Who’s afraid of superbugs?

By Judith Garber | August 3, 2020

The Covid-19 pandemic is easily the most urgent public health care issue at the moment, but public health experts warn that we may be facing even more serious health threats in the future. One of these is antibiotic resistance, which impacts 2.8 million people each year. Antibiotic resistance happens when bacteria become resistant to existing drugs used to treat infections; this can lead to “superbugs” that infect large numbers of people.

Clinicians can play a key role in mitigating this threat by being careful to prescribe antibiotics only when necessary, known as “antibiotic stewardship.” Still, antibiotics are frequently overprescribed for pneumonia patients, for children, and even for Covid-19 patients. An estimated 30% of outpatient antibiotic prescriptions are unnecessary.

Do doctors perceive antibiotic resistance as an urgent threat? Not so much, a recent study in the BMJ finds. Researchers conducted focus groups of primary care doctors in four major cities to assess their perceptions and attitudes of primary care physicians around antibiotic resistance. Here are some of their key takeaways:

Antibiotic resistance is not the top priority

PCPs believe that other public health issues such as obesity, diabetes, and opioid use, are more of a problem than antibiotic resistance. This makes sense, as primary care patients rarely if ever experience antibiotic resistance in the outpatient setting, whereas obesity, diabetes, and opioids are issues that come up often.

PCPs often have little time to spend with patients, so it likely benefits patients more to talk with them about treatment for one of their chronic health conditions, rather than spend the time educating them about antibiotic resistance.

Primary care isn’t the worst offender

In the focus groups, PCPs saw hospitals and urgent care facilities as the real problem, not primary care. They have a point; a 2018 study found that more inappropriate antibiotic prescribing happens in urgent care centers and emergency departments than primary care offices. Yet overprescribing in primary care is still common, and doctors in medical offices are still more likely to prescribe inappropriate antibiotics than those at retail clinics.

PCPs also listed patient demand as a major factor that increases overprescribing. “We’re under pressure all day,” one pediatrician in Birmingham said in a focus group. “You don’t want to get written up, potentially, for being insensitive, or not taking care of them, or physician ratings.”

Policy implications

The focus groups show that PCPs see antibiotic resistance as a less important public health issue than others, and are reluctant to take responsibility for overprescribing of antibiotics. How can we encourage PCPs to hold themselves accountable for overprescribing while not punishing them for issues outside their control?

Part of the solution has to be tackling systemic issues in primary care such as lack of time with patients and administrative burden. If PCPs had the time to discuss with patients why antibiotics aren’t the answer for certain conditions, unnecessary prescriptions might decrease. We also need broader interventions to address our prevalent culture of prescribing, in which patients and clinicians have been conditioned to expect a “pill for every ill.”

In the shorter term, educational interventions are important to help stem overprescribing. PCPs welcomed the idea of more education for both clinicians and patients. Educational efforts have proven to be effective, and active educational programs like trainings are more effective than passive efforts like brochures. These programs could give clinicians information and skills they need to avoid overprescribing, while teaching patients about when antibiotics are appropriate and when they are not. They could also potentially create a sense of urgency around the issue, which, according the focus groups, is lacking among PCPs.

PCPs reacted negatively to the idea of creating a metric for tracking antibiotic prescribing; this is not surprising given the adverse effects that some quality improvement metrics have had on primary care practices. Sending antibiotic overuse letters that show how PCPs compare to their peers could tap into their competitive spirit and motivate them to take action. At the same time, implementing similar interventions at urgent care clinics, EDs, and hospitals is important to reduce overall antibiotic use.

Superbugs are potentially as dangerous as any epidemic, yet–like other public health crises–the threat may not be taken seriously until the crisis is here. Both clinicians and patients can help reduce this threat–but only if we start now.

To eliminate medication overload, serious cultural, educational, and policy changes are needed. This action plan offers recommendations for policymakers, health care institutions, clinicians, and patients across five key categories to reduce harm from multiple medication use. Suggested Citation: Eliminating medication overload: A national action plan. Working Group on Medication Overload. Brookline, MA: The Lown Institute, 2020. DOI: https://doi.org/10.46241/LI.YLBW4885

Pharmaceutical marketing is a significant factor in the growing public health crisis of medication overload, which puts millions of older adults at risk of preventable harm and premature death. This issue brief provides recommendations to reduce pharmaceutical industry influence by limiting pharma sales rep visits to clinicians and direct-to-consumer advertising.

This issue brief provides recommendations for clinical practice guidelines and electronic health records that would give clinicians the information they need to appropriately prescribe and deprescribe.