The Prevalence of the Overprescription of Antibiotics in the Context of Rising Antibiotics Resistance and Alternative Strategies to Identify Bacterial Infections in Sore Throat Patients
The Prevalence of the Overprescription of Antibiotics in the Context of Rising Antibiotics Resistance and Alternative Strategies to Identify Bacterial Infections in Sore Throat Patients
While most sore throats are caused by viral infections, in a small proportion of cases, the cause is a bacterial infection, which sometimes needs to be treated with antibiotics. Group A beta-haemolytic streptococcus (Strep A), which is responsible for most bacterial respiratory tract infections in adults, is also able to cause suppurative and non-suppurative complications, and an antibiotics treatment is sometimes required (Shepard, Smith, Aspley, & Schachtel, 2014). However, the fear of complications has led to antibiotics prescription rates which are much higher than the actual incidence of the bacteria. This is because diagnosis in cases of sore throats can be misleading, and it often leads to overprescribing antibiotics.
Furthermore, previous research has shown that there are only limited symptomatic benefits to the use of antibiotics in patients with acute sore throats (Little al. 2013). Consequently, the overuse of antibiotics in sore throat patients in order to avoid complications not only presents limited benefits in what the evolution of the disease is concerned in most cases, but may also be unnecessary since there are several tests which can be successfully used in order to determine the kind of treatment that should be applied.
Background and Significance
Antibiotics prescription is rising in primary care, having exceeded the peak of the 1990s’ (Little et al. 2014). This is a major issue in contemporary medicine, because indiscriminate antibiotics use leads to antibiotics resistance, which may cause certain infections to become untreatable (Little et al.). Physicians usually prescribe antibiotics in order to avoid complications. However, research has shown that complications appear very rarely in respiratory tract infections. For example, Thus, as Little et al. (2014) showed in their study, only 164 participants from a total of 11 950 patients (1.4%) presented any complications as a result of following the current treatment protocol.
Furthermore, presently, there are several types of tests which can be used in order to determine the kind of germ which causes the infection. Some of the most commonly used tests are the rapid streptococcal antigen detection tests (RADTs) which can be used during consultations in order to provide an immediate diagnosis by identifying the presence of Strep A (Leydon et al. 2013). However, physicians have expressed several concerns in regards to the use of these tests, based on the fact that they are time consuming, and they are not entirely reliable (Leydon et al.). On the other hand, patients have been shown to be more trustful and reassured regarding the progress of their sickness after being diagnosed using RADTs (Leydon et al.).
Other methods of rapid diagnosis include the antigen test and clinical scores (Little et al. 2013). Studies which aimed to discover the benefits of using these tests in clinical practice have recorded positive results. In a study involving 624 participants, the authors found that patients who were diagnosed using the clinical scores recorded less antibiotics use than patients assigned to the delayed antibiotics control group (Little, et al.). The same positive results were recorded when using an antigen test based on the test scores, although the differences between these two types of tests were not significant (Little et al.).
These tests are particularly important since studies have shown that clinical examination alone is likely to misdiagnose sore throats to a great extent. Thus, in their study, Shepard, Smith, Aspley, & Schachtel (2014) found that based on clinical examination alone, 86% of their 402 participants would have been mistakenly diagnosed with the Strep A, and would have received an antibiotics treatment unnecessarily. Furthermore, the authors found that, even in cases where the sickness aggravates in lack of an antibiotics treatment, the latter can be safely delayed for 4 days without any risk of complications.
Overprescribing antibiotics in acute sore throats is a typical practice for the medical world today, particularly because diagnosing a respiratory throat infection correctly is extremely difficult due to the fact that many of the symptoms are common for both viral and bacterial. For example, acute pharyngitis, one of the most common respiratory tract infections, which constitutes roughly one third of the total cases (Little al. 2014), is most often treated with antibiotics although important complications rarely appear. While avoiding complications which may result from bacterial infections of the respiratory tract is a priority for the general practitioners, complications are extremely rare and may not justify the need for antibiotic treatments in most cases.
