Why we use antibiotics unnecessarily: Preserving antibiotics now and into the future
Chief Public Health Officer of Canada's Spotlight Report 2019
Antibiotic prescription: the cultural ingredients
Why do people take antibiotics when they might not need them? Like many aspects of health care, the decision is more than just a medical one.
As described in detail below, prescription and use of antibiotics is driven by many factors. The trusting relationship between patients and healthcare providers is particularly important to prevent unnecessary use of antibiotics. This relationship can be influenced by organizational factors, such as how busy the medical clinic is, the medical culture in the clinic, and the availability of guidelines and tools.
At the broader level, how we view antibiotics as a society and our public expectations about how they work and when they should be used also play a part in unnecessary antibiotic use. Together these factors create a culture that can influence antibiotic prescribing.
Most of the research on how these social factors influence antibiotic prescribing comes from other countries. There is a lack of information on what is driving Canadians to use antibiotics unnecessarily. Here we describe what is happening in countries similar to Canada, starting with the relationship between patients and their healthcare provider, then to factors within the medical system, and then finally, to societal views about antibiotics.
Patient and provider relationships
The relationship that nurses, doctors, and other healthcare providers build with their patients is one of the most important predictors of antibiotic use.
Patients and healthcare providers who trust each other and have a good relationship generally have better communication on health issues. Patients who ask questions and listen to options take antibiotics less often. Similarly, providers who know their patient, listen to their patient, and are able to explain a course of action in an understandable way are less likely to prescribe unnecessary antibiotics.Footnote 28, Footnote 29, Footnote 30, Footnote 31
Misunderstandings can lead to unnecessary antibiotic use.Footnote 32, Footnote 33, Footnote 34, Footnote 35 Healthcare providers sometimes think that their patients expect an antibiotic prescription, when in reality they seek advice and reassurance.Footnote 36
For example, parents of young children might want to make sure their child's illness isn't serious or want advice on how to help their child feel better, instead of specifically seeking antibiotics. At times, providers may also prescribe an antibiotic to maintain positive relationships with their patients or believe that a patient's satisfaction is associated with leaving the medical visit with a prescription.Footnote 37, Footnote 28, Footnote 39
When healthcare providers prescribe antibiotics, they do so within a medical practice and within the broader healthcare system. Certain factors in this system can influence the relationship between patients and providers and affect the likelihood of unnecessary prescription of an antibiotic.
Time pressures and quick fixes
Saving time can be a motivating factor for both patients and healthcare providers. In busy clinics, healthcare providers may have little time for each patient and writing a prescription can be a fast way to conclude a doctor's office visit.Footnote 32, Footnote 40, Footnote 41 This time pressure can affect the relationship, as there may be less time for healthcare providers to share information and for patients to ask questions.
Outside the clinic, time pressures can also be a motivating factor for a patient who is sick and not attending work or school.Footnote 28 In this case, receiving a prescription can help justify the person's need to stay home and restFootnote 10 or, in other cases, may be perceived as a way to get back to work more quickly.Footnote 28, Footnote 42, Footnote 43
A person's ability to take time off from work due to illness depends on:
- where they work
- the type of work they do
- their financial situation
Organizations with sick-leave policies make it easier for employees to rest at home, which also prevents the spread of infection and keeps the rest of an organization's workforce healthy. But when a parent needs to return to work and bring their children back to daycare or school, they often feel pressure to ask for an antibiotic prescription.Footnote 28
Seeking reassurance for a child's ear infection in a busy medical clinic: Amanda's story
"It was a few years back when the incident happened. My daughter was 2 and a half years old. It was in the middle of the night and she had been up a few times. She barely had a fever yet was upset and crying.
The next morning, a Saturday, I did not know if I should seek care since our family doctor's office was closed. I had heard about a walk-in clinic that was open on the weekend and decided to go there because I did not want to wait until Monday for her family doctor.
I went mostly because I wanted to know what she had. I thought she had an ear infection but wasn't 100% sure, and if it was something more serious, I wanted to make sure. You hear of people who do not seek care in these situations, thinking that it is nothing serious, and then it turns out to be meningitis. This is why it is important to get these issues documented and recorded.
After we arrived at the clinic, my daughter was seen fairly quickly by a doctor and a medical student. Almost immediately, I was told that my daughter had an ear infection, that kids get these all the time, and then received a prescription for an antibiotic called amoxicillin. The doctor and the medical student left the room immediately after.
The whole encounter lasted less than 5 minutes and I felt very rushed and unimportant. There was no opportunity to discuss alternative options. I did not feel comfortable to voice my concerns to the doctor because I did not want to make her look bad in front of her medical student. I took the prescription but did not get it filled. Instead, I went home, gave my daughter a Tylenol, and had her rest.
