Physician Responses to a Community-Level Trial Promoting Judicious Antibiotic Use

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