This practice raises certain concerns which need to be addressed and evaluated against the potential benefits of overprescribing antibiotics for sore throats. Thus, the overuse of antibiotics can lead to unpleasant side effects for the patients (Shepard, Smith, Aspley, & Schachtel 2014), and to antibiotics resistance. It is not likely to improve the state of most patients sufficiently as compared to symptomatic treatments so as to justify its use in simple sore throats. However, in order to assess the consequences of reducing the use of antibiotics in treating sore throats, it is necessary to evaluate the results obtained by physicians who do overprescribe antibiotics against the results obtained by physicians who avoid overprescribing them. Either way, alternative ways of threating sore throats must be developed in order to reduce the use of antibiotics in the treatment of sore throats.
Antibiotics resistance is a global problem which threatens to lead humanity back to the preantibiotic era (Shepard, Smith, Aspley, & Schachtel 2014). Antibiotics resistance is viewed extremely seriously by the medical world today, to the extent that in the U.K., the Chief Medical Examiner has included it in the country’s risk register, which means that this threat is perceived as equally important to that of a terrorist attack (Shepard, Smith, Aspley, & Schachtel 2014). Furthermore, antibiotics are not useful in most forms of sore throat, shortening the duration of the symptoms with approximately 16 hours. Most often, physicians use clinical examination as their only test to diagnose viral and bacterial sore throats, although it has been shown repeatedly that they are not successful. While the standard test in this regard is the throat culture, laboratory testing takes longer to complete. New generations of antigen tests are better in this regard, but they cannot be used alone (Mistik, Gokahmetoclu, Blaci, & Onuk (2015). New generations of tests are currently tested by researchers in order to come up with more effective ways of diagnosing respiratory tract infections.
The reason why the antibiotics use has increased in the past decades also constitutes an important aspect of the issue. Apparently both doctors and patients are responsible for this rising trend. In a study conducted in Delhi, the researchers found that, apart from diagnostic uncertainty, doctors explained that they are pressured by the patients, who demand more powerful medicine (Kotwani et al. 2010). Educated patients, who may gather their information from the internet, may make precise demands on the antibiotics they would like to use (Kotwani et al.). Patients are often unsatisfied when they are not prescribed antibiotics, since they could buy other types of medication on their own, and they want the physicians to prescribe them something else than what they could buy on their own (Kotwani et al.). Other reasons pertaining to the physicians include the lack of time due to overcrowding which does not allow them to study the cases closely, and the fear of losing patients. Self-medication is an important aspect in the overuse of antibiotics. Patients may buy antibiotics over the counter and use old prescriptions to but medication several times (Kotwani et al.). Easy access to information on the internet gives patients the impression that they are capable of taking a decision in regards to their own health. In addition, patients may get scared reading the potential complications of respiratory infections, and they may insist to receive an antibiotics prescription for this reason.
Perspectives, Incidence and Prevalence
In the UK, upper respiratory tract infections represent one of the most common causes for general practitioner consultations, accounting for approximately 5.5 million visits annually (Shepard, Smith, Aspley, & Schachtel, 2014). Half of the patients who present coughs, colds, and sore throats caused by viral agents will be treated with antibiotics due to misdiagnosed infections, in order to avoid any complications (Mistik, Gokahmetoclu, Blaci & Onuk 2015). Approximately 80% of the antibiotics are prescribed in primary care settings and up to 75% of these are meant to cure respiratory tract infections (Gonzalez 2001). As the below figure shows, the number of antibiotic prescriptions is much higher than the number of actual bacterial infections. The incidences of overprescription are higher for Upper Respiratory Tract Infections (URI), which represent the most important reason for medical visits to the general practitioner office. More than half of the antibiotics prescribed in this occasion are not needed Gonzalez 2001).
Source: Gonzales R, Malone DC, Maselli JH, Sande MA (2001). Excessive antibiotic use for acute respiratory infections in the United States. Clin Infect Dis. 33:757-762.
