Hospital-based antimicrobial stewardship programs (ASPs) benchmark their success against two goals - cost reduction associated with decreased drug utilization, and, aspirationally at least (because it is a difficult outcome to measure) reduction in the spread of antibiotic resistance.
Both outcomes are consequential. At the institutional level, effective ASPs can save $200,000 - 900,000 annually, according to the IDSA. And antibiotic resistance is a problem of global proportions. In the US alone, over 2 million individuals are sickened by antibiotic-resistant infections and 23,000 die each year (CDC, 2013).
Here's the problem. Neither hospital cost savings nor the global threat of a "post-antibiotic era" are compelling to the practitioner at the bedside or in his examining room, whose only goal is to do the best, right thing for the patient in front of him. And these are the individuals, at the end of the day, whose decisions matter the most.
That's why, in putting together a conference for our Family Medicine residents on appropriate antimicrobial use in children, I didn't mention cost savings at all. It is also why I talked about the resistance problem not as a headline, but as a footnote. For the practitioner, it is most important to understand that the problem of antibiotic over-use is one that impacts each individual patient. Over-use errors, at bottom, are no different than other kinds of medical error. Though outcomes vary, we risk serious, avoidable harm to our patients. This is an issue not of economics but of standards-of-care and ethical practice. The message - once again - is primum non nocere.
Complications of Non-indicated Antibiotic Therapy- Allergic reactions
- Stevens-Johnson Syndrome
- Toxic epidermal necrolysis
- Antibiotic associated diarrheal illness
- C. difficile colitis
- Alterations in the gut microbiome
- Obesity and Type 2 diabetes
- Others
Why do physicians make these errors?
The literature points to some common themes. In the February issue of the journal Pediatrics, Poole and colleagues report on antibiotic use in US emergency departments. While they find errors across the board, there is a clear disparity between treatment in pediatric EDs (those that treat mostly children) and general emergency rooms. The latter, being far more numerous, are the site of care for more than 80% of children seeking emergency treatment. The authors' conclusion is that more children receive antibiotics for conditions not warranting such treatment if they are seen in a non-pediatric ED. And when antibiotics are warranted, they are less likely to receive medication consistent with expert guidelines when seen in these "adult" EDs.
The authors go on to speculate that differences in training and experience fuel these disparities and others. This is not surprising. Previous studies have demonstrated similar differences in treatment for children with asthma, croup and head injury.
Nor is the knowledge problem limited to children and Emergency Departments. A Dutch study evaluating outpatient care by 84 general practitioners found that individual physicians over-treated at significantly different rates (Akkerman, 2005). Logistic regression analysis found that practitioners who had practiced longer AND scored poorly on a knowledge test about respiratory tract infections were most likely to over-prescribe when compared with their peers. Perceived time pressure and contact with pharmaceutical salesmen also increased risk.
As songwriter Todd Rundgren wrote, "Love is the answer." When it comes to avoiding errors of antibiotic overuse and avoidable harm to children, medical knowledge and keeping up to date with the literature seem to run a close second.
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