As a practising pharmacist working on antimicrobial stewardship at St. Joseph’s Health Centre, Bradley Langford often wondered what it would be like to turn his attention to the problem outside the hospital’s walls, where over 90% of human antibiotic use occurs. In 2016, Bradley got the call from Public Health Ontario (PHO) to do just that, initially as a consultant antimicrobial stewardship pharmacist. Now, is the acting lead for PHO’s Antimicrobial Stewardship Program, Bradley’s interest and portfolio spans different health care sectors including acute, long-term and primary care.
He has been an active leader in communicating the importance of appropriate antibiotic prescribing in his practice and on social media. Bradley co-founded a monthly Twitter chat focused on discussing antimicrobial stewardship, bringing together pharmacists, physicians, nurses, specialists and health professionals from around the world.
In 2017, Bradley joined Choosing Wisely Canada’s Using Antibiotic Wisely Working Group focused on developing resources for clinicians and patients on appropriate antibiotic prescribing in primary and long-term care. He provides his perspective as a pharmacist who is leading local and provincial initiatives for antimicrobial stewardship.
Choosing Wisely Canada: What are some of the main drivers of antibiotic overuse in community settings, such as primary care?
Bradley Langford: Understanding antibiotic overuse can be challenging but there is a growing body of research to help us learn about the barriers and inform potential solutions. From the evidence we currently have, we know there is a lot of opportunity for improving appropriateness in antibiotic prescribing. Dr. Michael Silverman, who is the Chair of Infectious Disease at Western University in London Ontario, led a study that reviewed antibiotic prescriptions in older adults who went to a primary care doctor in Ontario for an upper respiratory tract infection. The study found 46% of these patients received a prescription for antibiotics, even though the infection was most likely viral and not bacterial. The study found that physicians who are later in their career and those with busier practices were more likely to prescribe unnecessary antibiotics. This gives us a sense of potential targets for future interventions to improve antibiotic use.
In Canada over 90% of human antibiotic use is outside of the hospital. So, much of our work at PHO focuses on evaluating antibiotic use in the community setting. Dr. Kevin Schwartz, Infection Prevention and Control Physician at PHO, is leading a research program to determine factors associated with antibiotic overuse in Ontario and identify opportunities to improve. So far, we have seen wide variability between prescribers in terms of the amount and duration of antibiotics prescribed. What’s interesting is that differences in patient populations explain very little of this variability. One of the most likely factors driving these differences is prescriber habit, suggesting that there’s an opportunity to reduce this variability and improve the quality of care for patients. As a next step, PHO is currently involved in a study funded by the Canadian Institute of Health Research’s (CIHR) Strategy for Patient Oriented Research (SPOR) Innovative Clinical Trial Multi-Year Grant to obtain a deeper understanding of antibiotic misuse and reach out to high prescribing physicians to improve practices and reduce potentially unnecessary antibiotic prescriptions.
CWC: The Silverman study you mentioned above was focused on unnecessary antibiotics for upper respiratory infections. What strategies can primary care providers and patients use to address this problem?
BL: There are many strategies available for both clinicians and patients focused on reducing unnecessary antibiotic prescriptions for upper respiratory tract infections. I believe it’s very important that clinicians are aware of the resources and guidelines available as a first step. As a second step, clinicians should consider how they communicate their recommendations to patients.
We need to validate the patient’s concern that they do in fact have an illness, but that antibiotics will not be beneficial. We also need to provide patients with strategies that will help them improve. In many cases, patients do not necessarily want to leave with a prescription, but do want to leave with a plan to relieve their symptoms. Tools such as a viral prescription pad can help support this conversation and provide patients with practical advice. A viral prescription pad outlines ways patients can relieve their symptoms without antibiotics and instructions on how to do so.
Delayed prescriptions are also a useful approach that can be used for certain upper respiratory tract infections that will likely resolve without the need for antibiotics, such as middle ear infections. Delayed prescriptions inform the patient to wait a certain amount of time before filling the script to see if their symptoms improve. This approach allows the patient (and the prescriber) to feel some peace of mind having the prescription available, but also offers an alternative plan to help cope and manage without antibiotics. If the patient improves, they will not need to fill the prescription.
There is some evidence that clinicians may overestimate their patient’s desire for antibiotics. A brief conversation to establish patient concerns and beliefs, combined with the use of these tools, can help to improve patient understanding, satisfaction and reduce unnecessary antibiotic use.
CWC: What are the challenges of reducing unnecessary antibiotic prescribing?
BL: I think this is an interesting question because very often it is assumed that knowledge is the main barrier and if we provide enough information, clinicians will automatically improve the quality of their antibiotic prescribing.
But we know through discussion with patients, clinicians, and evaluating the literature that the problem appears to be more complex than just a knowledge gap. There are a lot of behavioural aspects of antibiotic prescribing that presents us with a new challenge, but also an opportunity, in how we approach antibiotic overuse. For example, a clinician may fear that by not prescribing an antibiotic for an upper respiratory infection, this could lead to worsening of infection and subsequent harm. This fear, along with the underestimated risk of harm from the antibiotics themselves, often leads to an unnecessary antibiotic prescription.
Clinicians tend to also believe that the problem of antimicrobial resistance, which is largely precipitated by antibiotic use, may be something that is much bigger than them and their patient population. This can be the feeling that antimicrobial resistance is a larger global issue and that their individual clinic or practice cannot change. The problem is, if every clinician feels this way, the social or moral obligation to using antibiotics appropriately is not going to be addressed. It can be very challenging to overcome this way of thinking and sending guidelines or additional information may not always lead to the practice changes we need to address this complex issue.
How are these challenges being addressed in the province and globally?
The CIHR SPOR Grant I mentioned earlier provides us with a great opportunity to address some of these challenging behavioural aspects which influence antibiotic prescribing. The grant, led by Dr. Noah Ivers, Scientist and Family Physician at Women’s College Hospital, works with a team of clinicians, researchers, and patients to improve physician antibiotic prescribing through audit and feedback. Audit and feedback provides personalized prescribing data back to clinicians and compares these results with peers and offers practical suggestions and resources to improve their prescribing.
To support our study, we found that 25% of primary care physicians in Ontario prescribed 65% of antibiotic prescriptions in the province. These findings demonstrate there is a small group that is prescribing a majority of antibiotic prescriptions in primary care. This presents us with a target audience to reach out to using the audit and feedback intervention. This approach has been shown to be effective and has been used globally to address the overuse of antibiotics.
CWC: What is your motivation for being involved in antimicrobial stewardship?
As an antimicrobial stewardship pharmacist in a hospital setting, I have witnessed the impact of antibiotic overuse first hand. Infections caused by bacteria resistant to all modern antibiotics and deaths caused by severe C. difficile infections were sobering examples of how important it is to use antibiotics wisely. Over the years in this role, I have gained insights into challenges and opportunities to address the complex issue of antibiotic stewardship in clinical settings. I have the privilege of then applying these strategies and solutions provincially and nationally, which I hope can help to address this problem on a large scale.