What can be done to reduce unnecessary antibiotics: Preserving antibiotics now and into the future

Chief Public Health Officer of Canada's Spotlight Report 2019

There are a number of ways that patients, healthcare providers, and health system leaders can help reduce unnecessary use of antibiotics.

What patients can do

The public can help prevent the problem of antibiotic resistance by trying to avoid infections and using antibiotics appropriately when infections occur.

Protect yourself from infection

An easy way to reduce your risk of catching an infection is to wash your hands:

• before eating or preparing food
• after using the washroom
• after coughing or blowing your nose

Also, when you are sick, stay home, if possible, to avoid spreading germs, and avoid close contact with other people until you feel better. Cough and sneeze into your arm, not your hands. Maintaining a healthy lifestyle, including healthy diet and physical activity, can help keep you well. You can also use condoms to protect yourself and others from infections that can spread through sexual contact, including antibiotic-resistant gonorrhea.

Keep vaccinations up to date

These can protect you and your family members from various bacterial infections. For example, the DTaP vaccine protects against the bacteria that cause diphtheria, tetanus, and whooping cough, while the meningococcal vaccine prevents infection by bacteria that can cause meningitis.^{Footnote 62} Of note, research has shown that young children who receive a pneumococcal vaccine need fewer antibiotics for ear infections than children who are not vaccinated.^{Footnote 63}

Antibiotics are often unnecessarily prescribed for symptoms of influenza, a viral respiratory infection. If you catch influenza, antibiotics will not help with symptoms. Getting the yearly influenza vaccine may help you avoid influenza and avoid spreading it to others. The introduction of the universal influenza immunization program in Ontario has been shown to reduce the number of influenza-associated antibiotic prescriptions in the province.^{Footnote 64} In addition, the influenza vaccine is associated with reductions in middle ear infections and less use of antibiotics in children.^{Footnote 65}

If you do get sick, always speak with a healthcare provider before using antibiotics. Antibiotics work through various mechanisms and not all antibiotics work for all infections. To avoid contributing to the development and spread of antibiotic resistance, you should always follow the treatment directions given to you by a healthcare provider and not take leftover antibiotics, or antibiotics that have not been prescribed for you.

Talk to your provider and ask questions

You can ask whether an antibiotic prescription is really necessary and talk about your expectations around antibiotics. Nurses, doctors, and other healthcare professionals sometimes assume that their patients want an antibiotic and feel obliged to prescribe one, when what patients are really seeking is reassurance about the seriousness of their health problem and clear communication.^{Footnote 36}

Having an open conversation with your provider about your views and concerns can help avoid these misunderstandings. While one unnecessary dose of antibiotics might seem like a small concern, a study from the United States suggests that 1 in 4 antibiotics are prescribed in situations where they are definitely not needed, and another 1 in 3 are prescribed for conditions where they may not be needed.^{Footnote 66}

When speaking with your healthcare provider, consider discussing the following 5 questions:^{Footnote 67}

1. What are you most worried about?
2. What are you expecting from today's visit?
3. What are your treatment options?
4. What are the benefits and harms of antibiotics?
5. What do you think about the options?

Remember your immune system and your microbiome

Your body has a built in defense mechanism to fight off infection and antibiotics are not always necessary. Antibiotics only work against infections caused by bacteria.

Antibiotics can't make you feel better when you have a:

• cold
• influenza
• other viral illness

Oftentimes, infections caused by bacteria or viruses will go away on their own. In fact, 7 out of 10 people feel better within a week, whether or not they use antibiotics for bronchitis^{Footnote 68} and 9 out of 10 people feel better within 1 to 2 weeks, whether or not they use antibiotics for sinus infections.^{Footnote 69}

Antibiotics also have side effects and can destroy the normal bacteria that make up your microbiome and help keep you healthy.

