Improving Antibiotic Stewardship by Managing Patient Expectations
Posted in GUMC Stories
NOV. 6, 2015–During the “Antibiotics: Panacea or Problem?” colloquium held Nov. 3 in the Research Building Auditorium as part of the eighth annual GUMC Convocation, panelists representing the fields of infectious disease, family medicine and public health addressed the growing threat of antibiotic resistance.
Moderated by Edward Healton, MD, MPH, executive vice president for health sciences and executive dean of the School of Medicine, the event featured Martin Blaser, MD, the Muriel and George Singer professor of medicine and professor of microbiology, as well as the director of the Human Microbiome Program, at New York University Langone Medical Center.
As the 2015 Cura Personalis Award winner, Blaser explained that one of the factors driving increased use of antibiotics is that doctors and patients alike believe that taking them is unlikely to be harmful though it may be helpful for treating an ailment. “Because of the miraculous nature of antibiotics, we’ve given them a blind eye. We think they might help and they won’t hurt,” he said. “We think they have benefits but not costs.”
Blaser identified two specific costs during his opening remarks. Until recently, infections from methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. diff) were only contracted in hospitals. But today, people in the community who have not been hospitalized are developing these infections as well. “The more antibiotics we use, resistance grows, and the patients in the hospital are getting more and more resistant organisms,” Blaser said. “And unfortunately, problems that were confined to the hospital are now spilling out into the community.”
At the colloquium, Blaser was joined by GUMC faculty members including infections disease specialist Jesse Goodman, MD, MPH, professor of medicine and director Georgetown’s Center on Medical Product Assess, Safety and Security. Goodman has convened a group of physicians in the Washington area to address antibiotic resistance in the hospital setting. In addition, two primary care physicians on the frontlines of the antibiotic stewardship, Dan Merenstein, MD, associate professor of family medicine, and Ranit Mishori, MD, MHS, professor of family medicine, discussed their experiences. Mishori says the growing antibiotic resistance has affected her patients.
“We are seeing it in the community as well. We see it in STDs, with the highest rates of gonorrhea that is resistant to all kinds of antibiotics, with resistance to skin infections through MRSA,” Mishori said. “We see it in all kinds of common organisms in the upper respiratory system that are now resistant, as well as in urinary tract infections that are now resistant.”
Patients frequently ask Mishori for antibiotics but she sometimes doesn’t have enough time to explain why they are not the best course of action for every ailment. “When I have patients every 15 or 20 minutes and they’re very persistent and they want to be fixed tomorrow and I’m 30 minutes behind schedule, will I have the patience and do I even have the communication skills to explain to my patients why I’m not going to give them antibiotics? And the answer often is no,” she said. “This is one of the reasons why I have, on occasion, prescribed antibiotics inappropriately.”
Both patients and physicians need to reconsider their views on antibiotics, Goodman said. “What we’re talking about with stewardship is really a complete culture change,” he said. “Patients have to think differently about antibiotics so they can affect the demand side, and physicians and health systems have to think differently about it so that we behave differently.”
Understanding the pressures that physicians are under as well as the nature of most common ailments will help patients avoid unnecessary antibiotics, Merenstein explained. For example, most of the time when a patient has a runny nose, the condition will resolve itself in 7-14 days, while a cough will typically last 17-21 days. “People need to understand that before they go to a physician, because if you go to a physician, you’re going to get antibiotics,” he said.
Having better diagnostic tools to determine whether a condition is being caused by a virus or a bacterium would immediately reduce the numbers of unnecessary prescriptions for antibiotics, Goodman said. Such tools could also attempt to identify the most effective antibiotics for a particular patient. “This is an area in which I think technology can revolutionize what people are doing,” he said.
Merenstein challenged the idea that improved tests are necessary, explaining that primary care physicians are capable of diagnosing typical infections. “We can get more tests,” he said. “I am all for more tests but unless you work with primary care physicians and get a change in the culture of medicine, it’s not going to do anything.”
The pervasive and global nature of antibiotic resistance means that multiple approaches will be necessary to solve the problem. “The solutions are not exclusive,” Blaser said. “We can have multiple solutions. It’s a problem that took us 60 years to get to. It’s not going to go away overnight.”