Challenging Dogma - Spring 2011

Monday, May 23, 2011

Countering the United States' Passive Attempts at Tackling Antibiotic Resistance - Casey Godbout

Antibiotic resistance is a major global issue that has the ability to affect any individual in a variety of circumstances. It is viewed as a pressing concern in the scientific community based on substantial costs for healthcare systems, increased morbidity and mortality, and implications for a bleak future of treating microbes. The World Health Organization's (WHO) central focus of the 2011 World Health Day was antimicrobial resistance, yet was this vital concern effectively addressed?
Resistance is an evolutionary adaptation (mutation) of a microbe due to the presence an antibiotic that tends to spread rapidly in response to excessive use and misuse. While it is now being recognized by many government and health organizations, it has been an imminent concern since the first signs of resistance to penicillin in the mid 1940s. Complacency in the 1980s, has led to a reduction in novel antibiotic development and increased number of deaths due to multidrug resistant (MDR) and extremely drug resistant (XDR) infections. In the United States alone, the annual cost of antibiotic-resistant infections ranges from $21-$34 billion and 8 million additional hospital days due to these infections (1). What was once believed to be traditionally endemic to hospital settings have subsequently become endemic in community settings as well.
Developing countries run the risk of microbes developing resistance faster due to issues of illegal, poor quality and counterfeit drugs, as well as shortages of essential medications. Additionally, individuals in poorer countries are subject to crowded and generally unsanitary conditions, which allow resistant microbes to spread and thrive (2). But why, in a medically advanced, highly developed nation do we see such excess in deaths attributable to infection with resistant microbes? Surely, the United States has the resources, sanitation, knowledge, diagnostic capabilities and greater capacity to slow the spread of inevitable adaptations and reduce illness. The answer is a unanimous yes, but the current attitude that has evolved in our society is generated by laziness, convenience of access to antibiotics and a lack of economic incentive to pursue such high standards of care.
At the patient level, individuals have grown accustomed to the ease of acquiring antibiotics from pharmacies and physicians. The first signs of a sneeze or a cough warrants the need to treat, whether or not that treatment is biologically effective. Antibiotics treat bacterial infections, not viral infections, yet patients are convinced (generally due to past experiences) that these pills still cure their symptoms. At the provider level, the conflict arises from the difficulty in conveying information to the patient, particularly when that patient is a distraught parent with a sick child. Physicians are often conflicted by the patient's need for rapid treatment, and whether or not to clinically diagnose the pathogen and take time to sufficiently explain antibiotic use to patients. This is where the overuse comes into play. On the other end, patients who do develop bacterial infections may be prescribed antibiotics and do not "take as directed" by their physician. As soon as the patient starts to feel healthy again, they discontinue use of the antibiotic, and allow any mutant/resistant microbes to survive and multiply (3). This is considered the misuse of antibiotics. Combined, overuse and misuse of antibiotics have allowed antibiotic resistance to become a serious concern in a developed nation.
In this paper, I will first analyze the flaws of the current approaches to antibiotic resistance in the United States by way of behavioral science and models. I will then make suggestions for improving the approach by synthesizing evidence-based research with patient and provider beliefs and behaviors.

Critique 1: The Health Belief model's failure to address antibiotic resistance

The Health Belief Model assumes that people are rational when making decisions about their health. Many campaigns that address antibiotic resistance utilize this model to reduce the overuse and misuse of these drugs. These campaigns focus heavily on passive education of patients, providers, and in some cases, policy makers about resistance and adherence to antibiotic regimens. The Health Belief Model assumes that a person's health related behavior depends on their perception of the severity of antibiotic resistance, the person's susceptibility to adverse antibiotic resistance outcomes, the benefit of taking preventive action against future resistance and the barriers to taking that action (3).
To illustrate the ineffectiveness of antibiotic resistance interventions, the CDC's Get Smart: Know when Antibiotics Work campaign is an ideal example. This campaign offers substantial information about when antibiotics are appropriate for use, symptom relief for non-bacterial infections, quizzes and FAQs that test individual's knowledge of antibiotic resistance, and materials for a variety of audiences including PSAs, articles, brochures, fact sheets and developing partnerships with the CDC's campaign. The assumption is that from the established partnerships, health departments and institutions may be educated and effectively disseminate information to reduce misuse and increase adherence, while simultaneously educating the general population(5).
This campaign, among others, follows the basic assumption that once people are educated about the severity of and susceptibility to antibiotic resistance, they will make rational health-related decisions:
1. Once patients comprehend that resistance correlates to ineffective treatments and potential mortality, they will reduce their demand for antibiotics.
2. Once they realize their susceptibility to antibiotic resistant microbes they will not misuse antibiotics, and adhere to their regimen.
3. Once they are educated they will understand the benefits, albeit future benefits, of not taking antibiotics with a viral infection.
4. Once they are educated there will no longer be barriers keeping them from utilizing antibiotics correctly and effectively.
These four critical perceptions of the HBM are complete fallacies in regard to antibiotic resistance. As clean-cut as they may appear, common medical practice has driven patients towards far-fetched perceptions of the growing problem.
Perceived susceptibility is low among the majority of patients. Most patients (and this applies to many disease-related situations) may not believe that this will affect them or their children directly. Additionally, even when the patient recognizes their own susceptibility, action will not occur unless the individual perceives the severity to be at such a significant level that it will cause detrimental results. People, particularly people engaging in health-related decision-making, are not rational and focus substantially on the present. This realization therefore supports the discrepancies of the HBM, because it does not address emotional factors such as fear, cultural beliefs, and social and economic factors.

