The following article was written by Martha M. Williams, DHSc, MS, PA-C, of Brandywine. The article was published by the Urgent Care Association, which is the national trade organization for urgent care medicine, in honor of Antibiotic Awareness Week. Williams is an experienced and doctorally educated physician assistant with a strong internal medicine background that firmly fights for healthcare equity.
The alarms in the room started sounding. I looked at the monitors on the wall and my heart sank as the nurse rushed to the bedside. She pushed a few buttons on the IV pump and pulled out her phone. It was the moment I knew we’d lost him. No matter the number of vasopressors, antiarrhythmics, or antibiotics, my father-in-law wasn’t going to make it out of this critical care unit alive. I took my husband’s hand and braced him for the news that was coming in a very short time from the attending physician: Our beloved “J” was going to die from sepsis.
Where We Find Ourselves
Shockingly, despite widespread antibiotic use, one in five deaths worldwide occur because of sepsis (WHO, 2020). Medical experts advocate for appropriate antibiotic use to prevent microbial antibiotic resistance and to help ensure that antibiotics remain effective in the treatment of infectious disease and its complications, when absolutely needed, as in sepsis. Unfortunately, in the United States, at least 28% of antibiotic prescriptions are not necessary (CDC, 2023). As we find ourselves in midst of U.S. Antibiotic Awareness Week (Nov. 18-24), the Centers for Disease Control and Prevention reminds us all to “Be Antibiotics Aware” so that we all can be better antibiotic stewards.
But what does it mean to be an antibiotic steward? Healthcare professionals have heard this time and time again. Many of us have even made a pledge to be one, but can we really put into words and actions what it means? Per the good ol’ Merriam-Webster a steward is “one appointed to supervise the provision and distribution” of products. Therefore, an antibiotic steward is entrusted to provide and distribute antibiotics not when asked, but when deemed necessary by medical examination and testing.
And this is where things can get tricky. One of the more enlightening data sets from the 2022 CDC Report on Antibiotic Use was that antibiotic prescriptions per 1,000 persons were vastly different depending on geographic area. I spent my young childhood in the state of California where current antibiotic prescribing rates are low, at 411 prescriptions per 1,000 individuals. My present home of West Virginia has one of the highest rates: 1,022 prescriptions per 1,000 individuals! The South and, in particular, the Appalachian region are where most of these antibiotics were prescribed. We know that these areas also carry high rates of obesity, diabetes, and hypertension, so they could be, in theory, more prone to infections. However, the data supports an overuse of antibiotics as diagnosis codes tend to lean towards upper respiratory infections, bronchitis, otitis media, sinusitis, and pharyngitis, so patient expectations may also play a role.
Because We Can, Does Not Mean We Should
A surprising 2017 study from the Journal of Antimicrobial Chemotherapy found that 30 percent of primary care patients were prescribed an antibiotic and less than 10% of those patients accounted for over half of the antibiotics prescribed in the study time period. A 2020 study published in Clinical Infectious Diseases found that after implementing the CDC’s Core Elements of Antibiotic Prescribing in emergency rooms and primary care clinics that return visits for the same presenting condition did not increase while simultaneously all cause hospitalizations decreased.
The Light at the End of The Tunnel
How do we combat years of antibiotic overprescribing and generational expectations of patient-clinician relationships with being a good antibiotic steward? The unfortunate answer is that there is not a one size fits all approach. Rather, a multifactor approach is needed. The CDC’s website on Antibiotic Prescribing is a great starting point. From there you can access training modules for healthcare staff, patient education products, and third-party evidence-based research and guidelines, as well as even a clinician and organizational checklist for their Core Elements program. Looking at the urgent care clinician’s role, most of this can be distilled down to patient education. And we can look to other public health initiatives for success, like fluoridation and childhood vaccination programs.
Practicing as an antibiotic steward is possible if we put our patient to the forefront of care and just explain the reasonings behind antibiotic stewardship. And if concerned about patient satisfaction, don’t worry — a 2020 study in Open Forum Infectious Diseases found that patient satisfaction remains unchanged following antibiotic stewardship program implementation.
I encourage all urgent care clinicians to engage in self-reflection and work on performance improvement. In 2021, a study published in Primary Care Respiratory Medicine found that physicians tended to prescribe antibiotics when they had higher levels of diagnostic uncertainty. Reviewing the latest evidence-based recommendations can help to support clinicians on when to use testing and what examination findings support the usage of antibiotics. Consider enrolling in the CDC’s Antibiotic Stewardship Course found on the TRAIN website. I strongly encourage you to review your prescribing practices in the Medicaid public prescribing records. Your results may surprise you.
We all strive to take the best care of our patients while delivering an excellent patient experience. These goals are not in conflict with each other in practicing antibiotic stewardship. I cannot say for certain that improved antibiotic usage would have prevented “J”’s death and I know I cannot turn back the clock to keep him here with us. But I do know that as a clinician, I want to provide a better future for his children and grandchildren. And in the spirit of excellent patient care, as he was one of the best EMTs I know, I promise myself to be a good antibiotic steward.
I hope you join me in that goal, too.