On paper, doctors should know better — antibiotics treat only bacterial infections, and yet, physicians sometimes give them to patients who have viral infections. For patients, an unnecessary antibiotic can mean short-term side effects, like diarrhea, or more-persistent impacts, like microbiome disruption. But on a grand scale, the overuse and misuse of antibiotics pressure bacteria to gain resistance, the ability to thwart the drugs intended to kill them.
Given that antibiotic resistance is one of the world's leading public health threats, earlier this year, I went to Japan to investigate a program that has been remarkably effective at curbing the overuse and misuse of the drugs. I wanted to understand why doctors sometimes prescribe antibiotics when they're not needed and what approaches have been shown to improve their prescribing habits.
Nicoletta Lanese: Could you explain the focus of your work?
I think about the decision-making about how an antibiotic is used as not simply a decision that is about pathophysiology or microbiology — it's about social dynamics. Clinicians are sensitive to a lot of other features in the care delivery environment beyond what they know to be true about antibiotics, what they know to be true or apparent about the potential infection that a patient has.
Julia Szymczak is a medical sociologist at the University of Utah School of Medicine. (Image credit: Courtesy of Julia Szymczak)JS: Diagnostic uncertainty is a major challenge for clinicians. Differentiating viral versus bacterial is not [straightforward] — you don't have a slam-dunk perfect test. There are attempts to develop things to help, but the diagnostic uncertainty piece is really challenging.
In the ambulatory or the outpatient setting, where the vast majority of human antibiotic use occurs, one of the more common themes that you will hear when you talk to clinicians is that patients often want antibiotics that are not needed. That relationship is more complicated than it appears on its face, but that is a major pressure point for clinicians.
JS: The major one is time pressure. I had a pediatrician who said they had — I can't remember the figure, but it was like 800 seconds for a sick visit. They broke it down into seconds. Their experience of time in the outpatient setting is so intense. Certainly clinicians in the inpatient setting [hospitals] feel time pressure, but the decision-making is distributed over an admission, which still might only be two days, but two days is different than literally five minutes.
Someone is coming to you to get something for a problem. Oftentimes, your assumption is that what they're coming to you for is an antibiotic. The encounter is already shaped by the patient's expectation — or your [the doctor's] expectation of the patient's expectation. There's literature that shows that, in many scenarios, clinicians might perceive that a patient wants an antibiotic when the patient actually doesn't.
Efforts to reduce doctors' antibiotic use have been very successful over the past decade, but there is still room for improvement. (Image credit: Tanja Ivanova via Getty Images)Then, you're in an environment where there are competing priorities around how that patient is going to evaluate your care. If a patient is unhappy because you didn't give them an antibiotic and you're concerned about the patient-satisfaction score, which is being watched by your leadership, but no one's monitoring your antibiotic use, that could tip you into the prescription of an antibiotic that isn't needed.
NL: You said it's often difficult for doctors to explain their reasoning around antibiotics. Do you think that's because the technicalities of resistance are hard to explain, or something else?
Briefly: The biomedical stuff is often not the hard part. What's difficult is countering a patient who you think has already made up their mind about what they need and convincing them that they don't need it. It involves not just the provision of microbiological facts but having to explain why their past diagnoses might not have been accurate or their previous clinicians didn't make a good decision. Or people might talk about their social network: "Well, so and so got antibiotics for that." And it's like, I'm not their doctor. I didn't see them. I'm making a decision about you.
I don't think it's about the education, about the likelihood of this being viral and "antibiotics don't work for viral infections." It's a lot more countering beliefs that aren't necessarily accurate [such as antibiotics always being needed for certain symptoms] and dealing with social awkwardness.
JS: In my life of explaining to people, mostly clinical and epidemiologic audiences, there is a bit of a professional pride about evidence-based practice. Clinicians are educated deeply, and they're experts; they should be applying this evidence to every patient every time. But I always start [by saying], "You guys are human too, right?"
This idea of the cold, logical, rational actor, I mean, doesn't apply anywhere in medicine. But in particular, I think this is a great [example of a] scenario where that perfect model of decision-making just gets completely upended by contextual and structural factors, as well as social and emotional factors.
The dynamic between parents and pediatricians can shape how and when antibiotics get prescribed. (Image credit: Cavan Images / Ladanifer via Getty Images)JS: A lot of my portfolio is in pediatrics, and in fact, that's where I started my work. I was a postdoctoral fellow at the Children's Hospital of Philadelphia, so I have spent a lot of time doing pediatric research.
Then, of course, the fragility of children [is a factor], and the concern of the illness going off the rails. That feels more fearful than it does for a middle-aged adult.
When you look nationally [in the U.S.], pediatricians have done the best at improving their prescribing. Some of the biggest leaps and bounds in outpatient stewardship, it started in pediatrics. So pediatricians tend to be on the cutting edge, I would say.
JS: One of the most common ones is the use of "audit with feedback," this idea of prescribing report cards where you give clinicians information at regular intervals about how well they use antibiotics and then compare it to their colleagues in their practice or in their entire health system. That's been demonstrated to work, but not in isolation.
Another piece that has been demonstrated to work, if clinicians use it, is that many electronic health records have pathways or order sets or guidelines embedded. So, if a clinician's like, "I'm going to diagnose [urinary tract infection] UTI in this patient," there's a UTI pathway that they can click on that will give them evidence-based laboratory testing and management strategies. It takes them fewer clicks to get the stuff that they need.
NL: When it comes to interventions for outpatient settings, are there strategies that just don't seem to work?
I do think that the surrounding cultural context will always play a role, to some degree, in how interventions to improve clinical decision-making will fare.
NL: Could you elaborate on why educating patients isn't the best approach?
I do think we are seeing more interest from the lay public in things like the microbiome and gut health and the role of antibiotics in potentially disrupting those things. I think education to the public that directly connects to individual-level harms is more motivating than population-level harms.
JS: I do think that the surrounding cultural context will always play a role, to some degree, in how interventions to improve clinical decision-making will fare. I have also written a bit about that in another commentary that delves into the observation in the United States that we have considerable regional variation in antibiotic use that is not explained by clinical factors.
NL: Regarding Japan's incentive program, which pays pediatricians "tips" for improving their antibiotic use, do you think a similar approach would be motivating for U.S. pediatricians? Would it be feasible to implement that kind of strategy here?
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A better approach may be in aggregate and [to] reward health systems or clinics for improved antibiotic use for conditions in which antibiotics are never needed, for example.
Editor's note: This interview has been condensed and edited for clarity.
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