Strategies for promoting judicious use of antibiotics by doctors and patients

doi:10.1136/bmj.317.7159.668

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Edward A Belongia, senior epidemiologista,
Benjamin Schwartz (bxsl@cdc.gov), medical epidemiologistb

^aEpidemiology Research Centre, Marshfield Clinic, Marshfield, WI, USA,
^bRespiratory Diseases Branch, Disease Control and Prevention, 1600 Clifton Road, MS E-61, Atlanta, GA 30333, USA

Correspondence to: Dr Schwartz

Recent antibiotic use is a well documented risk factor for infection or colonisation with resistant pathogens.1^–7 Despite this recognition, unnecessary antibiotic prescribing remains common. In the United States more than a fifth of all antibiotic prescriptions for children and adults are written for upper respiratory tract infections or bronchitis, conditions that are almost always viral. 8 9 Similar rates of unnecessary antibiotic use have been described in Britain.10 These findings are consistent with results from focus groups among doctors, in which participants have estimated that 10% to 50% of outpatient antibiotic prescriptions are unnecessary.11

Only limited data are available to evaluate whether reducing antibiotic prescribing will reduce the spread of resistance. In Finland the proportion of group A streptococcal infections resistant to macrolides was nearly halved after a successful campaign to reduce the use of macrolide antibiotics.12 A cross sectional survey in Iceland found that carriage of penicillin resistant pneumococci was strongly associated with both individual and community-wide levels of antimicrobial use,13 and there is some evidence that an intervention programme has decreased the proportion of pneumococcal infections caused by penicillin resistantstrains.14

Summary points

Unnecessary antibiotic use for viral illness is common and has led to increasing rates of antibiotic resistance among Streptococcus pneumoniae and other community acquired pathogens

Factors that contribute to antibiotic overuse include lack of education, patients' expectations, past experience, and economic incentives

Multifaceted interventions are needed to reduce unnecessary antibiotic use; peer education and feedback on doctors' use of antibiotics can promote behaviour change

Educational interventions for the public should include a public relations campaign with simple messages, clinic based patient education, and community outreach activities

Health organisations should develop policies to support judicious antibiotic use and evaluate whether existing policies may unintentionally promote overuse of antibiotics