Overuse Contributes to Spread of Antibiotic-Resistant Bacteria

This article was originally published in the Northwestern University News Center. Visit the podcast

Simple behavioral interventions can be effective at curbing inappropriate antibiotic prescribing if adopted for the long term, according to a recent study published in the Journal of the American Medical Association (JAMA).

Jeffrey Linder, ’97 MD, MPH, chief of General Internal Medicine and Geriatrics in the Department of Medicine and the Michael A. Gertz Professor of Medicine, was the first author of the paper. Stephen Persell, MD, MPH, associate professor of Medicine in the Division of General Internal Medicine and Geriatrics and director of the Center for Primary Care Innovation, was also a co-author.

The study is a follow-up to a 2016 study — also published in JAMA and co-authored by Linder and Persell — that demonstrated the effectiveness of two behavioral interventions in decreasing the rate of physicians prescribing unnecessary antibiotics for acute respiratory infections (ARIs).

The majority of antibiotics prescribed in the United States are for ARIs, yet research suggests that roughly half of these prescriptions are for infections that antibiotics will not improve.

Overuse of antibiotics contributes to the spread of antibiotic-resistant bacteria, increases healthcare costs, and exposes patients to unnecessary risk of side effects. Still, traditional efforts to reform prescription practices — such as education and published guidelines — have been largely unsuccessful, and antibiotic misuse remains a significant issue.

In the study published last year, a team of investigators used insights from behavioral science to design three interventions to reduce unnecessary antibiotic use for ARIs in primary care settings.

They discovered two to be effective: In the first, clinicians were required to enter written justifications for prescribing antibiotics into patients’ electronic health record (EHR). In the second intervention, clinicians received emails that compared their inappropriate prescribing rates with “top performers” who had the lowest rates.

On average, the two low-cost interventions prevented one unnecessary antibiotic prescription for every eight patients.

In the current study, the investigators examined whether these effects persisted 12 months after the interventions were stopped.

They discovered that the rate of inappropriate antibiotic prescribing for ARIs increased after the behavioral interventions were removed, while the rate continued to decrease in the control practices.

However, between the two interventions, peer comparison was found to have a more long-lasting effect, with a statistically significant difference persisting even one year after the intervention was removed. The authors suggest it may be because clinicians made judicious prescribing part of their “professional self-image,” while the justification intervention, on the other hand, relied on EHR prompts.

Overall, the findings suggest that such behavioral interventions need to be applied long-term in order to influence clinician decision-making and effectively reduce antibiotic overuse, according to the authors.

“Given the impact during the study period and the relatively low cost of the interventions, it may make sense for clinics to permanently retain the interventions,” Linder said.