Antibiotic Overuse

Aka: Antibiotic Overuse, Antibiotic Stewardship, Hospital Antibiotic Stewardship, Delayed Antibiotic Prescription

1. See Also
   1. Antibiotic Resistance
   2. Clostridium difficile
   3. Healthcare Associated Infection
2. Epidemiology
   1. Antibiotics are not indicated or are incorrectly used in up to 50% of cases
3. Adverse Effects: Antibiotics
   1. Antibiotic Associated Diarrhea (including Clostridium difficile)
   2. Antibiotic Resistance (e.g. MRSA, PRP, VRE, Carbipenem resistant Gram Negatives, Gonorrhea, Tuberculosis)
   3. Life-Threatening Drug-Induced Rashes (e.g. DRESS)
   4. Anaphylaxis (esp. Penicillins)
   5. Stevens-Johnson Syndrome (esp. Sulfonamides)
   6. Tendinopathy (Fluoroquinolones)
   7. Nephrotoxicity (e.g. Aminoglycosides)
   8. Psychosis (Clarithromycin, Ciprofloxacin)
   9. QT Prolongation (Erythromycin, Fluoroquinolones)
4. Prevention: Antibiotic Overuse
   1. Education for patients for when antibiotics are inappropriate (see resources below)
      1. Employ exam room and pharmacy posters and newsletters (see resources below)
   2. Dispel myths
      1. Sputum or nasal drainage color does not indicate Bacterial Infection
      2. Most Upper Respiratory Infections, Bronchitis, Conjunctivitis are viral
      3. "That antibiotic does not work for me anymore"
   3. Watchful waiting is a reasonable strategy
      1. Otitis Media resolves without antibiotics in two thirds of cases
         1. Contingency plan to start antibiotics for fever, night awakening, Vomiting
      2. Acute Sinusitis in the first 10-14 days
         1. Contingency plan to start antibiotics for persistent symptoms >14 days
      3. Diverticulitis
         1. Uncomplicated cases may be observed for 2-3 days
   4. Shorter antibiotic courses are effective
      1. Uncomplicated Pyelonephritis and Pneumonia antibiotic courses are now 5 days
   5. Viral Infections have effective treatments (just not antibiotics)
      1. Nasal Saline, Guaifenesin (mucinex) and Oxymetazoline (afrin) for sinus congestion
      2. Albuterol for Acute Bronchitis
      3. Ibuprofen or Tylenol for fever and myalgias
   6. Select most narrow range appropriate antibiotic when indicated
      1. Follow IDSA Guidelines
   7. Prophylactic antibiotic regimens have become more selective in who requires treatment
      1. See SBE Prophylaxis
      2. See Surgical Antibiotic Prophylaxis
   8. Antibiotic allergies are often not allergies
      1. Results in overuse of broader spectrum antibiotics
      2. See Penicillin Allergy
   9. Teach patients to be astute medical consumers
      1. Do I really need that antibiotic, doctor?
   10. Consider Delayed Antibiotic Prescription
       1. Example: Acute Sinusitis <10 days of symptoms (to start if symptoms refractory to non-antibiotics at >10-14 days)
       2. Delayed Antibiotic Prescriptions result in decreased antibiotic use, without adverse outcomes
       3. Stuart (2021) BMJ 373:n808 [PubMed]
5. Prevention: Hospital Antibiotic Stewardship
   1. Document indications for each antibiotics initiation, continuation and expected duration
      1. Enter stop dates for inpatient antibiotic orders
   2. Review antibiotic therapy for appropriate use every 48 to 72 hours
   3. Obtain appropriate cultures, imaging and other tests to best identify source of infection
      1. Follow IDSA and other established empiric guidelines until cultures are available
   4. Review culture results frequently, and narrow antibiotic spectrum when able
   5. Transition to oral antibiotics as able
6. Resources
   1. CDC Hospital Antibiotic Stewardship Core Elements
      1. https://www.cdc.gov/antibiotic-use/core-elements/hospital.html
   2. CDC: Know When Antibiotics Work
      1. http://www.cdc.gov/getsmart/community/for-hcp/index.html
7. References
   1. (2015) Presc Lett 22(9): 51-2
   2. (2019) Presc Lett 26(12): 70
   3. Cagle (2022) Am Fam Physician 105(3): 262-70 [PubMed]