Inappropriate Prescribing, Penicillin Resistance: Causes and Remedies

A recent paper sheds light on the causes of inappropriate antibiotic prescribing and misconceptions about infectious disease that can lead to it.

Inappropriate antibiotic prescribing—prescribing antibiotics for viruses or self-limiting bacterial infections—is a common problem. Despite aggressive, very public efforts to reduce this problem, it continues. The primary diagnoses associated with inappropriate prescribing are all upper respiratory in nature: the common cold, rhinosinusitis, pharyngitis, acute bronchitis, and acute otitis media.

Resistance to common antibiotics goes hand-in-hand with inappropriate antibiotic prescribing. The Center for Disease Dynamics, Economics, and Policy indicates that Streptococcus pneumoniae, which causes community-acquired pneumonia and bacterial meningitis, has become alarmingly resistant to narrow spectrum antibiotics such as penicillin. The center predicts that 8 of every 10 infected patients will be unresponsive to first-line, narrow spectrum antibiotics in the near future.

A paper by Michelle Froh, a candidate for a Masters in Nursing at Washington State University, sheds light on causes of inappropriate prescribing and misconceptions about infectious disease that can lead to inappropriate prescribing. Froh reviews a number of key facts about inappropriate prescribing and covers mechanisms that can address perceived problems.

• Primary Care Providers (PCPs) often prescribe antibiotics because they worry about patient satisfaction, cave in to patient demand for antibiotics, or lack time to educate patients about appropriate antibiotic use. Sadly, prescribing an antibiotic inappropriately is faster than educating patients about why an antibiotic won’t help.
• Misconceptions that lead PCPs to prescribe inappropriately include signs or symptoms such as pharyngitis, purulent nasal discharge, or persistent cough. Sputum color, produced nasally or from a cough, and pharyngitis don’t indicate bacterial etiology.
• When PCPs guess what patients wanted from a visit for an acute respiratory tract infection (assuming patients wanted antibiotics), most are wrong.
• In the natural course of a respiratory infection, patients’ symptoms worsen until day 3 or 4, then improve over the next 10 to 14 days. Patients generally seek care on day 3 or 4, so if the PCP prescribes an antibiotic then, improvement generally occurs, but the antibiotic is not necessarily the reason for the improvement.
• Patients who ask for antibiotics are usually trying to treat symptoms (e.g. pain and lost sleep), not supposed bacterial infection. More suitable interventions can be used.

The author stresses that many evidence-based treatment guidelines are available and can help PCPs differentiate between conditions that need treatment with an antibiotic and those that don’t. Appropriate mechanisms in lieu of immediate antibiotics include giving parents a safety-net prescription when recommending observation alone, although this approach requires educating the parents about when and why to fill the prescription. Penicillin treatment failure in patients with pharyngitis is approximately 30%, and patients who fail penicillin treatment will generally need cephalosporins.

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.