What healthcare providers can do

Take the time to talk with patients about their health and foster good relationships

This can go a long way to preventing overuse of antibiotics. Share your knowledge about:

• antibiotics
• how they work
• ways to feel better when the infection is likely caused by a virus

You can also counsel your patients not to save antibiotics for future infections. Given that 600 million medical prescriptions are dispensed in community pharmacies in Canada every year and pharmacists already play an important role during the quality check of prescriptions,^{Footnote 70} pharmacists are well positioned to engage patients at the time of purchasing an antibiotic, and to assist practitioners in determining the optimal treatment.^{Footnote 71}

Shared decision making

Shared decision making is recognized as an effective strategy for reducing overuse of treatments in general and reducing decisional conflict around treatment options.^{Footnote 72} In shared decision making, providers help their patients make informed decisions about treatment by discussing benefits and harms, and taking time to understand their values and preferences.

Evidence shows that passive sharing of information with patients through posters and leaflets is not enough to reduce antibiotic use.^{Footnote 73}, ^{Footnote 74}

Promote appropriate antibiotic use

Several organizations have developed tools that may help in this effort, including delayed prescriptions and viral prescriptions.

A delayed prescription for antibiotics is intended to be filled in a few days if symptoms do not improve, allowing time for lab tests to come back or for a person's body to fight the infection on its own.

In a similar manner, "viral prescriptions" explain why an antibiotic isn't being prescribed and provide instruction on things the patient can do to feel better, such as:

• rest
• drink plenty of fluids
• take over-the-counter pain relief medication

While more research is needed to determine their effectiveness in the Canadian context, evidence from outside Canada suggests they are good tools to manage risks and reduce unnecessary antibiotic use.^{Footnote 75}, ^{Footnote 76}, ^{Footnote 77}, ^{Footnote 78} Working with a researcher or research team to rigorously test these interventions in your practice is another way you can help determine whether such strategies are effective.

As healthcare conditions can influence antibiotic prescribing behaviours, healthcare providers could benefit from innovative solutions to help them tackle organizational or structural challenges, such as time-pressure or access-to-care issues. For example, telemedicine (providing medical care from a distance using information and/or telecommunications technology) may help remove barriers by offering an alternative way for patients to access health care in remote Canadian regions.^{Footnote 79}

Stay up to date on antibiotic prescription guidelines and best practices, along with local antibiotic resistance patterns

This can help you make informed choices about which antibiotics to use. Appropriate prescribing is about more than just knowing when to prescribe and when not to prescribe an antibiotic. It is also about making a decision to:

• provide the right drug
• in the right dose
• at the right time
• for the right duration

For example, it is important not to use a broad-spectrum antibiotic for an infection where a narrow-spectrum antibiotic would be effective. How long to advise patients to take antibiotics has also evolved. It used to be common to tell patients to finish the whole course of antibiotics, due to concerns about ineffectiveness of shorter treatment periods and increased risk of antibiotic resistance. However, neither of these concerns is supported by scientific evidence.^{Footnote 80}, ^{Footnote 81} When discussing the duration of treatment with patients, healthcare providers can take a more tailored approach that considers the patient, the reason for antibiotics and duration compared with the best available evidence.^{Footnote 80}, ^{Footnote 81}

To improve prescribing, providers can take advantage of opportunities to engage in continuing professional education around antibiotic prescribing and antibiotic resistance. Research suggests that giving healthcare providers access to in-person educational seminars on appropriate prescribing can reduce unnecessary antibiotic prescribing.^{Footnote 82}, ^{Footnote 83}, ^{Footnote 84}

What health system leaders can do

Health system leaders working in medical associations, government, medical accreditation bodies, and other groups can work collectively to address antibiotic use. More judicious use of antibiotics has the potential to benefit health care systems in multiple ways, such as by reducing costs and improving quality of care.^{Footnote 85}, ^{Footnote 86}

