (AMS).1 Given their accessibility and expertise in medication management, pharmacists practicing in primary care settings play an important, yet underutilized role in supporting AMS initiatives.3

Antibiotic use in the community poses a unique challenge to AMS, placing increased emphasis on the relationship between provider and patient. Upper respiratory tract infections (URTI) are one of the most common indications for antibiotic overuse in the community.4 The majority of URTIs are caused by viruses, however perceived patient demand acts as an important driver of inappropriate antibiotic prescribing for these infections.5 In these situations, clinicians often focus on patient satisfaction and providing value in addition to the emotional, financial, and reputational consequences of not prescribing antibiotics.6 In addition, there may be a tendency for patients and clinicians to over-estimate the benefit of antibiotics, while under-estimating their risks.7-10 Perceived patient desire for antibiotics coupled with these misconceptions of benefit and harm lead to a perfect storm for antibiotic overuse use in the outpatient setting.

Shared decision-making (SDM) is an approach to calm this storm by empowering the patient to be involved in evidence-informed decision-making while improving both the patient and provider’s collective consideration of the benefits and risks of antibiotic use.11 A mnemonic for this process, SHARE, provides a simplified way to remember and prioritize the five steps in this process.12

  • Seek your patient’s interest in participating
  • Help your patient explore and compare the benefits and risks of treatment options (including no treatment)
  • Assess your patient’s values, beliefs, and preferences
  • Reach a decision together with your patient
  • Evaluate and follow up on the decision

From an AMS perspective, inter-professional efforts to discuss the risks and benefits of antibiotics can aid in improved antibiotic prescribing. Physician-led SDM in primary care has been shown to decrease inappropriate antibiotic prescribing without compromising clinical outcomes.13Also in primary care but a different patient population, pharmacist-led SDM for patients using antidepressants was associated with improved adherence, patient satisfaction, and beliefs about medications.14 Pharmacists are often the first health-care provider a patient encounters when seeking symptom relief for URTI, and the last provider a patient interacts with prior to beginning an antibiotic. Utilizing tools for SDM, whether pharmacists are acting as a prescriber (e.g., in a collaborative practice setting) or educating their patients before or after a prescription (e.g., in a retail pharmacy setting) pharmacists are well-positioned to ensure the patient truly understands the role of antibiotics.

The following are key tools to aid in SDM for antimicrobial stewardship.

1. The viral prescription pad is a physical prescription the patient can take home with actionable items for supportive care for a viral URTI.

2. Decision aids can also be used to guide discussions between clinicians and patients while better visualizing antibiotic benefits and risks.

As medication experts, pharmacists practicing in primary care settings play a crucial role in reducing antibiotic overuse. By taking time to SHARE in a two-way dialogue about the risks and benefits of antibiotics, pharmacists can be pivotal in reducing the risk of AMR for their patients and their communities.

Bradley Langford is a pharmacist consultant at Public Health Ontario and an antimicrobial stewardship pharmacist at Hotel Dieu Shaver Health and Rehabilitation Centre in Ontario, Canada. Langford’s practice and research interests include the implementation and evaluation of antimicrobial stewardship initiatives in all healthcare settings.

Audry Hawkins is a PGY-2 Infectious Diseases Pharmacy Resident at MUSC Health. She is an active member of multiple organizations and the current resident member of the ACCP ID PRN Executive Committee.

The Society of Infectious Diseases Pharmacists (SIDP) is an association of pharmacists and other allied healthcare professionals who are committed to promoting the appropriate use of antimicrobial agents and supporting practice, teaching, and research in infectious diseases. We aim to advance infectious diseases pharmacy and lead antimicrobial stewardship in order to optimize the care of patients. To learn more about SIDP, visit sidp.org.

References

1. Merton T, Images G. What Drives Inappropriate Antibiotic Use in Outpatient Care? :8. Centers for Disease Control and Prevention (U.S.). Antibiotic resistance threats in the United States, 2019 [Internet]. Centers for Disease Control and Prevention (U.S.); 2019 Nov [cited 2021 Jan 20]. Available from: https://stacks.cdc.gov/view/cdc/82532

2. Schwartz KL, Brown KA, Etches J, Langford BJ, Daneman N, Tu K, Johnstone J, Achonu C, Garber G. Predictors and variability of antibiotic prescribing amongst family physicians. Journal of Antimicrobial Chemotherapy. 2019 Jul 1;74(7):2098-105

3. Bishop C, Yacoob Z, Knobloch MJ, Safdar N. Community pharmacy interventions to improve antibiotic stewardship and implications for pharmacy education: A narrative overview. Res Social Adm Pharm. 2019 Jun;15(6):627–31.

4. Fleming-Dutra KE, Hersh AL, Shapiro DJ, Bartoces M, Enns EA, File TM, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. JAMA. 2016 May 3;315(17):1864–73.

5. Thomas M, Bomar PA. Upper Respiratory Tract Infection. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 [cited 2021 Jan 20]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK532961/

6. Kohut MR, Keller SC, Linder JA, Tamma PD, Cosgrove SE, Speck K, et al. The inconvincible patient: how clinicians perceive demand for antibiotics in the outpatient setting. Fam Pract. 2020 Mar 25;37(2):276–82.

7. Langford BJ, Daneman N, Leung V, Wu JHC, Brown K, Schwartz KL, et al. The second-hand effects of antibiotics: communicating the public health risks of drug resistance. JAC-Antimicrobial Resistance [Internet]. 2019 Dec 1 [cited 2021 Jan 29];1(dlz059). Available from: https://doi.org/10.1093/jacamr/dlz059

8. Légaré F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J. Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial. CMAJ. 2012 Sep 18;184(13):E726–34.

9. Martinez KA, Rood M, Jhangiani N, Kou L, Boissy A, Rothberg MB. Association Between Antibiotic Prescribing for Respiratory Tract Infections and Patient Satisfaction in Direct-to-Consumer Telemedicine. JAMA Intern Med. 2018 Nov 1;178(11):1558.

10. Coxeter PD, Del Mar C, Hoffmann TC. Parents’ expectations and experiences of antibiotics for acute respiratory infections in primary care. The Annals of Family Medicine. 2017 Mar 1;15(2):149-54.

11. Grad R, Légaré F, Bell NR, Dickinson JA, Singh H, Moore AE, et al. Shared decision making in preventive health care. Can Fam Physician. 2017 Sep;63(9):682–4.

12. Agency for Healthcare Research and Quality. The SHARE approach essential steps of shared decision making. 2014. Available: www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/tools/shareposter/index.html (accessed Dec 22, 2021).

13. van Esch TEM, Brabers AEM, Hek K, van Dijk L, Verheij RA, de Jong JD. Does shared decision-making reduce antibiotic prescribing in primary care? J Antimicrob Chemother. 2018 Nov 1;73(11):3199–205.

14. Aljumah K, Hassali M. Impact of pharmacist intervention on adherence and measurable patient outcomes among depressed patients: a randomised controlled study. BMC Psychiatry. 2015 Sep 16;15(1):219.