II. Epidemiology
- Antibiotics are not indicated or are incorrectly used in up to 40 to 50% of cases
- Up to 10 million yearly U.S. inappropriate Antibiotic prescriptions for pediatric Upper Respiratory Infections
III. Adverse Effects: Antibiotics
- See Adverse Drug Reaction (includes Drug-Induced Skin Reaction)
- Antibiotic Associated Diarrhea (including Clostridium difficile)
- Antibiotic Resistance (e.g. MRSA, PRP, VRE, Carbipenem resistant Gram Negatives, Gonorrhea, Tuberculosis)
- Life-Threatening Drug-Induced Rashes (e.g. DRESS)
- Anaphylaxis (esp. Penicillins)
- Stevens-Johnson Syndrome (esp. Sulfonamides)
- Tendinopathy (Fluoroquinolones)
- Nephrotoxicity (e.g. Aminoglycosides)
- Psychosis (Clarithromycin, Ciprofloxacin)
- QT Prolongation (Erythromycin, Fluoroquinolones)
IV. Prevention: Antibiotic Overuse
- Education for patients for when Antibiotics are inappropriate (see resources below)
- Employ exam room and pharmacy posters and newsletters (see resources below)
- Dispel myths
- Sputum or nasal drainage color does not indicate Bacterial Infection
- Most Upper Respiratory Infections, Bronchitis, Conjunctivitis are viral
- "That Antibiotic does not work for me anymore"
- Watchful waiting is a reasonable strategy
- Otitis Media resolves without Antibiotics in two thirds of cases
- Contingency plan to start Antibiotics for fever, night awakening, Vomiting
- Acute Sinusitis in the first 10-14 days
- Contingency plan to start Antibiotics for persistent symptoms >14 days
- Diverticulitis
- Uncomplicated cases may be observed for 2-3 days
- Otitis Media resolves without Antibiotics in two thirds of cases
- Shorter Antibiotic courses are effective
- Uncomplicated Pyelonephritis and pneumonia Antibiotic courses are now 5 days
- Most Upper Respiratory Infections do not require Antibiotics
- No Antibiotics are needed for the Common Cold, Influenza, Laryngitis and non-Streptococcal Pharyngitis
-
Viral Infections have effective treatments (just not Antibiotics)
- Nasal Saline, Guaifenesin (mucinex) and Oxymetazoline (afrin) for sinus congestion
- Albuterol for Acute Bronchitis
- Ibuprofen or Tylenol for fever and myalgias
- Select most narrow range appropriate Antibiotic when indicated
- Follow IDSA Guidelines
- Prophylactic Antibiotic regimens have become more selective in who requires treatment
-
Antibiotic allergies are often not allergies
- Results in overuse of broader spectrum Antibiotics
- See Penicillin Allergy
- Teach patients to be astute medical consumers
- Do I really need that Antibiotic, doctor?
- Consider Delayed Antibiotic Prescription
- Example: Acute Sinusitis <10 days of symptoms (to start if symptoms refractory to non-Antibiotics at >10-14 days)
- Delayed Antibiotic Prescriptions result in decreased Antibiotic use, without adverse outcomes
- Stuart (2021) BMJ 373:n808 [PubMed]
V. Prevention: Hospital Antibiotic Stewardship
- Document indications for each Antibiotics initiation, continuation and expected duration
- Enter stop dates for inpatient Antibiotic orders
- Review Antibiotic therapy for appropriate use every 48 to 72 hours
- Obtain appropriate cultures, imaging and other tests to best identify source of infection
- Follow IDSA and other established empiric guidelines until cultures are available
- Review culture results frequently, and narrow Antibiotic spectrum when able
- Transition to oral Antibiotics as able
VI. Resources
- Antimicrobial Stewardship (AHA Physician Alliance)
- Antibiotic Use (CDC)
- CDC Hospital Antibiotic Stewardship Core Elements
- CDC: Know When Antibiotics Work
VII. References
- (2015) Presc Lett 22(9): 51-2
- (2019) Presc Lett 26(12): 70
- Cagle (2022) Am Fam Physician 105(3): 262-70 [PubMed]
- Sur (2022) Am Fam Physician 106(6): 628-36 [PubMed]