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Upper Respiratory Infections & The Role of Antimicrobials · The SHEA Podcast

• 0:43
  SPEAKER_02: Thank you for the introduction.
• 0:44
  SPEAKER_02: Today, Ellen and I are excited to talk about outpatient antimicrobial stewardship interventions that may have a positive impact on the prescribing practices specifically related to the treatment of children with acute bacterial infections of their upper respiratory tract.
• 1:01
  SPEAKER_02: First, we think it's really important to point out that nationally and globally, the focus on antimicrobial stewardship is increasing as mortality from drug-resistant infections continues to rise, and it's estimated that such infections will cause more deaths than cancer by the year 2050.
• 1:18
  SPEAKER_02: So, given this very sobering information, it has been recognized that stewardship efforts need to continue to expand beyond the inpatient setting to address antimicrobial prescribing practices in outpatients, where a majority of the antibiotic prescribing occurs in both children and adults.
• 1:35
  SPEAKER_02: So, Ellen, given your expertise in upper respiratory tract infections, can you highlight for us where you see some prime opportunities for stewardship interventions?
• 1:45
  SPEAKER_01: The first issue that is really compelling is the magnitude of antibiotic use.
• 1:50
  SPEAKER_01: In 2014, 266 million courses of antibiotics were dispensed to outpatients in the United States by community pharmacies.
• 2:00
  SPEAKER_01: It turns out that a majority of all expenditures for antibiotics, actually more than 60%, are associated with outpatient rather than the inpatient setting.
• 2:11
  SPEAKER_01: In addition, those expenditures account for somewhere between 80 and 90% of all antibiotic use, underscoring how important antimicrobial stewardship in outpatients will continue to be.
• 2:25
  SPEAKER_01: Although the volume of outpatient antibiotic prescribing is greatest in U.S.
• 2:29
  SPEAKER_01: clinics that see adults, pediatric practices account for 27 million prescriptions and emergency centers for 14 million prescriptions in a single year.
• 2:42
  SPEAKER_01: The really worrisome statistic is that at least 30% of the antibiotics prescribed in the outpatient setting are completely unnecessary.
• 2:52
  SPEAKER_01: That is, no antibiotic was needed at all.
• 2:55
  SPEAKER_01: Besides the 30% that are completely unnecessary, there are another 20% in which either an antibiotic was prescribed in the wrong dose or for the wrong duration.
• 3:08
  SPEAKER_01: One of the ways that the American Academy of Pediatrics has tried to encourage appropriate antibiotic use is in the development of guidelines for the diagnosis and management of conditions like acuteitis media and acute bacterial sinusitis, which are some of the most common indications for the use of antibiotics.
• 3:29
  SPEAKER_01: The American Academy of Pediatric Guidelines encouraged the use of stringent criteria for diagnosis and treatment of both conditions.
• 3:37
  SPEAKER_01: Deb, in your antimicrobial stewardship role, what are some of the strategies that you use to engage practitioners in a discussion about appropriate antibiotic prescribing?
• 3:48
  SPEAKER_02: Ellen, that's a great question that really gets to the heart of developing stewardship interventions.
• 3:54
  SPEAKER_02: At our institution, we have a large affiliated health system with over 50 practice locations and several hundred providers with varying prescribing habits.
• 4:04
  SPEAKER_02: So understanding their concerns about antibiotic prescribing and perceived barriers to using Nerospectrum drugs is so important for developing stewardship interventions.
• 4:14
  SPEAKER_02: The social behavioral influences on antibiotic prescribing are dramatic.
• 4:19
  SPEAKER_02: Issues include avoiding risks associated with not treating, time constraints associated with educating patients, and general fatigue or the time of day of decision making.
• 4:30
  SPEAKER_02: All of these have been shown to impact prescribing decisions.
• 4:34
  SPEAKER_02: I acknowledge these issues when speaking with providers while also addressing the common misperception that antibiotic overuse is not a problem locally.
• 4:43
  SPEAKER_02: I often find that educating providers about the pervasive and growing problem of antibiotic resistance can be very impactful.
• 4:50
  SPEAKER_02: Despite attempts of the stewardship community to get the word out, so to speak, many providers have not truly recognized the scope and severity of the issue.
• 4:59
  SPEAKER_02: So I often start by educating providers about the problem of antibiotic resistance by using global data and then local data whenever feasible, which is very meaningful.
• 5:09
  SPEAKER_02: The presentation of local or even provider-specific data can really impact attitudes and drive change.
• 5:15
  SPEAKER_02: I find that once providers buy in to wanting to do something about the problem, then addressing some of the common sociobehavioral barriers to appropriate prescribing becomes much easier.
