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Antibiotic Utilization in a Community Setting
Antibiotics are key for treating bacterial infections such as pneumonia, skin and soft tissue infections. Antibiotic use makes surgery, and use of medical devices in patients possible by greatly reducing mortality risk due to infection. Antibiotic resistance is a global natural phenomenon. Strains of bacteria can evolve to develop defence mechanisms to antibiotic exposure, resulting in failure of the antibiotic. Although this is a natural process the rate at which this occurs is increasing due to inappropriate use of antibiotics.1 This means in the future treatment for common infections will be rendered ineffective, increasing mortality. It is estimated that by 2050, 10 million deaths per year may result from antibiotic resistance if interventions are not put in place. 2 With the discovery of new antibiotics declining in the past twenty years and an increase in antibiotic use, antibiotic resistance poses a great threat to public health globally. Many factors contribute to antibiotic resistance such as inappropriate prescribing and poor adherence to treatment guidelines. With studies being carried out and a greater understanding of the antibiotic resistance threat, there is a great urge to tackle the increasing resistance rate. The community setting accounts for approximately 90% of antibiotic use, with respiratory tract infections (RTI) making up majority of antibiotic prescriptions, followed by skin infections.3,4
What contributes to antibiotic resistance?
Unnecessary antibiotic use
Unnecessary prescribing of antibiotics is a major contributor to antibiotic resistance. This involves exposing patients to antibiotics for self-limiting or viral infections for which antibiotics are ineffective. A study carried out in the Republic of Ireland (ROI) evaluated antibiotic prescribing by health care professionals, paying particular attention to the necessity of antibiotic prescriptions. The study has shown that the majority of antibiotics were issued for upper respiratory tract infections, coughs and sore throats accounting for more than 60% of the antibiotic prescriptions studied. 4 These conditions are generally identified to be viral and self-limiting, therefore many of these prescriptions may have been avoidable. Taking antibiotics for a viral infection will not resolve the patients symptoms nor speed up the process. This increases patient exposure to antibiotics unnecessarily, while increasing the risk of adverse reactions such as C.difficile infection.5,6 It needs be noted that this study carried out in ROI cannot be representative of the global scale of antibiotic use. As stated in the study, certain patient groups have to pay for a GP consultation which may result in an increased expectation for antibiotic treatment. The prescribers decision may be influenced by this pressure from patients.
Prescriber and public attitudes
The idea of prescribers being influenced to prescribe antibiotics is a recurrent theme that has appeared when investigating antibiotic use. If the attitudes of the public and prescribers can be changed this may help tackle an important area that contributes to antibiotic resistance. A questionnaire study investigated the idea of pressure to prescribe by looking at the attitude of patients and prescribers towards antibiotics. The paper demonstrates that of those who thought they had an infection, over 70% wanted and expected an antibiotic to be prescribed. The patients view were compared with the prescribers opinion, who felt antibiotics were definitely indicated in only one fifth of the patients who received antibiotics. Patient pressure influenced the prescribers decision in 20-40% of cases.7 Another survey-based paper explored patient satisfaction in consultations for respiratory tract infections. Prescribers were of the opinion that patients who expected an antibiotic would be left unsatisfied if they did not receive one, and that they were more likely to revisit for a second consultation. The study revealed that there was in fact no difference in satisfaction for those who received antibiotics and those who did not receive treatment.8 Patient satisfaction depended on the information and reassurance they received during the consultation. This study provides important evidence surrounding attitudes towards antibiotic prescriptions. Doctors may overestimate the influence of antibiotic prescriptions on patient satisfaction, centering on a treatment strategy rather than providing factual information to the patient about the harm of inappropriate antibiotic use and resistance. This plays a role in the over prescribing of antibiotics. Education to the public about antibiotic use and resistance would be beneficial in combating the emerging resistance rate.9 An increased public awareness of the future threat antibiotic resistance may reduce the expectation of patients to receive an antibiotic, this would also increase patient confidence when the prescriber feels treatment is not necessary.
