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 Over-prescription of antibiotics for conditions that do not require
them exposes more bacteria to the drugs and speeds resistant
mutations - making the drugs less effective when they are actually
needed.
A recent World Health Organization survey found that more than half
of people surveyed believed, incorrectly, that antibiotics could
treat cold and flu.
Doctors may feel that patients ‘want’ antibiotics – or they may be
in the habit of prescribing them, even when they are not warranted,
said Tammy C. Hoffmann of the Center for Research in Evidence-Based
Practice (CREBP) at Bond University in Australia, senior author of
the new review.
Primary care doctors may be less likely to see the negative effects
of antibiotic resistance, because most of the 25,000 American deaths
last year from antibiotic resistance occurred in hospitals, not in
primary care offices, Hoffmann said.
According to her team’s new review of past research, when patients
and doctors discuss antibiotic prescribing together, fewer drugs are
given out.
“What is good is that this is one of the first reviews of shared
decision making interventions that demonstrates a good clinical
outcome (decreased antibiotic use without damage to patient
satisfaction),” Hoffman told Reuters Health by email.
The new review included 10 randomized controlled trials involving
more than 1,000 primary care doctors and hundreds of thousands of
patients in the U.K. and Europe. The trials tested interventions to
encourage collaboration between doctors and patients on antibiotic
prescribing decisions.
Some involved training doctors in specific communication skills to
establish patients’ concerns and beliefs about the need for
antibiotics, their harms and benefits, and to agree on a management
plan. Others also included giving written information about
antibiotics to patients, and encouraging discussion with doctors
about whether they are necessary.
Within six weeks of these consultations, antibiotic prescriptions
for acute respiratory infections were lower in the training and
education groups than in comparison groups that had received no
intervention.
In eight of the trials, almost half of patients in the comparison
groups were given an antibiotic prescription, compared to 29 percent
in the shared decision-making groups.
Longer-term effects were unclear, the researchers report in their
results in the Cochrane Library.
“Shared decision-making means that the options are discussed; the
natural course of the illness is discussed (i.e., these infections
usually get better by themselves, so the option of not taking
antibiotics is certainly one option that is reasonable to consider
and discuss),” Hoffman said.
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In these discussions, patients can weigh the marginal amount of
benefit that is often provided by antibiotics in common acute
respiratory infections against the risk of harm, she said.
“Not all patients will want to be involved in collaborative decision
making with their clinician and that is fine if that is their choice
– but they should be at least offered the opportunity,” Hoffman
said. “It shouldn’t be used as a way of convincing a patient to do,
or not do, something.”
Dr. Ralph Gonzales of UCSF School of Medicine, who studies
antibiotic prescribing practices, told Reuters Health, “My one
reaction to shared decision making around this topic is that the
decision to use a medication that has public health implications
because of how it provides antimicrobial resistance is not
necessarily one that is ideal for shared decision making."
Involving patients in treatment decisions makes most sense when the
benefits and harms primarily will affect the individual patient,
such as deciding whether or not to screen for or treat certain
slow-moving cancers in advanced age, Gonzales said in a phone
interview.
The harms of antibiotic over-prescription affect the general public
rather than the individual, he said.
“Patients should not be making decisions about treatments that have
larger societal and public health implications, with no individual
benefit,” he said.
In theory, if a patient truly wants an antibiotic, even if it will
not treat their respiratory infection, the doctor would prescribe it
in a shared decision-making situation, which would go against the
evidence, Gonzales said.
SOURCE: http://bit.ly/1Oc48FE Cochrane Library, online November 11,
2015.
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