• 5:26
  SPEAKER_01: Deb, you make a great point about educating providers about growing antibiotic resistance.
• 5:32
  SPEAKER_01: We already mentioned the importance of reminding them about clinical practice guidelines.
• 5:37
  SPEAKER_01: I find that most seasoned practitioners are well aware of the guidelines, although they are not always strictly adherent to them.
• 5:45
  SPEAKER_01: On the other hand, I always relish the opportunity to teach trainees and more junior practitioners about the guidelines and the data behind them.
• 5:54
  SPEAKER_01: For example, focusing on correctly diagnosing acute otitis media by emphasizing the importance of the bulging tympanic membrane is extremely helpful.
• 6:04
  SPEAKER_01: The newer guidelines that were published in 2013 provide very clear-cut guidance on the criteria for diagnosing acute otitis media.
• 6:14
  SPEAKER_01: Although a major challenge is the necessity for removing serumen from the external canal to get a good look at the tympanic membrane, knowing that moderate to severe bulging is the gold standard for diagnosis eliminates a lot of the previous uncertainty in diagnosis.
• 6:32
  SPEAKER_01: Deb, how do you think the doctor-patient relationship can be used to foster appropriate antibiotic use?
• 6:39
  SPEAKER_02: Well, educating parents about the importance of stewardship, both from the standpoint of its impact on society, but also from the standpoint of avoiding adverse effects in their child, is a critical intervention.
• 6:52
  SPEAKER_02: Several recent studies have found no difference in clinical outcomes in children treated with narrow versus broad spectrum antibiotics for acute bacterial upper respiratory tract infections, but did find an increase in adverse events, such as diarrhea, sometimes from Clostridium difficile, as well as allergic reactions in those who were treated with broad spectrum drugs.
• 7:13
  SPEAKER_02: So one of my first recommendations to providers is to begin discussions about appropriate antibiotic prescribing as soon as possible in the relationship with the patient and family.
• 7:22
  SPEAKER_02: It often is easier to begin providing education about antibiotic stewardship during well visits when parents are not worried about an acute illness in their child.
• 7:32
  SPEAKER_02: Education can be in the form of posters, pamphlets, waiting room videos, in-person nurse education, and recommendations specifically made by the provider.
• 7:42
  SPEAKER_02: The Centers for Disease Control and Prevention's Antibiotic Awareness Campaign, which was formerly called the Get Smart Campaign, has many wonderful resources available on the CDC website to address patient and parent education.
• 7:55
  SPEAKER_02: When providers consistently use these educational resources with patients and make specific comments about the importance of and their commitment to stewardship, it can go a long way in helping patients and their families comply and feel comfortable with their providers' future recommendations.
• 8:11
  SPEAKER_02: In fact, studies have shown that even without stewardship education, overt requests for antibiotics from parents are not as common as estimated by providers.
• 8:21
  SPEAKER_02: So physicians are poor at predicting which patients actually want an antibiotic.
• 8:26
  SPEAKER_02: Parents are most satisfied with a good explanation for their providers' recommendations, and then a contingency plan should their child's condition worsen or not improve.
• 8:37
  SPEAKER_01: I completely agree.
• 8:38
  SPEAKER_01: Using the example of otitis media, it can be helpful for providers to have conversations about this is how I treat and why.
• 8:47
  SPEAKER_01: But it is equally important for providers to listen to the concerns of their patients.
• 8:52
  SPEAKER_01: For example, we have all heard parents come in and say, amoxicillin never works for Johnny's ear infection, so please don't give us that.
• 9:01
  SPEAKER_01: The traditional recommendation from the American Academy of Pediatrics over the last decade has been to prescribe high dose amoxicillin.
• 9:10
  SPEAKER_01: The decision to use a broader spectrum drug with enhanced activity against betalactomase producing organisms depends on the actual microbiology of middle ear isolates, which it turns out is a pretty dynamic affair.
• 9:27
  SPEAKER_01: Changes in the microbiology of middle ear isolates is attributable to widespread use of pneumococcal vaccines.
• 9:35
  SPEAKER_01: Currently, the prevalence of Streptococcus pneumonia is down and haemophilus influenza is up, including beta-lactomase producing haemophilus influenza.
• 9:45
  SPEAKER_01: Amoxicillin clavulinate is recommended in situations in which the cause of the middle ear infections is likely to be haemophilus influenza.
• 9:55
  SPEAKER_01: This certainly includes children who have been recently treated with amoxicillin, those who present with conjunctivitis, and anyone who fails to respond to amoxicillin.
• 10:06
  SPEAKER_02: Alan, you bring up some important information.
• 10:09
  SPEAKER_02: I want our listeners to know that the White House has issued a national action plan to combat antibiotic resistance, with the goal of reducing inappropriate outpatient antibiotic use by 50% by the year 2020.