Adherence to guidelines
Appropriate antibiotic selection, dose and duration of treatment are very important in ensuring safe antibiotic use that will protect the public from the future threat of antibiotic resistance. A cross sectional study carried out in the English primary care sector considered the connection between compliance to antibiotic guidelines and antibiotic resistance. It was identified that a considerable proportion of prescriptions for respiratory indications were outside the recommended treatment duration, in more than 80% of cases. This study provides alarming figures, highlighting that respiratory tract infections accounts for approximately 1.1 million excess treatment days with antibiotics, which could have been avoided if appropriate guidelines had been followed. It is positive to see however, that other non-respiratory conditions such as pyelonephritis only exceeded recommended guidelines in less than 20% of cases.6 Other studies also reported that 80% of antibiotic prescriptions were not strictly in accordance with guidelines.4 There is a clear trend of large numbers of prescriptions deviating from duration guidelines. It should also be noted that a deviation in antibiotic choice can also be seen, with second and third line agents being selected rather than first line as expected.4 It is clear that guidelines and recommendations are in place however they are not being followed as closely as required in order to reduce the risk of antibiotic resistance. A qualitative study carried out in Australia looked at GP prescribing against guidelines and how they help them make a clinical decision.10 GPs agreed that guidelines played an important role in standardization of healthcare provided to patients which was important. Experienced GPS didnt feel the need to check guidelines with some of them having a preference to antibiotics they prescribed for certain indications. This is a common trend among prescribers with many having a go to antibiotic for certain indications. Although this may be suitable for the treatment of infection it can result in an increase in second and third line agents being used, were as first line agents are preferable in order to reduce the risk of antibiotic resistance.
Self-medicating with antibiotics
A questionnaire study carried out in China explores another issue contributing to antibiotic resistance. It looks at self-medicating with antibiotics, with particular focus on treatment of children. This is a perfect example of antibiotic misuse that contributes to antibiotic resistance. The study found that almost half of respondents kept antibiotics at home for children, with approximately 30% of these using antibiotics to treat illnesses such as cold, sore throat and fever, illnesses which do not warrant antibiotic use. These antibiotics were left over from previous prescriptions and some pharmaceutical purchases. 11 This study only looks at the use of leftover antibiotics in China however it is extremely likely that this is a problem globally. Another study carried out in Rwanda also provides evidence of students self-medicating with antibiotics, of those who chose to self-medicate, 50% of these used antibiotics for a common cold.12 Lack of patient knowledge is a contributing factor to inappropriate antibiotic use. A questionnaire carried out in Serbia found that surprisingly over 50% of people thought antibiotics could treat a common cold. A lack of knowledge lead to a three times greater chance of self-medicating with antibiotics in comparison to those with adequate knowledge.13 Education if extremely important in tacking antibiotic resistance and could be regarded as the best approach to improving antibiotic prescribing.9
Occurrence of Infections
Otitis media in pediatrics is a common ailment seen in a community setting that carries a significant amount of antibiotic prescribing.4,14 In many cases otitis media is a self-limiting condition, however some patients require antibiotic treatment. In a move to reduce antibiotic use, antibiotic prescribing for otitis media has reduced in the UK. A cohort study carried out in the United Kingdom investigated the impact of reduced prescribing on the incidence of mastoiditis, a complication of otitis media. The paper found that the declining use of antibiotics over the course of this study was not linked to any increase in the incidence of mastoiditis. The paper identifies that in order to reduce one case of mastoiditis which is rare, a significant number of otitis media cases would need treated with antibiotics which would not be feasible. The benefit of reduced antibiotic use in this scenario outweighs the risk of mastoiditis.14 This paper is positive as it provides evidence that reducing patient exposure to antibiotics for self-limiting conditions does not increase their risk of complications, and this should be taken by example. This study does mention however that although this is positive to see, prescribers need to be aware of signs of complications when the do occur in order to reduce serious consequences for the patient.
