Antibiotic Resistance: Use of Delayed Prescriptions for Viral Syndromes in Urgent Care

Purpose: Widespread use of antibiotics leads to a development of antimicrobial resistance, an increasing global problem. The rise of antibiotic-resistant bacterial strains represents a serious threat to the public. The Centers for Disease Control and Prevention (CDC) estimates at least two million illnesses and 23,000 deaths are caused by antibiotic resistant bacteria in the United States (CDC, 2014). The strategy of delayed antibiotic prescribing, sometimes called “wait and see” prescriptions, may reduce antibiotic use for viral syndromes in primary care settings. The overall purpose of this scholarly project is to explore delayed prescriptions used by providers in two urgent care settings, with a potential to reduce the amount of antibiotics consumed by patients for viral syndromes. These diagnoses include influenza, upper respiratory infection (URI), pharyngitis, sinusitis, acute bronchitis, acute otitis media (AOM). Significance of the Project: There have been numerous studies in the past addressing the importance of reducing antibiotic use. The need to slow the emergence of resistant bacteria by judicious use of antibiotics in healthcare and agricultural settings will require the cooperation and engagement of healthcare providers, healthcare leaders, pharmaceutical companies, and patients. Providers are well aware of the dangers of prescribing antibiotics for viral syndromes and have strict requirements as to which patients they will issue delayed prescriptions. According to the American College of Emergency Physicians (ACEP), antibiotics are given to patients with acute bronchitis 65% to 80% of the time, acute pharyngitis visits receive antibiotics 60% of the time, and acute sinusitis receives antibiotics 80% of the time out of 4 million annual outpatient visits (Radecky, 2014). Using antibiotics for conditions that have only a marginal, self-limiting or no clinical effect has been labelled unnecessary or inappropriate antibiotic use or antibiotic overuse or misuse (Hoye, USE OF DELAYED PERSCRIPTIONS IN URGENT CARE 8 Gjelstad, & Lindbaek, 2013). Factors contributing to overuse of antibiotics could include patient demand, lack of information on viruses and antibiotics, perceived ideas of duration of illness, uncertainty of diagnosis and inability to spend time with patients due to volume. According the Journal of Urgent Care Medicine (JUCM), 52.9% of visits to urgent care centers in 2014 were for viral syndromes, otitis media, URI, coughs, and 1.6% influenza visits (JUCM, 2015). There is evidence that the majority of patients believe that antibiotics are an appropriate treatment for these diagnoses. Methods: Urgent care centers have been around for about a decade and considered new models of healthcare in the niche between primary care offices and emergency departments. Urgent care centers have extended hours and envisioned as functioning as low-acuity emergency departments with extended services such as Radiology, and Lab testing. They mainly have emergency board certified physicians, but some may have primary care providers on duty. Generally urgent care centers are open selected hours seven days a week. This project was conducted in two urgent care centers in two different counties, with a combined patient volume of 16,000 yearly. The urgent care centers used in this project are affiliated with a major hospital system in central New Jersey. The providers currently work at both urgent care centers on a rotational basis, as well as the emergency department of the main hospital. The physicians were asked to participate and welcomed the project. With the diagnosis of viral syndrome, the provider would recommend a delayed prescription for an antibiotic. At discharge, the nurse would explain the dangers of antibiotic resistance using patient handouts from the CDC’s “Get Smart about Antibiotics” (CDC, 2014). The patient was asked to wait four days and if the symptoms were not better, they would be able to begin their antibiotic instead of returning USE OF DELAYED PERSCRIPTIONS IN URGENT CARE 9 for another visit. A phone survey was conducted on day five -post visit to determine if the patient filled or did not fill the prescription. Project Outcomes: Through patient education and the use of handouts, this project proved that educating patients at time of discharge could increase the likelihood of the patient’s decision not to fill their delayed prescription. Of sixty-eight patients surveyed by phone, thirty-four did not fill their antibiotic prescriptions and thirty-four patients did fill their antibiotics within the fiveday range. There was a significant difference in who filled their prescriptions and who did not, by whether the provider or the nurse handed out the education packet to the patient. The nurse given the education packet had a better response to patients not filling their antibiotic. Though the cumulative percentage of patients who did not fill their