Mechanism of Action of Antibiotics. Benefits vs. Harms. Notable Adverse Effects. C. Difficile. Antibiotic Resistance. QT prolongation/gi upset

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1 Mechanism of Action of Antibiotics Benefits vs. Harms Actual Bactericidal Bacteriostatic Proposed Virucidal Patient anxiolytic Clinician anxiolytic Promotes patient and clinician happiness Cure Symptom relief Prevention of complications Prevention of person to person transmission Adverse events C. difficile infection Antibiotic resistance Cost Notable Adverse Effects Beta-lactams Sulfonamides Macrolides Quinolones rupture toxicities Hypersensitivity/rash Rash/Neutropenia QT prolongation/gi upset Peripheral neuropathy Tendonitis and tendon Cardiac effects Central nervous system Image source: antibiotic safety.png FDA MedWatch 2016 May 12 C. Difficile Antibiotic Resistance 453,000 cases/year 29,000 deaths 1/3 in outpatient setting Lessa FC et al. N Engl J Med Jun 11;372(24):2369

2 What Do Patients Think? 29% think that antibiotics kill viruses 24% think that antibiotics work for most coughs and colds 89% believe that it is possible to build immunity to antibiotics over time Only 30% believe that antibiotic resistance is a significant problem James 51 yo BM with lifelong history of asthma that now only affects him when he is sick. He uses albuterol and fluticasone as needed. He has asthma exacerbations twice a year in the Spring and Fall around the change of seasons. He now presents with productive cough and SOB. No fever. He tells you he always gets treated with a z pak and steroids and feels better in a few days. Exam reveals some wheezing with a peak exp flow 65% of predicted Carter RR et al. Open Forum Infect Dis May 30;3(3):ofw112 Appropriate Initial Treatment 1. Give him azithromycin only 2. Give him a azithromycin and have him use the fluticasone inhaler 3. Tell him it is likely a viral infection and the azithromycin is unlikely to help him. Suggest oral steroids only 4. Tell him it is often a viral infection but since he has asthma and the cough is productive you will give him the azithromycin as well as the steroids Azalea Trial RCT of 199 patients with asthma exacerbation comparing azithromycin vs. placebo in addition to usual care No benefit with azithromycin Trial stopped early due to recruitment issues 45% of 4,582 patients screened excluded for antibiotic treatment in the prior 28 days Johnston SL et al. JAMA Intern Med Nov 1;176(11): Beth 26 yo WF calls you on call on a Saturday afternoon with a cough and cold for 3 days. No fever or chills. No history of asthma. She is a nonsmoker. Cough is productive of green phlegm and the cough is keeping her awake at night. Patients Do Not Want Antibiotics! Patients want to feel better Patients want empathy Patients do not like taking medications Patients know antibiotics are a mixed blessing Patients fear they will become resistant Linder JA et al. J Gen Intern Med Oct;18(10):

3 CS Talking With Patients Talking starts with listening What do they think is going on? Share your thought processes What is bothering them the most? Are there nonmedical issues present (work, school absence) Symptom Relief Fluids and rest Analgesics: Throat lozenges, Acetaminophen, NSAIDs, Steroids Cough suppression: Honey, OTC meds, codeine Nasal congestion: Saline irrigation, topical decongestants Herbal therapies: Pelargonium sidoides, Andrographis paniculata What s In A Name? Exam Room Posters Questionnaire asking attitudes to treatment for cough for 1 week with grey phlegm RCT of 459 patients Dissatisfaction with lack of antibiotic treatment 26% if called bronchitis 17% if called viral illness 13% if called a cold 14 community clinic providers randomized to exam room poster vs. standard practice control for 1 year Poster indicated practice commitment to appropriate prescribing Inappropriate antibiotics 60.00% 50.00% 40.00% 30.00% Poster 20.00% Control 10.00% 0.00% Phillips TG et al. J Am Board Fam Pract Nov Dec;18(6): Meeker D et al. JAMA Intern Med Mar;174(3): Maria A Commitment to Our Patients about Antibiotics atients, Antibiotics only fight infections caused by bacteria. Like all drugs, they can be harmful and should only be used when necessary. Taking antibiotics when you have a virus can do more harm than good: you will still feel sick and the antibiotic could give you a skin rash, diarrhea, a yeast infection, or worse. Antibiotics also give bacteria a chance to become more resistant to them. This can make future infections harder to treat. It means that antibiotics might not work when you really do need them. Because of this, it is important that you only use an antibiotic when it is necessary to treat your illness. How can you help? When you have a cough, sore throat, or other illness, tell your doctor you only want an antibiotic if it is really necessary. If you are not prescribed an antibiotic, ask what you can do to feel better and get relief from your symptoms. Your health is important to us. As your healthcare providers, we promise to provide the best possible treatment for your condition. If an antibiotic is not needed, we will explain this to you and will offer a treatment plan that will help. We are dedicated to prescribing antibiotics only when they are needed, and we will avoid giving you antibiotics when they might do more harm than good. If you have any questions, please feel free to ask us. 43 year old Hispanic female comes in because of 2 days of green nasal discharge and some mild facial pressure. Temp to 101 on day 1. Swollen turbinates and minimal maxillary tenderness on exam. She says she always gets antibiotics when her sinuses start to bother her. You indicate this may be the start of a sinus infection but it is likely viral at this point and antibiotics are unlikely to help. Sincerely,