In many cases, patient pressure also represents a cause for antibiotics overprescription. A 2001 study in the United States estimated that 55% of all antibiotics prescribed for upper respiratory infections were unnecessary (Mossialos et al. 2010). However, only 10-15% of these infections are typically caused by a bacterial agent (Shepard, Smith, Aspley, & Schachtel, 2014). Cordoba’s (2015) cross-sectional study involved 6 different countries. In all the studied countries, there were practitioners who always prescribed antibiotics to their patients, while other practitioners never did. The prescribing style for Russia was three times more heterogeneous than the style of practitioners form Denmark. Furthermore, in Spain, Russia, and Argentina, patients’ requests led to antibiotics prescription. The Danish group had the most homogenous prescribing style and the Sweden group was also less heterogeneous than the groups from the first three countries. This shows that in countries with strong political leadership, homogenous antibiotics prescription is more likely and patients are less likely to ask for antibiotics.
Review of Healthcare Cost of Problem
The overprescription of antibiotics poses an important burden on the healthcare system, and entails great costs for the society as a whole. Thus, the excessive antibiotics prescription rates lead to a much higher cost of healthcare. Gonzalez (2001) estimated that excessive antibiotic prescription cost approximately $ 700 million yearly. Improving the diagnostic methods of specific acute respiratory infections with 10% would also result in a decrease of the antibiotics cost with $ 1.75 million per year.
Antibiotics resistance is also extremely costly for the society. Each year in the United States, more than 2 million people acquire infections with bacteria which are resistant to the antibiotics that had been specifically produced to treat the infections (Center of Disease Controls and Prevention, 2013). More than 23, 000 people die each year as a direct result of antibiotic-resistant infections, and many more die of complications of these infections (CDC). Antibiotics-resistant infections require costlier and more complex treatments, the higher use of healthcare and doctor visits and result in higher risk of disability and death overall, as compared with infections which are easily treated with antibiotics.
In the United States, antibiotics resistance already creates a $ 200 billion excess in healthcare costs and this problem is likely to become even more serious in the future. In U.K, the annual cost associated with antibiotics resistance is $20 million (Messialos et al., 2010). Furthermore, the loss of productivity which occurs when people are unable to work adds another $15 billion to the cost (Center of Disease Controls and Prevention, 2013). Finally, antibiotics research and the development of new medicine meant to solve the problem of antibiotics resistance are very costly and difficult to pursue. While this is already a requirement for the future, the cost of antibiotics research is increased by the fact that new antibiotics need to be developed faster.
Evidence of Support for APRN’s Role in the Solutions
Antibiotics resistance poses a great challenge for healthcare providers to prescribe antibiotics judiciously. Healthcare providers are consequently required to change their evaluation, diagnosis and treatment and prescribing methods. The key role for APRN’s in the context of large-scale antibiotics overprescription and increasing antibiotics resistance, is to base each antibiotics prescription on following strict clinical guidelines in each occasion. The findings in this paper suggest that evidence based practice, and a thorough understanding of the primary reasons that lead to the overprescription of antibiotics and inappropriate use. Practitioners are sometimes pressured to offer antibiotics prescriptions to patients based on other factors than the firm belief that this is the right treatment for the health problem. As Dekker (2015) shows, often patients are influenced by the patients themselves, who manifest their expectation that they would be prescribed antibiotics. This was also noticed in other studies, such as Kotwani et al (2010), as well as Cordoba (2015). However, it is apparent that this pressure is likely to be higher in countries where antibiotics use is less efficiently regulated, or where patients may not be well –educated regarding the negative impact of antibiotics (Cordoba). As Cordoba showed, in Argentina, Spain, Russia and Lithuania, the pressure from patients is more significant than in Sweden and Denmark, where antibiotics use is better regulated. This is also the case for India, where patients expect to be prescribed antibiotics, particularly because the cost of a consultation is high and they need to feel that they received an efficient treatment they could not have taken by themselves (Kotwani et al.).
Another important reason for antibiotics overprescription is diagnosis uncertainty. Many studies have shown that antibiotics are prescribed in cases of viral infections, because practitioners are unable to provide an efficient diagnosis. As Mistik et al (2015) showed, during the study they conducted, 78% of the antibiotics prescriptions that general practitioners offered to the patients were unnecessary. Consequently, a more efficient method of diagnosis is needed in order to avoid overprescription. This enables practitioners to understand the pressure that may come from patients, as well as their needs and expectations more accurately. Patients however may not be as demanding as the doctors may think, and their expectations may be interpreted wrongly. Even though the prescribing style should be fairly the same for all general practitioners, there are great differences from country to country, and even within the same country. This illustrates the influence of outside factors, such as strong legislation and patient education in choosing whether to prescribe antibiotics or not.
