How can unnecessary antibiotic use in primary care be avoided?

Strategies to Reduce Unnecessary Antibiotic Use in Primary Care

Key Recommendations

Implementing a multidisciplinary antibiotic stewardship program is essential to reduce unnecessary antibiotic prescribing in primary care settings. 1 These programs should include several evidence-based interventions working together to change prescribing behavior.

Organizational and System-Level Strategies

• Establish a formal antibiotic stewardship team that includes primary care physicians, infectious disease specialists, pharmacists, and administrators 1
• Develop and implement local antibiotic prescribing guidelines that are created with input from frontline clinicians to increase acceptance and adherence 2
• Create antibiotic formularies and policies that restrict certain broad-spectrum antibiotics to appropriate indications 1
• Set minimum clinical standards for antibiotic prescribing and regularly audit adherence 1
• Implement electronic health record clinical decision support systems (CDSS) that provide guidance at the point of care 1
  • These systems should incorporate patient data, local recommendations, and laboratory results
  • Alerts should be streamlined to avoid information overload

Provider-Focused Interventions

• Provide regular education and training on appropriate antibiotic use 1

  • Active educational formats (seminars, roundtable discussions) are more effective than passive approaches
  • Include infectious disease topics in departmental meetings and conferences

• Implement peer comparison feedback on prescribing patterns 3

  • Share individual prescribing rates compared to peers with the lowest prescribing rates
  • Target high prescribers for more intensive interventions

• Use point-of-care diagnostic testing to guide treatment decisions 1

  • C-reactive protein (CRP) testing has been shown to reduce antibiotic use by 14% in primary care
  • Rapid strep testing for pharyngitis can help identify bacterial infections requiring antibiotics

• Implement post-prescription review to evaluate antibiotic appropriateness 1

  • Follow up on culture results to switch to narrow-spectrum antibiotics when possible
  • Consider telephone follow-up for patients discharged with antibiotics

Patient-Focused Interventions

• Educate patients about appropriate antibiotic use 1

  • Explain that antibiotics cannot reduce the severity or duration of viral infections
  • Provide clear information about the expected duration of common illnesses

• Use delayed prescribing strategies for conditions where antibiotics might be beneficial but aren't immediately necessary 1

  • Provide prescriptions with instructions to fill only if symptoms worsen or persist

• Enhance pharmacist involvement in patient education 1, 4

  • Pharmacists should inform patients about:
    • Common duration of respiratory illnesses
    • Symptomatic treatment options
    • Potential side effects of antibiotics
    • Proper disposal of leftover antibiotics

Targeting High-Impact Conditions

Focus stewardship efforts on conditions with the highest rates of unnecessary prescribing 5:

• Common cold (antibiotics never indicated)
• Acute bronchitis (52.6% unnecessary prescribing)
• Acute sinusitis (48.4% unnecessary prescribing)
• Acute otitis media (39.3% unnecessary prescribing)

These four conditions account for approximately 80% of unnecessary antibiotic prescriptions in primary care 5.

Implementation Considerations

Measuring Success

• Track overall antibiotic prescribing rates per 1,000 visits
• Monitor the percentage of unnecessary antibiotic prescriptions
• Assess guideline-concordant prescribing (right drug, right duration)
• Evaluate antibiotic resistance patterns in the community

Potential Barriers

• Patient expectations and demand for antibiotics (accounts for approximately 14% of unnecessary prescriptions) 6
• Time constraints in busy primary care settings
• Diagnostic uncertainty
• Fear of missing bacterial infections or complications

Sustaining Change

Research shows that multifaceted interventions can achieve sustained reductions in antibiotic prescribing even after some components are discontinued 3. A study in VA primary care clinics demonstrated:

• 35.6% reduction during the intervention period
• 26.8% reduction one year after intervention components were discontinued
• Significant improvements in guideline-concordant prescribing

Conclusion

Reducing unnecessary antibiotic use requires a comprehensive antibiotic stewardship program that combines organizational support, provider education, clinical decision support, and patient engagement. By focusing on high-impact conditions and implementing evidence-based interventions, primary care practices can significantly reduce inappropriate antibiotic prescribing, thereby improving patient outcomes and combating antimicrobial resistance.