4 Maria In the past, when she does not get antibiotics initially she always has to come back a few days later to get treated. She indicates she is a lawyer and has a court case next week and want to be better by then. Shared decision making Patients need options Patients need data Adult patients need to be treated as adults Delayed prescriptions Post dated prescriptions Ask patients to delay filling From CMAJ: legare 1 at.pdf Delayed Prescriptions Do They Work? Delayed Antibiotics vs. None RCT of 405 Spanish patients with acute, uncomplicated respiratory infections Immediate prescription Delayed prescription Patient led strategy Delayed prescription Collection strategy No prescription Rates of Atbx Usage 556 patients aged 3 years with acute respiratory tract infection 5 strategies used for patients not needing antibiotics Requiring patients to recontact clinic to request prescription Postdating the prescription Allowing patients to collect prescription from clinic Giving patients prescription but asking them to wait before use (patient led) No prescription 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Rates of antibiotic usage de la Poza Abad M et al. JAMA Intern Med Jan;176(1):21 9 Little P et al. BMJ Mar 6;348:g1606

5 Managing Sore Throats Patients can learn: Sore throats that are not strep do not need atbx Rapid tests can be used to guide therapy Consistent messaging essential Not needing antibiotics Not sick Always address symptoms Inappropriate antibiotics still common 19% of pediatric sore throats 54% of adult sore throats Procalcitonin Procalcitonin is a 114 amino acid peptide precursor of calcitonin Normally gene expression is limited to neuroendocrine cells and suppressed elsewhere In the presence of bacterial infection, gene expressed in various extrathyroid tissues and procalcitonin is secreted into circulation Interpretation of procalcitonin levels < 0.1 mcg/l antibiotics strongly discouraged mcg/l antibiotics less strongly discouraged mcg/l antibiotics recommended > 0.5 mcg/l antibiotics strongly recommended Use of procalcitonin algorithm in ED settings associated with Reduced initiation of antibiotics (73% vs. 88%) Reduced treatment failure at 30 days (OR 0.78, 95% CI ) Fleming Dutra KE et al. JJAMA May 3;315(17): Schuetz P et al. JAMA Sep 9;302(10): Schuetz P et al. Cochrane Database Syst Rev Sep 12;(9):CD C reactive protein (CRP) Group Level Interventions RCT of 258 adults with acute LRTI or sinusitis Physicians advised (but not required) to consider antibiotic prescribing based on CRP level no prescription when CRP < 20 mg/l delayed prescription when CRP mg/l immediate prescription when CRP > 100 mg/l 80% 70% 60% 50% 40% 30% 20% 10% 0% CRP Control Peer comparisons Accountable justification Financial incentives Physician reminders Educational brochures Multi faceted approach Cals JW et al. Ann Fam Med Mar Apr;8(2): Hallsworth M et al.lancet Apr 23;387(10029): Meeker D et al. JAMA Feb 9;315(6): Arnold SR et al. Cochrane Database Syst Rev Oct 19;(4):CD The Not Prescribing Toolkit CDC Resources Talking to patients Changing the language Exam room posters Patient information handouts Delayed prescriptions Testing (procalcitonin, CRP) Image courtesy of: FAQs Printable exam room posters Patient education handouts Symptomatic relief How to take antibiotics What is delayed prescribing What is watchful waiting faqs.html