Advance practice nurses can start by understanding and correcting their own prescription habits. Several solutions have been provided in this paper for the overprescription of antibiotics, in case of sore throats, which include using clinical scores, an antigen detection test, the implementation of 4 days delay in antibiotics prescriptions. Communicating effectively with the patients and educating them concerning the risk of antibiotics overprescription can decrease their demand of antibiotics and reduce the pressure on the practitioner to prescribe them.
Research Question: In unexperienced nurse prescribers, what factors contribute to the decision to overprescribe antibiotics and to what extend is addressing these factors likely to reduce this trend?
(P)-Population: Advanced Practice Registered nurses with up to 3 years -experience who regularly prescribe antibiotics for respiratory tract infections.
(I)-Intervention: Semi-structured interviews with up to 10 nurse prescribers and one training session. There will be two interview sessions, one prior to the intervention and one after the intervention.
(C)- Comparison: The data generated by the initial interview will be compared with the data obtained from the second sets of interviews, following the training session.
(O)-Outcome: The study plans to measure to what extent knowledge on patient misconception regarding antibiotics use, antibiotics resistance, and alternative strategies to diagnose and treat respiratory tract infections are likely to decrease the overprescription of antibiotics.
(T)-Time: The initial interviews are meant to establish the antibiotics prescription patterns for Advance Practice Research Nurses and to identify the factor which determine them to overprescribe antibiotics. This set of interviews will be closely followed by a 2-hour training sessions which is meant to provide new information to nurse practitioners regarding the issue, in order to help them communicate with patients more effectively. This will be followed after 4 weeks by a second set of interviews which is meant to follow-up on the nurse practitioners implementation of the new strategies. Therefore, the outcome will be measured after 5 weeks.
References
Centers for Disease Control and Prevention (2013). Antibiotic resistance threats in the United States. Retrieved from http://www.cdc.gov/drugresistance/threat-report-2013/.
Cordoba, G. (2015). Prescribing style and variation in antibiotic prescriptions for sore throat: cross-sectional study across six countries. BMC Family Practice 16(7): 1-8.
Dekker, A., Verheij, T. & van der Velden, A. (2015). Inappropriate antibiotic prescription for respiratory tract indications: most prominent in adult patients. Family Practice 32(4):401-407.
Kotwani, A. et al. (2010). Antibiotic use in the community: what factors influence primary care physicians to prescribe antibiotics in Delhi, India?. Family Practice 0: 1-7.
Leydon et al. (2013). A qualitative study of GP, NP and patient views about the use of rapid streptococcal antigen detection tests (RADTs) in primary care: ‘swamped with sore throats?’ BMJ Open 3(e002460):1-7.
Little, P., Hobbs, R., Moore, M. et al. (2013). Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomized controlled trial of PRISM (primary care streptococcal management. BMJ Open 347(f5806):1-10.
Little, P., Stuart B., Hobbs, R et al., (2014). Antibiotic prescription strategies for acute sore throat: a prospective observational cohort study. Lancet Infectious Diseases 14: 213-219.
Messialos, E. et al. (2010). Policies and incentives for promoting innovation in antibiotic research. European Observatory on Health Systems and Policies. Retrieved from: http://www.euro.who.int/__data/assets/pdf_file/0011/120143/E94241.pdf
Mistik, S., Gokahmetoclu, S., Blaci, E. & Onuk, F. (2015). Sore throat in primary care project: a clinical score to diagnose viral sore throat. Family Practice 32(3): 263-268.
Shepard, A., Smith, G., Aspley, S. & Schachtel, B. P. (2014). Randomised, double-blind, placebo-controlled studies on flurbiprofen 8.75 mg lozenges in patients with/without group A or C streptococcal throat infection, with an assessment of clinicians’ prediction of ‘strep throat. International Journal of Clinical Practice 69:59-71.
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