How Can Patient Pressure for Antibiotic Prescriptions Be Managed?

Antimicrobial drug resistance is increasing every day, and inappropriate antibiotic prescribing is a global public health problem. The World Health Organization has reported that antimicrobial resistance is one of the 10 greatest global public health threats facing humanity. Patient pressure is also an important cause of inappropriate antibiotic prescribing. Analyses of adult and pediatric consultations suggest that various techniques can be used to change expectations and reduce antibiotic prescribing.

At this year's annual meeting of the European Society for Paediatric Infectious Diseases, Prof. Dr. Tanya Stivers of the University of California Department of Sociology presented some of her team's studies examining clinical prescribing patterns.

Rational Antibiotic Use

Inappropriate prescribing is a widespread and recognized problem in medicine, particularly in primary care (family medicine). Effective antibiotics used by doctors to treat many serious infections are already becoming useless. Stivers stated that this problem does not arise from a lack of understanding about the cause of illness and antimicrobial resistance, or from patients explicitly requesting antibiotics; instead, it seems to arise from doctor-patient interaction during the consultation.

Note: Antimicrobial is a general term for drugs developed against all microorganisms (bacteria, fungi, viruses and parasites).

In pediatric practice, doctors were found to prescribe antibiotics in 62% of cases in which they had already clinically diagnosed a viral respiratory infection — for which antibiotics were unnecessary — when parents were perceived to be "expecting" a diagnosis requiring antibiotics, compared with 7% when no such perception existed.

Adult patients were found to use the following methods to obtain antibiotic prescriptions:

• Influencing: Patients try to make doctors view the problem as more severe (for example, “A stabbing sore throat”).
• Steering: Patients steer doctors toward a bacterial problem (for example, “I have tried every medicine, but it just will not go away” and similar statements). Steering was found to occur in 41% of consultations.
• Resisting: Patients challenged the diagnosis or treatment in 40% of consultations (for example, “There was a swelling yesterday” and similar statements).

Influencing and steering resulted in antibiotic prescriptions for 60% of patients without signs of bacterial infection, compared with 30% when these methods were absent (p<0.05).

How Can These Pressures Be Resisted?

Stivers made recommendations based on original data from video recordings of 570 pediatric consultations. The latest findings came from an analysis of 68 adults attending primary care in Southern California for upper respiratory infections, with inappropriate prescribing identified in 37% of these cases.

When investigating antibiotic prescribing, it is useful to examine a typical primary care consultation. A brief healthcare visit is a staged process involving opening the consultation, identifying the problem, gathering information, counseling and then closing the encounter. It is important to know that patients shape prescribing decisions here and that good mutual communication affects the outcome.

In Stivers's experience, influencing, steering and resisting led to antibiotic prescriptions for 60% of people without signs of bacterial disease, compared with 30% when patient pressure was absent.

How Can We Change Practice?

Global experience suggests that printed materials aimed at doctors (such as leaflets and infographics) provide only marginal benefit. Patient education does work, but it also needs to be repeated.

Try a 3-Way Communication Plan

Stivers recommends a 3-way communication plan influencing the consultation process to counter these pressures:

• Forecasting / Preliminary Diagnosis: Situations suggesting that the patient's symptoms may be viral emerge at the beginning of the consultation. This approach was found to reduce antibiotic prescribing to 33%, compared with 59% when there was no preliminary diagnosis.
• Positive Treatment Plans without Antibiotics: Early positive recommendations are less likely to be resisted than negative recommendations given at the end of a consultation. (For example, “I will give you medicine to help you get over this.”)
• Persuasion: This involves explaining the diagnosis and nature of the illness (cough, cold, etc.), providing information about viral and bacterial differences and describing antibiotic risks. If persuasion works, antibiotic prescribing falls to 33%, but without it the rate is 63% (p<0.05). (An effective preliminary diagnosis and positive recommendation should generally eliminate the need for persuasion.)

Stivers's research suggests that these techniques work but must become a natural part of routine clinical practice. Available data showed that doctors rarely offered a preliminary diagnosis and used persuasion in 53% of cases when they encountered resistance. Positive recommendations were used in 89% of cases, but their effect was reduced because the doctor was vague and nonspecific.

Awareness Is Necessary but Not Sufficient

In conclusion, Stivers says awareness is necessary to address inappropriate prescribing but is not enough. The challenge is to reconsider health policies and ways of communicating about antibiotics. After saying there is no disadvantage to using preliminary diagnosis, positive recommendations or persuasion, she asked, “Even if we can reduce antibiotic prescribing by 5-10%, would it not be worth it?”

Answers to Questions

A question-and-answer session followed Stivers's presentation:

• Doctors want to please. Stivers challenged this point, saying satisfaction does not depend on antibiotic prescribing and doctors often misjudge what patients want. She said explaining other treatment options is important because patients often simply want “things they can do”.
• Decision fatigue is often a factor. She stated that evidence shows antibiotic prescribing is more common toward the end of a shift, that doctors should avoid negotiating with patients because it lengthens the consultation, and added that an early preliminary diagnosis could help here.
• Vaccine-opposing parents often want active treatment. She said communication can be difficult here, and positive instructions would be more successful than attempts to persuade, probably resulting in less parental resistance (for example, “We will give you a vaccine today.”).
• Concern was expressed about manipulating patients before a definitive diagnosis. Could this cause a serious bacterial infection to be missed? Stivers acknowledged this as a gamble and suggested a “neutral” preliminary statement such as “We have been seeing many viral infections recently.”
• Cultural differences may have an effect. As an example, she highlighted that discussions between doctors and parents in China focus more on oral versus intravenous administration than on antibiotic versus non-antibiotic medicines.
• Possible litigation is a factor in prescribing. Stivers said her recommended prescribing approach should not interfere with appropriate treatment management and that the clinical picture can change, so antibiotics should be prescribed when necessary.
• Audits may improve inappropriate prescribing in a short time. Video-recorded consultations may have influenced treatment management. She answered that inappropriate antibiotic prescribing would be higher in consultations that were not recorded.
• Increased medical testing during patient care may reduce unnecessary prescribing. She said this had been documented in countries such as Sweden, but evidence from China suggested that many patients would still receive antibiotics even when a bacterial cause was ruled out.
• At the end of her presentation, Stivers said that when parents insist on antibiotic treatment, they should be told what is better for them, and also emphasized that “how we say something matters”.

Conclusion

Resistance to antimicrobial drugs is a global health threat that endangers sustainable health goals. The World Health Organization has reported that antimicrobial resistance is one of the 10 greatest global public health threats facing humanity. Resistance to the antibiotic “Ciprofloxacin” ranges from 8% to 93% in Escherichia coli and from 4% to 80% in Klebsiella pneumoniae. Colistin, one of the newer-generation antibiotics, is the only last-resort treatment for life-threatening infections caused by carbapanem-resistant Enterobacteriaceae. Once resistance develops to last-resort antibiotics, our hands may be tied. Using antibiotics when necessary is therefore everyone's shared responsibility.