prescriptions was slightly greater than 50%, the outcome has the potential to decrease the amount of antibiotics the public consumes with delayed prescriptions and education at discharge. Clinical Significance: The practice of overprescribing of antibiotics has contributed to an increase in resistance and treatment failures for bacterial illnesses. Patient satisfaction has become a large part of the healthcare system and was taken into consideration in this project. Patients are requesting antibiotics for diagnosed viral infections due to their lack of education, the proper use for antibiotics, and dangers from misuse such as allergic reactions, abdominal pain and most common, diarrhea and vomiting. Healthcare providers can help lower the prescription rates of antibiotics with educational information as well as using delayed prescriptions. Increasing knowledge about antibiotic misuse can be statistically significant in demonstrating that adding education can decrease the use of antibiotics when not needed. Time with the patient at discharge and patient education proved to be significant therefore beneficial to not filling the delayed antibiotic prescription. USE OF DELAYED PERSCRIPTIONS IN URGENT CARE 10 Antibiotic Resistance: Use of Delayed Prescriptions for Viral Syndromes in Urgent Care Section 1 Background Antibiotic abuse and antimicrobial resistance are global problems. Antibiotics save millions of lives each year in the United States and around the world. The rise of antibiotic-resistant bacterial strains represents a serious threat to the public health. Antibiotics can be a tremendous value to the community but misuse can lead to antibiotic resistance and death globally. Unnecessary use of antibiotics causes millions to die each year from resistance to antibiotics due to over use and tolerance. The CDC launched an initiative designed to categorize drug resistant infections called “superbugs” and estimated that 2 million people a year were infected with “superbugs” with 23,000 deaths (Ross Johnson, 2014). URI’s in children were found to account for more than 75% of all antibiotics prescribed under the age of twelve (Ross Johnson, 2014). Although research shows that bacterial infections are only responsible for 38% of acute rhino sinusitis, 6% to 18% of acute respiratory infections (ARI) and 5% to 15% of pharyngitis, 53% of patients are prescribed antibiotics (Legare, Labrecque, Godin, LeBlanc, Launer and Grimshaw, 2011). According to the American College of Emergency Physicians (ACEP), antibiotics are given to patients with acute bronchitis 65% to 80% of the time, acute pharyngitis visits receive antibiotics 60% of the time, and acute sinusitis receives antibiotics 80% of the time (Radecky, 2014). Resistance for individuals is of concern, but the public health issue of the overall community population resistances has major public health concerns. The Centers for Disease Control and Prevention (CDC) estimates at least two million illnesses and 23,000 deaths are caused by antibiotic-resistance bacteria in the United States (CDC, 2014). The need to slow the emergence of resistant bacteria by judicious use of USE OF DELAYED PERSCRIPTIONS IN URGENT CARE 11 antibiotics in healthcare and agricultural settings will require the cooperation and engagement of healthcare providers, healthcare leaders, pharmaceutical companies, and patients. Approximately one-third to one-half of all antibiotics used in outpatient settings is either unnecessary or incorrectly prescribed (Ault, 2015). The CDC (2014) states that patient satisfaction related to acute bronchitis, is most dependent on the doctor-patient communication as to whether it is appropriate for an antibiotic to be prescribed or not. The CDC also reports that purulent secretions of the nares and throat are not indicative of bacterial infections. The common cold and flu can cause symptoms of sore throat, nasal congestion, and cough for up to fourteen days (CDC, 2014). These viral syndromes can be long and uncomfortable episodes, but antibiotics are not the answer. An expert review by Sipani (2008), describing the “Economics of Antibiotic Resistance”, suggests that for improving antibiotic usage, strategies such as guidelines, control committees, and treatments for all patients to be treated with the most effective, least toxic, and least costly antibiotic for optimal use. Alternative treatment options such as education of health professionals and patients regarding infection control measures can be incorporated (Sipahi, 2008). Pharmaceutical companies have also slowed the development of manufacturing new antibiotics due to the low profits and the antiquated models of the FDA approvals (Sipahi, 2008). Aside from resistance to antibiotics from overuse, allergic reactions, abdominal pain, diarrhea, vomiting and even death from anaphylaxis, has cause major concerns for many patients and parents. The widespread use of antibiotics has led undesirable consequences such as yeast infections in women and more ser