• 10:22
  SPEAKER_02: In addition, the Healthy People 2020 antibiotic-related goals include reducing the number of antibiotic prescriptions for ear infections in young children.
• 10:31
  SPEAKER_02: Ellen, what do you give providers and families about when and if watchful waiting for acute bacterial upper respiratory tract infection is appropriate?
• 10:40
  SPEAKER_01: Deb, my current approach to reducing antibiotic overuse is to stress diagnostic accuracy.
• 10:47
  SPEAKER_01: This is the importance of the American Academy of Pediatrics guideline, which endorses a diagnosis of acuteotitis media dependent for the most part on visualization of a bulging tympanic membrane.
• 11:00
  SPEAKER_01: If the clinician is confident in that finding, I recommend the use of antibiotics.
• 11:06
  SPEAKER_01: Similarly, when considering a diagnosis of sinusitis, I stress the use of stringent clinical criteria that had been outlined in the American Academy of Pediatrics guideline for the diagnosis and treatment of acute bacterial sinusitis.
• 11:22
  SPEAKER_01: While there is definitely a high spontaneous cure rate for both acute dotitis media and acute bacterial sinusitis, using antibiotics in the treatment of either of these two conditions is totally appropriate.
• 11:35
  SPEAKER_01: Using antibiotics in children with uncomplicated viral upper respiratory infections is not appropriate.
• 11:42
  SPEAKER_01: The stringent criteria delineated in the guideline are meant to help the clinician discriminate between those two conditions.
• 11:50
  SPEAKER_01: In children who meet criteria for sinusitis on the basis of 10 days of symptoms without improvement, I am comfortable with waiting a few days longer for spontaneous resolution to occur as long as the family and the clinician agree on this strategy and a follow-up plan is assured.
• 12:09
  SPEAKER_01: I remind families that serious complications of common respiratory tract infections are very rare.
• 12:16
  SPEAKER_02: So those points are very helpful for providers and families to guide decisions about when to treat.
• 12:22
  SPEAKER_02: Another issue that is frequently raised as a defense of the prescription of broader rather than narrow spectrum drugs is a report of drug allergy by the parents.
• 12:32
  SPEAKER_02: Parents either report their own allergies to penicillin with the concern that their child also will be allergic, or they report that their child once had a mild rash after receiving ammoxicillin in the past.
• 12:43
  SPEAKER_02: Ellen, in these cases, what guidance do you give to providers about the risk of drug allergy and how to determine the best antibiotic for treating an acute bacterial upper respiratory tract infection in their patient?
• 12:55
  SPEAKER_01: As I'm sure you are aware, Deb, there is no predictable pattern to the inheritance of drug allergy.
• 13:02
  SPEAKER_01: More importantly, however, only about one in ten people who claim to be penicillin allergic actually are.
• 13:09
  SPEAKER_02: The issue of parental overreporting of drug allergies is a hot topic in the antimicrobial stewardship community.
• 13:15
  SPEAKER_02: I try to remind providers to specifically ask about the details of what happened when the patient received the antibiotic in the past and clearly document the specifics of the reaction in the medical record or remove the allergy designation if it is not accurate or appropriate.
• 13:30
  SPEAKER_02: Oftentimes parents report a vomiting episode or mild gastrointestinal upset as allergy.
• 13:35
  SPEAKER_02: Cleaning up the medical record in this way allows for more appropriate prescribing moving forward, especially if the patient sees another provider in the future.
• 13:45
  SPEAKER_01: Clarifying information in the medical record about allergies is an important intervention.
• 13:51
  SPEAKER_01: We talk a lot about the use of informatics for optimizing inpatient antimicrobial prescribing.
• 13:57
  SPEAKER_01: What electronic health record interventions have you seen used in the outpatient setting?
• 14:03
  SPEAKER_02: One of the most effective uses of the medical record to impact outpatient prescribing is to track and report antimicrobial prescribing data on individual providers in order to do peer comparisons.
• 14:15
  SPEAKER_02: Behavior is most likely to change for the better when individuals are informed that they are not, quote, top performers compared to their peers.
• 14:24
  SPEAKER_02: Having providers participate in continuing medical education and quality improvement activities to track and improve their own antibiotic prescribing can be quite effective, and the medical record is most effectively used in this way.
• 14:38
  SPEAKER_01: Well, Deb, it looks like there are a lot of opportunities for addressing outpatient antibiotic use.
• 14:44
  SPEAKER_01: I really enjoyed our discussion today, and I think we presented some helpful points for providers to consider when caring for their outpatients.
• 14:58
  SPEAKER_00: Join us at this year's K Annual Conference.