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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Response to Drs. Scott and Stein
Judicious Antibiotic Prescribing and Beyond
Knowledge is not enough
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Christopher J. Stille, Worcester, MA Associate Professor of Pediatrics, University of Massachusetts, Jonathan A. Finkelstein
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We thank Drs. Scott and Stein for their interest and thoughtful comments on our paper. We agree that it is important to perform studies that explain why an intervention worked (or, more importantly, didn’t work) in order to learn the most from an intervention study. We also agree that qualitative and mixed method studies that examine patient behaviors related to antibiotic requests and use in acute respiratory infections are critical. The strength of the approach used by Dr. Scott, especially when combined with work such as that by Stivers et al.(1) and Mangione-Smith et al.(2), is that we can learn what works at the level of individual patient encounters. As our intervention was conducted at the level of physician practices and entire communities in Massachusetts(3), the intensity of exposure of each family to the educational intervention was relatively small. However, we did survey parents and physicians in both intervention and control communities to understand how the intervention affected their knowledge about, and demand for, antibiotics. This study has been published separately.(4) Additionally, Dr. Scott’s insight that many interventions target only knowledge rather than other determinants of behavior is an important one. As this paper primarily addressed determinants of physician prescribing, we did not discuss some of the tools included in the REACH intervention that were directed more toward parents, many of which were behaviorally oriented. We agree that taking a family-centered approach that considers perceptions of illness and targets behaviors in addition to knowledge is likely to be most effective. Sincerely, Christopher J. Stille, MD, MPH Jonathan A. Finkelstein, MD, MPH References (1) Stivers T. Non-antibiotic treatment recommendations: delivery formats and implications for parent resistance. Soc Sci Med. 2005; 60:949- 964. (2) Mangione-Smith R, McGlynn EA, Elliott M. Parental expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med. 2001; 155:800-806. (3) Finkelstein JA, Huang SS, Rifas-Shiman S, Kleinman K, Stille CJ, Daniel J, et al. Impact of a 16-community randomized trial to promote judicious antibiotic use in Massachusetts. Pediatrics. 2008; 121:e15-e23. (4) Huang SS, Rifas-Shiman SL, Kleinman K, Kotch J, Schiff N, Stille CJ, et al. Parental knowledge about antibiotic use: results of a cluster- randomized multi-community intervention. Pediatrics. 2007; 119:698-706. Competing interests: None declared |
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Richard A. Stein, New York City, USA Medical Scientist
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Bacteria are ubiquitous, indispensable and irreplaceable, and history proves that often prokaryotes were the major decision makers. One of the medical and public health crises of our time, antimicrobial resistance, might well hold the key to our love-hate relationship with bacteria. Several strategies were described to limit the emergence of resistant strains, and reducing antibiotic prescriptions becomes a priority, particularly amidst huge amounts of antibiotics used in agriculture, farming and aquaculture, fields that are beyond the direct control of healthcare providers. In an insightful article that is both timely and of high interest, Stille et al. examine the impact of interventions that target physicians’ offices and intend to promote judicious antibiotic use. They conclude that brief, consistent reminders are most effective, and their results raise some hope that we can implement strategies that will delay the much-feared "post-antibiotic era". At the same time we have to remember that this is not the only approach. As relevantly pointed out in a recent review (2), probably no single level of action will ideally work. Instead, it is the multifaceted interventional approach that will accomplish the best outcome. Judicious prescribing is a crucial approach, and also raises many questions. While many studies show a decrease in resistance after reducing antibiotic use, the situation is not always a straightforward one. For example, a study revealed (1) that despite a huge decrease in sulphonamide prescriptions from 320,000 in 1991 to 7,000 in 1999, resistance remained high (46% vs. 39.7% in 1999 vs. 1991, respectively). Furthermore, we need to consider antibiotic control in a very dynamic context - for example, reducing hospital cephalosporin prescriptions by 80% in a study (3) was accompanied by a 44% reduction in extended spectrum beta-lactamase- producing Klebsiella; however, the use of imipenem increased concomitantly by 141% and caused a 69% increase in the incidence of imipenem-resistant P. aeruginosa. An important aspect the manuscript mentions is direct-to-consumer marketing. Its position in context of antimicrobial resistance needs to be urgently addressed, particularly since it was implicated in increased patient expectations and greater requests for antibiotics (4). A consumer is estimated to be exposed to 100 minutes of drug advertising for every minute spent with his/her physician (5). When it comes to antibiotics, the implications extend far beyond the individual, and into the community; also, they are substantially different than for other pharmaceuticals, because resistance affects people who were never exposed to the antibiotic. References 1. Enne VI, Livermore DM, Stephens P et al. Persistence of sulphonamide resistance in Escherichia coli in the UK despite national prescribing restriction. Lancet 2001; 357(9265): 1325–1328. 2. Foucault C, Brouqui P. How to fight antimicrobial resistance. FEMS Immunol Med Microbiol 2007; 49(2): 173-83. 3. Rahal JJ, Urban C, Horn D et al. Class restriction of cephalosporin use to control total cephalosporin resistance in nosocomial Klebsiella. JAMA 1998, 280(14):1233-1237. 4. Mintzes B, Barer ML, Kravitz RL et al. How does direct-to-consumer advertising (DTCA) affect prescribing? A survey in primary care environments with and without legal DTCA. CMAJ. 2003; 169(5): 405-412. 5. Brownfield ED, Bernhardt JM, Phan JL et al. Direct-to-consumer drug advertisements on network television: an exploration of quantity, frequency, and placement. J Health Commun. 2004; 9(6):491-497. Competing interests: None declared |
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John G. Scott, New Brunswick, NJ, USA Assistant Professor of Family Medicine, UMDNJ-Robert Wood Johnson Medical School
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Clinical trials are designed to test whether an intervention does or does not work, but in a complex intervention such as the one tested in the REACH trial, it is just as important to understand why the intervention works or not, and in which contexts, as well as what components of the intervention may be more effective than others. These questions can only be answered using qualitative and/or mixed methods, as Dr. Stille and his colleagues have admirably done in this paper. In previous work we have demonstrated that the decision to prescribe antibiotics for respiratory infections is a complex interactive process in which the patient (or parent) is at least as important as the clinician.1 A major strength of the REACH trial, therefore, was its attempt to include the community as well as clinicians in the intervention. Perhaps budgetary constraints prevented a parallel qualitative interview study of parents as well as clinicians in the intervention and control communities, but this was an unfortunate omission, since the perspective of parents would have been a valuable addition to understanding the strengths and weaknesses of the intervention. There seems to be an underlying assumption in this paper that better dissemination of knowledge to clinicians and patients will solve the problem of overprescribing of antibiotics. I suspect that this is only part of the answer, especially given the fact that both intervention and control clinicians clearly demonstrated adequate knowledge about judicious antibiotic prescribing, yet also acknowledged that their practice did not entirely reflect that knowledge. There is a mythology surrounding antibiotics as the powerful medicines that have conquered infectious disease. Such a myth has a life in the unconscious of both clinicians and patients and does not disappear automatically when the cognitive landscape changes. Future interventions to decrease inappropriate antibiotic prescribing should target not only knowledge, but also patients’ mental models of illness and should take into account the complex mutual influence that occurs in clinician- patient interactions. 1. Scott JG, Cohen D, DiCicco-Bloom B, Orzano AJ, Jaen CR, Crabtree BF. Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription. J Fam Pract. Oct 2001;50(10):853-858. Competing interests: None declared |
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