As mentioned previously, a reduction in antibiotic use in self-limiting conditions is beneficial in reducing antibiotic resistance, however antibiotics play a very important role in treating infection and are life-saving. A study carried out in England looked at the increasing rate of antibiotic prescribing for Staphylococcus aureus skin infections. Over approximately a 10 year period this study found an over 60% increase in antistaphylococcal drug prescription rates. The paper however found that the increase in prescribing wasnt due to treatment drift from other antibacterial drugs, but may indicate an increasing prevalence of staph infection. 15 Throughout the study Flucloxacillin which is the drug of choice for this indication which is positive to see. This study highlights that the need for antibiotics have been increasing over time, and in order to tackle antibiotic resistance, prevention measures should be put in place to reduce the incidence of infection, which in turn will reduce the number of antibiotics required.
Antibiotic resistant organisms
Although treatment of many common infections are being threatened by the emergence of antibiotic resistance, there are a number of bacterial organisms that are particularly high risk. Gonorrhoea is the second most common bacterial STI globally. The bacteria Neisseria Gonorrhoeae has the ability to mutate rapidly resulting in many strains become resistant to antibiotic treatment. A study in the US in 2017 found that 50% of isolates are resistant to one or more antibiotics.16 Gonorrhoea if left untreated can lead to many complications such as pelvic inflammatory disease and infertility.17 The increasing incidence of gonorrhoea infection, and the increase in antibiotic resistance of the causative agent Neisseria Gonorrhoeae bacteria is of great concern to global public health. The pathogen has a great ability to adapt leading to resistance resulting in a global epidemic.18 This bacteria is found to have widespread resistance to many antibiotics classes such as penicillin, tetracycline, cephalosporin.17 Main target to reduce the spread of antibiotic resistant pathogens is to prevent transmission of the infection. Education to public on safe sex, methods to prevent spread of STIs and the importance of getting screened regularly may help reduce the spread of resistant organisms. Treatment for gonorrhoea has progressed from effective use of oral penicillin to dual therapy and IM injection of third generation cephalosporins.18,19
Stewardship
Antimicrobial stewardship is a term that refers to ways in which antimicrobial use can be optimized in order to reduce the risk of resistance. This includes interventions and programmes to promote safe and effective use of antibiotics to preserve their use for future generations.20 The community pharmacy plays a key role in tackling antibiotic resistance and promoting antibiotic stewardship as it is usually the first interaction a patient has with a healthcare professional. This is therefore a key area to carry out antibiotic stewardship with patients, in order to reduce antibiotic burden. The pharmacist has an important role in targeting causes of resistance, by counselling patients on taking their antibiotic appropriately by following the dose and duration recommended, which increases patient compliance. Pharmacists can also advise the patient on alternative treatment for viral and self-limiting conditions which may help the number of visits to the GP for antibiotics. A qualitative study carried out in England and Wales analysed the role the community pharmacy has in antimicrobial stewardship. The focal point of this study is the issues pharmacists feel limit them in carrying out antimicrobial stewardship. 21 It is clear that pharmacists have adequate knowledge of what antibiotic resistance is and the importance of it, however there was a lack of awareness of any antimicrobial stewardship initiatives in the local community. The study mentions that GPs were confident in the pharmacists ability to deal with minor respiratory tract infections. Pharmacists did have uncertainty whether patients in more vulnerable groups such as elderly and very young needed an antibiotic or not, and were more likely to refer to the GP in these cases. Time and accessibility to information was a key limitation identified by pharmacists in this study. The vital role the pharmacists plays in dispensing of medicines can leave little time for over the counter consultations with patients. There was concern that less experienced pharmacy staff may be providing misinformation to patients when it comes to antibiotics. Another limitation highlighted in the study is the lack of access pharmacists have to patient medical records therefore they have no indication for infection when dispensing an antibiotic. Having patient records would be very beneficial as it would allow pharmacists intervention when inappropriate antibiotics are prescribed. This could increase the number of 1st line antibiotics being prescribed rather than second and third line agents. This may greatly help the effort to reduce antibiotic resistance.
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