Public health advocates are studying ways to reduce unnecessary prescriptions in order to avoid the acceleration of antibiotic resistance. This comes at a time when there are high levels of antibiotic use among COVID-19 patients, underscoring the need to establish stewardship programs. However, while 94% of primary care physicians agree antibiotic resistance is a problem in the U.S., 55% don’t see it as an issue in their own practice, according to recent research.

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Before the COVID-19 pandemic, the AMA and The Pew Charitable Trusts conducted focus groups with physicians in Chicago, Los Angeles, Philadelphia, and Birmingham, Alabama and a national survey of 1,550 primary care physicians in the U.S. Results were weighted by geographic region and medical specialty to mirror actual distribution of U.S. physicians using the AMA’s Physician Masterfile.

Published in the peer-reviewed journal BMJ Open, the journal article “Primary care physicians’ attitudes and perceptions towards antibiotic resistance and outpatient antibiotic stewardship in the USA: a qualitative study,” highlights the findings of the focus groups, which assessed perceptions about antibiotic resistance to better understand the barriers to effective stewardship.

The AMA and Pew Charitable Trusts also wrote the manuscript, “Primary Care Physicians’ Attitudes and Perceptions towards Antibiotic Resistance and Antibiotic Stewardship: A National Survey,” which reviews the findings of the national survey and was published in the journal Open Forum Infectious Diseases.

Results from the survey found that 91% of physicians felt that inappropriate prescribing was a problem in outpatient settings while only 37% felt it was an issue in their practice. Additionally, while 91% of respondents felt that antibiotic stewardship was appropriate office-based practices, they still ranked resistance as less important than other public health issues. Almost half also felt they would need a lot of help to implement stewardship, but were likely to implement efforts in response to feedback or incentives from payers or health departments.

From the eight focus groups from four major U.S. cities emerged several common themes that illustrated the attitudes of physicians about antibiotic resistance.

Physicians maintained the perception that antibiotic resistance was less important in their medical practice when compared to other public health issues commonly faced, such as obesity, type 2 diabetes and opioid misuse.

Additionally, “while many participants acknowledged that antibiotic resistance is a concern, many did not see it as an issue that impacted their patients or their daily practice,” said the study. “Instead, most participants considered antibiotic resistance as something affecting sicker, hospitalized patients.”

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However, some physicians did acknowledge an increase in resistant infections in patients with urinary tract or skin infections. Yet, they still classified antibiotic resistance as an issue affecting inpatient medicine.

Learn more from the AMA about three ways to slow spread of deadly antibiotic-resistant infections.

“Participants indicated that they believed inappropriate outpatient antibiotic prescribing is largely driven by clinicians other than themselves, namely those practicing in urgent care offices and retail clinics,” said the study. “This contributed to the feeling that resisting patient demand for antibiotics is futile, as patients can simply see another clinician and get what they want.”

Another common theme revolved around pressure from patients who expect antibiotics even when not medically indicated. This was a recurring theme that was revisited many times throughout the focus groups. However, some physicians—mostly pediatricians—indicated that if they had a long-standing relationship with a patient, they would be more likely to push back against prescribing an antibiotic.

Learn more in the article, “Focus Groups Reveal Primary Care Physicians’ Attitudes Toward Antibiotic Resistance and Stewardship,” written by Andrea Garcia, JD, MPH, director for Science, Medicine, and Public Health at the AMA, David Hyun, MD, a senior officer, and Rachel Zetts, MPH, an officer with The Pew Charitable Trusts’ antibiotic resistance project.

Focus group discussions looked at antibiotic stewardship efforts and participants displayed strong support for patient and physician education.

“Consistent with the perception of patient demand for antibiotics generating concern, participants emphasized that, in order for them to be able to effectively do their jobs, their patients need to be educated about when antibiotics are and are not appropriate and why judicious antibiotic use is critical to combating antibiotic resistance,” said the study.

Some educational options include written materials in different languages, videos for waiting rooms and direct-to-consumer advertisements. This education should be provided prior to a patient visit.

Additionally, many participants also indicated that physician education was important for outpatient antibiotic stewardship. Educational efforts were more helpful than other interventions, such as feedback on prescribing practices. However, physicians disagreed on whether education should be mandatory or voluntary.

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The AMA Ed Hub™, an online learning platform that consolidates all the high-quality CME, maintenance of certification, and educational content you need—in one place—with activities relevant to you, contains a collection of educational resources for physicians focused on antibiotic use, overuse, resistance and stewardship.

Compared to educational stewardship efforts, physicians were less supportive of measuring and providing feedback on antibiotic prescribing practices. Most felt that antibiotic use reports would require significant financial and time investments. Others argued that with antibiotic use measures, some physicians might manipulate the desired outcome to improve their antibiotic prescribing scores.

Additionally, many expressed dissatisfaction and distrust of quality measurement systems and reporting processes. They felt they would be over-measured and blamed for instances that were beyond their control. Lastly, physicians shared issues experienced with the inaccuracy of tracking and reporting systems. This has led physicians to dismiss the use of these reports.

Learn more from Pew about strategies for reducing inappropriate antibiotic use and view the chartbook to see a graphical depiction of the survey results.

The AMA supports antimicrobial stewardship programs as an effective way to ensure appropriate antibiotic use to reduce the burden of antimicrobial resistance and to improve patient outcomes, as well as incentives to create a sustainable antibiotic research and development enterprise.

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