A day or two later, she was feeling better."
Like all people, healthcare providers can be influenced by their peers' beliefs and actions. In medical clinics where antibiotics are over-prescribed, it can become the accepted practice or norm for all the providers. In these clinics, there is limited feedback from colleagues that can caution against inappropriate prescribing.Footnote 44, Footnote 45, Footnote 46
Some healthcare providers may be less comfortable with not knowing the cause of an infection, when dealing with ambiguous patient symptoms such as a sore throat or cough. This diagnostic uncertainty is one of the most commonly cited causes of inappropriate antibiotic prescribing.Footnote 29, Footnote 47
More than two thirds of family doctors who prescribed antibiotics unnecessarily in the United Kingdom said that they did so because they did not know whether an infection was viral or bacterial.Footnote 48 To avoid this feeling of not knowing and to minimize the unlikely possibility of missing a serious bacterial infection, healthcare providers sometimes prescribe, and patients sometimes request, antibiotics when these may not be needed.Footnote 28, Footnote 29, Footnote 30, Footnote 49, Footnote 50
Medical guidelines and antibiotic prescribing policies
Healthcare providers often receive guidance (called clinical practice guidelines) to help them make medical decisions. Few guidelines around the world consider antibiotic resistance in their recommendations.Footnote 51 Roughly 2 out of 3 medical guidelines for common infectious illnesses (pneumonia, urinary tract infections, ear infection, sinus infection, and sore throat) used in mainly high-income countries do not consider antibiotic resistance in their recommendations.Footnote 51
That said, it is unclear from the available evidence to what extent medical guidelines have an impact on healthcare providers' decisions to prescribe antibiotics.Footnote 38 For example, one Canadian study reported that providing physicians and pharmacists with user-friendly, web-based guidelines targeting the most common infectious conditions resulted in an immediate decrease in antibiotic use that lasted for at least 3 years.Footnote 52
However, another study suggested that passive guideline circulation alone is not enough to ensure that physicians are aware of, and follow, new and updated guidelines.Footnote 53
Between 1950 and 2012, the death rate from infectious diseases in Canada declined by 62% for men and 57% for women.Footnote 54 While most of the improvement was the result of public health efforts, such as routine childhood vaccination, improvements in food safety, access to potable water and improved sanitation measures, Canadians also benefitted immensely from the use of antibiotics.Footnote 54
The societal benefit of antibiotics in reducing deaths from infectious disease has shaped our expectations that antibiotics can be widely used to quickly treat all infections, a practice that in turn reduces their effectiveness.Footnote 10
Antibiotic prescriptions are so routine that patients sometimes expect a prescription as a regular part of their medical visit. A patient might specifically request an antibiotic, believing that it will help get rid of a cold or influenza, or help a child who is ill.Footnote 48, Footnote 55
In the United Kingdom, almost 1 in 10 adults who visit a medical clinic expected to have antibiotics prescribed every time or most times they visit.Footnote 48
A perhaps familiar example are urinary tract infections in seniors. In these cases, antibiotics are frequently prescribed when they are not always necessary. This can, in part, be driven by family members' expectations for antibiotics for elderly relatives.Footnote 56
As in other parts of the body, the urinary tract is populated by microbes that change over time and presence of bacteria does not always indicate an infection that requires treatment.Footnote 57 The need for antibiotics depends on symptoms of urinary tract infection, which can be difficult to determine for elderly patients, especially those with dementia.Footnote 58
Caregivers seeking medical care for elderly family members may need advice and reassurance in particular when a patient can't advocate for him/herself.
Antibiotic resistance is complex, and many people do not fully understand the role of antibiotics in the development of antibiotic-resistant bacteria. About 1 in 3 people in the United Kingdom have not heard of antibiotic resistance, and about 1 in 4 people do not believe it is due to unnecessary antibiotic use.Footnote 59
Research also suggests that most people believe antibiotic resistance is developed by the human body, rather than by bacteria, and believe that minimizing antibiotic resistance is beyond their control.Footnote 59 Patients may need information from their healthcare provider on how antibiotics work, the types of infections they are used for, as well as a warning that they should not be saved for future use.Footnote 60, Footnote 61
Healthcare access challenges in rural and remote communities: Dr. Peter Daley's story
"In my experience working in Newfoundland, community context matters and access to health care can impact antibiotic use.
We hear from some patients that they stockpile antibiotics at home for use and sharing when needed. We also hear about physicians giving antibiotics by phone without examining patients.
There are some incredibly remote areas, where a physician is not regularly available. This lack of access may lead to stockpiling of antibiotics in anticipation."
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