Choosing the right antibiotic for a bacterial infection is important. As important, though, is not taking antibiotics for conditions they don't fight, which leads to increased antibiotic resistance and development of superbugs, deemed a public health crisis.
Now Utah researchers have shown that use of a clinical decision support system and patient education reduces overall use of antimicrobials for colds, bronchitis and sinusitis, among other respiratory conditions that antibiotics don't help. The tool they used is a program on a PDA that helps a doctor determine if a respiratory infection requires an antibiotic and, if so, which one and even how much.
The study, published today in the Journal of the American Medical Association, shows that providing physicians with the PDA-program support helped reduce the number of antibiotics being used for respiratory infections. And when one was needed, it helped doctors pick the right antibiotic.
Anything that increases the likelihood of using the right treatment is good news, say Dr. Kim Bateman, medical director of HealthInsight and a family practice physician in Ephraim, and Dr. Matthew H. Samore, University of Utah professor of internal medicine, adjunct professor of medical informatics and a physician practicing at both the U. and Salt Lake VA hospitals.
They conducted the research in six Utah and six Idaho rural communities, using six other communities not involved in the training as controls. The three-year randomized trial included 407,460 inhabitants and 334 primary care clinicians. "It was a superb example of Utah and Intermountain West physicians, academicians, medical technologists and others working together to do research that helps the public," says Samore.
In half the communities, education campaigns aimed solely at the public were used.
In the PDA-program-assisted communities, prescription rates decreased 10 percent, while they went up slightly in the other communities. In a post-intervention phase of study, in cases where antibiotic use was classed as "never indicated," their use dropped 32 percent. Communitywide antimicrobial usage was measured using pharmacy data, while diagnosis-specific antimicrobial use was compared by chart review.
"The reason this study's important is it shows you can't do it by just talking to patients," who sometimes demand antibiotics when they feel ill, Bateman says. Samore calls it a culture of expectation. "It's a habit that needs to be broken somehow."
The PDA program is a decision tree (one answer leading to the next "branch") designed by Bateman using research on infections and discussions with infectious experts. He wrote the algorithm and programming was done by TheraDoc. Participating doctors were each given a Palm Pilot with the program so it was convenient. The study was funded by the Centers for Disease Control and Prevention.
Besides recommending a specific antibiotic and dose, it might conclude someone would do better with cough syrup instead, for example. In some cases, it tells the physician to consider hospitalizing the patient or do a culture or order X-rays. It's all just a recommendation; the doctor decides on actual treatment.
They found it didn't take extra time because the program is simple. And it gave added heft to a doctor's decision not to prescribe an antibiotic if it wouldn't help.
In the study communities, 71 percent of doctors used the tool. For those who did use it, writing prescriptions for antibiotics dropped to below 5 percent, Bateman says.
Researchers and clinicians have noted a rise in antibiotic resistance since the 1980s. When bacteria becomes resistant, it takes a larger dose or a different, stronger drug to conquer it, Bateman said. The big fear is a bug nothing will kill.
Of particular concern has been pneumococcus, the architect of bacterial pneumonia, which kills more people than other bacteria. It's also the cause of sepsis and is the second most common cause of meningitis. On the other hand, it's also responsible for some more mild infections, including some infections in the ear or sinus.
"It turns out that choosing the right antibiotic for this is important, Bateman says. "Some are broad but not as strong — more like a shotgun than a rifle. That includes newer, more expensive ones that doctors tend to gravitate toward."
Those in the penicillin class are the rifles, with narrow focus but underused, he says.
Samore says the broader-spectrum antimicrobials were also more likely to "kill innocent bystanders," normal flora, so other bacteria can take hold.
Studies show that three-fourths of antibiotics used outside the hospital are prescribed to treat viral respiratory infections. And using an antibiotic on a virus is pointless.
The researchers are now looking into whether a program that sends the prescription directly to the printer or faxes it to a pharmacy would be helpful.
E-mail: lois@desnews.com