Promote positive antibiotic prescribing practices

There is strong evidence in other countries that providing feedback to healthcare providers on their prescribing habits is an effective way to improve appropriate antibiotic use.^{Footnote 73}, ^{Footnote 87}, ^{Footnote 88} Given that healthcare providers are influenced by their peers, providing information that compares them with their top-performing colleagues is particularly effective, especially when combined with a "nudge" or alert to provide a justification when entering a prescription into an electronic medical record.^{Footnote 89}

Of note, while the availability of some rapid diagnostic tools may help healthcare providers manage the issue of diagnostic uncertainty and to optimize the antibiotic treatment duration^{Footnote 90}, ^{Footnote 91}, their impact on antibiotic prescribing practices in community and primary care environments remains poorly understood.^{Footnote 92} It is important to rigorously assess these actions to determine their effectiveness in the Canadian context.

Share knowledge, skills, and training

It takes a village of providers to guide appropriate use of antibiotics. Inter-professional organizations for nurses, doctors, dentists and pharmacists-all guided by different standards and protocols-can be brought together to develop and implement core competencies on appropriate:

• prescribing
• patient communication
• shared decision making

These can also be included in medical and health curricula and continuing education programs.

At the same time, educational campaigns using a variety of formats geared to different populations, such as parents and seniors, can help promote appropriate antibiotic use.^{Footnote 90}, ^{Footnote 93} Educational campaigns in medical clinics for parents of young children have shown effectiveness in reducing overall antibiotic use.^{Footnote 90}

Nationwide and community-level communication campaigns have also been shown to result in fewer unnecessary antibiotic prescriptions, especially for viral respiratory tract infections. Primarily tested in the United States and Europe, these types of campaigns use a variety of formats geared toward specific populations (like parents and older adults) and healthcare providers. A prominent and promising Canadian example is the "Do Bugs Need Drugs?" program in British Columbia that is not only targeting healthcare providers but also other groups such as children, teachers and seniors. There was also a 13% decrease in antibiotic prescription rates during the time of this initiative (2005 to 2018).^{Footnote 94} Campaigns alone, without other providers and organizational interventions, are not as effective as those linked with other actions.^{Footnote 93} Finally, patient-focused posters and brochures alone are ineffective at decreasing antibiotic use.^{Footnote 73}, ^{Footnote 95}

Continue investing in research and surveillance

There are no or limited data in Canada to show how many antibiotics are prescribed appropriately.^{Footnote 26} This type of data, along with other information, can provide a way to measure how well actions are working to improve appropriate antibiotic use. Across the country, we see regional differences in overall antibiotic use, but there is insufficient information to understand why these differences exist and how much of these differences is due to unnecessary use.

There is very little social science research in Canada that focuses on patient-provider relationships, expectations and beliefs around antibiotics, and how various social factors shape unnecessary use. Among the studies that exist in peer countries, it is unclear whether findings can be applied to the Canadian context.^{Footnote 49}, ^{Footnote 96} More information is needed to understand how community contexts (such as geography, infection patterns, public health activities, etc.) vary and influence healthcare providers' decisions around antibiotic prescription.

In Canada and abroad, research on antibiotic use tends to focus on the knowledge and attitudes of patients and providers, with much less focus on the health system and societal factors that may be at play.

Examples of research underway in Canada to better understand the social and cultural factors influencing antibiotic use in specific populations, include:

More research is needed on actions to promote appropriate antibiotic use in Canada, particularly around:

• whether existing programs, policies, and stewardship initiatives work
• which elements are most effective
• how they work to improve antibiotic prescribing in the community

Given the size of Canada and variation across the country, in terms of cultures and contexts, more rigorous assessments are needed to inform our current efforts. To plan effective strategies, it is important to know why and how something works to encourage appropriate antibiotic prescribing.

Related links

• Evidence synthesis summary: social and cultural drivers of antimicrobial use
• Evidence synthesis summary: interventions to address antimicrobial use
• About the Chief Public Health Officer of Canada

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