Antibiotic prescribing: can we make it easier?

Community-acquired pneumonia (CAP) is a common and sometimes fatal illness. Annually, up to 5.6 million cases of CAP are treated in the United States.1 With an average mortality of 12%, CAP is the sixth leading cause of death among Americans. It is not surprising, therefore, that a considerable literature on the management and outcomes of CAP has been generated and is best exemplified by the series of clinical practice guidelines from the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA). These guidelines are, in turn, used by many other organizations to measure and improve the quality of CAP practice patterns. Perhaps the most referenced, and contentious, aspects of these guidelines are the antibiotic treatment recommendations. Unlike most other therapeutic guidelines, antibiotic treatment guidelines are unique in needing to balance their impact on patient- and community-level outcomes. At the patient level, a powerful broad-spectrum antibiotic with few side effects and convenient dosing may be very attractive. However, widespread use of such an agent may lead to increased levels of antibiotic resistance in the community.2 In many ways, these trade-offs symbolize the broader moral dilemma that physicians face in practicing population-based medicine or delivering “managed care.” Investigating how knowledge and attitudes influence antibiotic treatment of CAP can help us to understand physician behavior more broadly. In this issue, Metlay et al. compare physician preferences for antibiotic treatment of outpatients with CAP with guideline recommendations and evaluate self-reported attitudes about antibiotic prescribing and population-based medical care.3 The authors asked equal numbers of generalist and infectious diseases (ID) physicians to rank 10 antibiotic choices for the treatment of uncomplicated CAP in a hypothetical outpatient, and then asked them a series of attitude questions to help elucidate potential influences on prescribing decisions. The authors report that relative to erythromycin, ID physicians preferred the newer, broad-spectrum antibiotics levofloxacin and azithromycin, while generalists had a relative preference for azithromycin alone. The antibiotic choice results are interesting, but hardly surprising. The ID physicians' responses were consistent with IDSA guidelines at the time, which recommended a macrolide (either 1st or 2nd generation), fluoroquinolone or doxycycline as a first-choice agent.4 In fact, ID physicians and generalists did not actually differ in their enthusiasm for azithromycin (33% of each group ranked azithromycin as their first choice), but rather in their lack of enthusiasm for erythromycin. The ID physicians' high ranking for levofloxacin may represent an inappropriate preference for broad therapy given the hypothetical patient they were asked to consider.5 However, azithromycin, while newer, is broader in spectrum than erythromycin only in that it has enhanced activity against H. influenzae, and is not considered a preferred agent for drug-resistant S. pneumoniae. Unfortunately, the community-level repercussions of unrestrained use of these newer agents are already materializing. In a recent report from the Centers for Disease Control and Prevention, over a period in which prescriptions for macrolides increased by 13%, macrolide resistance rates among invasive pneumococcal isolates in the United States doubled from 10% to 20%.5 Physicians ranked doxycycline lower than many other agents even though it possesses many attractive pharmacological properties. Despite use for over 3 decades, doxycycline has retained good activity against most CAP pathogens (including penicillin-resistant pneumococcus),7,8 is well tolerated, inexpensive, and is effective in mild-to-moderately ill hospitalized patients with CAP.9 The fact that both physician groups favored newer agents over older agents may be better explained by the pervasive power of pharmaceutical marketers and detailers in private practices, hospitals, and professional society gatherings, as well as in their advertisements in medical journals and other publications in the United States.10 The attitude assessment showed that physicians were concerned about and understood the impact of antibiotic prescribing practices on antibiotic resistance, but ranked clinical and patient-related factors as more important than concerns about promoting resistance when choosing an antibiotic. Perhaps this is because under most circumstances, the societal impact of an individual physician's antibiotic-prescribing behavior is an outcome not directly experienced by the physician or her patients. In contrast, physicians and patients do experience (and remember) treatment failures, adverse effects, and cost. More generally, what this study and clinical experience suggest is that it is hard for physicians to comply with population-based guidelines when there is a theoretical downside for the individual patient. Because many population-based guidelines are focused on resource utilization, physicians may believe that noncompliance will not adversely affect patient outcomes. Unfortunately, with antibiotic prescribing, the negative societal impact of current practice is more clinically palpable. How do we enable ambulatory physicians to prescribe fewer broad-spectrum agents when they are not clinically indicated? One strategy is to extend the finding that physicians with higher levels of societal concerns had a lower preference for levofloxacin, suggesting that such societal concerns can influence practice preferences in some physicians. Perhaps educational strategies that teach population- and evidence-based medicine can improve physician prescribing behavior in general. In addition, public and patient education on these same topics could provide additional support to help physicians do the right thing. This will need to be examined. With specific reference to CAP, additional steps to help counterbalance individual “benefit” and societal “risk” in antibiotic selection practices are improving diagnostic testing, defining the true clinical implications of resistance, and clarifying the importance of covering “atypical” organisms such as Chlamydia pneumoniaeMycoplasma pneumoniae. If history is a beacon, then physician education will not be enough, and additional physician facilitators will be needed. In the inpatient setting, active management of antibiotic prescribing (computer decision support, antibiotic rotation, restricted formularies, ID consultation) has shown promise in improving both clinical outcomes and resource utilization,11 as well as in altering antibiotic resistance profiles. Expanding this approach to the outpatient setting is a logical next step and will require a coordinated effort between federal agencies such as the Centers for Disease Control and Prevention, regional and local health care organizations (payors), providers, and community representatives. Antibiotic prescribing will be easier for physicians when they are not asked to balance the risks to society against benefit for their patients. Whenever there is a potential risk to the patient of a treatment that “society prefers,” it might be more ethical to ask policymakers, rather than individual physicians, to make those decisions. These challenges are not insurmountable. With recent increased awareness of both antibiotic resistance and patient safety issues among policy makers and the public, the timing may be right for a national push toward more innovative approaches to the management of outpatient antibiotic prescribing practices. What is clear is that we need to make these decisions easier.