Intervention I:

When tackling the issue of antibiotic resistance there is no doubt that effective education strategies are a necessary component to any intervention. Understanding the concepts associated with resistance is essential for policy-makers, public health leaders, physicians and patients as well as clear communication between parties. Education alone cannot solely be associated with resulting action however, and therefore an intervention must seek to rise above and beyond current methodologies.
Education can be classified as either passive or active. Passive education strategies aim to provide information and let the learner internalize this information and subsequently do what they want with it. Active learning strategies aim to teach by "doing." In regards to physicians, utilizing active learning strategies vs. listening to an hour lecture with PowerPoint, for example, has shown to be more beneficial. Working in one-on-one or group settings such a workshops, outreach groups, or building sessions may be most effective in physician and institutional change (3). It will help physicians at the group level, begin a cultural change and practice how to handle demanding patients by conveying the appropriate messages.
Critique 2: You can teach an old dog new tricks
Differences among antibiotic prescribing practices and use from place to place can best be validated by the Situated Learning Theory. The main premise of this behavioral theory is that "learning is not an accumulation of information, but a transformation of the individual who is moving toward full membership in the professional community" (6). Learning is also perceived as an enculturation process, in which after observation of behavior of other members of the community, individuals pick up the skills, imitate behavior and act in accordance with the community's norms (7). In the context of hospital and healthcare settings, knowledge is not solely based on what was learned, for example, in medical school, but rather what was adapted as a community and culture within the health institution. With this in mind, physicians practicing in certain health settings may be more or less likely to prescribe antibiotics to patients depending their institutions behaviors and norms. It is therefore likely to be difficult to alter any behaviors within an established medical culture, unless the adaptation is at a group level.
A major drawback in addressing antibiotic resistance comes from the preheld attitudes and beliefs of both practitioners and patients about antibiotic use. Intervention strategies that assume that passive education will result in new affirmed beliefs and a change in action are highly mistaken. Additionally, intervention strategies that assume that the proper use of antibiotics in the context of physicians, patients and healthcare systems are mutually exclusive also find little hope in reducing resistance.
Evidence-based research has concluded that internal clinician factors including knowledge, experience and training are primary factors in unnecessary prescribing of antibiotics as well as clinician specialty and level of training. The highest prescribers of antibiotics for colds, acute respiratory infections (ARIs) and bronchitis are likely to be older and practice in rural areas (4). All of these factors support differences in the culture of prescribing. Interventions like the CDC's Get Smart Campaign which focus primarily on passive learning, rather than group level, interactive teaching methods have a difficult time altering physician practices.
Patients are similar to physicians, in that they have grown accustomed to particular beliefs of antibiotic use through the hospital culture and general society. Studies show how patients seeking care for ARIs expect to receive antibiotics, and patients or parents who expect, receive them more frequently based on prior experiences. Being provided information via website, brochure, PSA, or by a doctor does not mean a patient will all of a sudden stop demanding antibiotics or appropriately adhere to their antibiotic regimen. Sociodemographic factors have also been found to be associated with excess antibiotic use, which may be related to different attitudes, knowledge and expectations in varying populations as well as physicians' attitudes about particular groups. The highest use of antibiotic therapy for colds, ARIs and bronchitis treatment falls within the <5 years of age category (3). This is representative of parents' expectations that doctors will always have the ability to provide quick antibiotic treatment that will cure their children, and alternately how doctors are faced with immense pressure from patients and social norms to do so.
A recently published study, implemented a methicillin-resistant Staphylococcus aureus (MRSA) bundle in VA hospitals across the U.S. in order to assess and prevent health care associated infections with MRSA. This initiative included universal surveillance, contact precautions, and hand hygiene practices, all of which should be the common culture of health institutions. The bundle proved to be highly effective in identifying and reducing the number of health care-associated MRSA infections. The other main focus of the study was to attempt to implement an institutional culture change. It is unbelievable that hand hygiene, contact precautions and surveillance methods are not the mainstream culture, but rather need to be implemented by means of a bundle within healthcare institutions (8).
Intervention 2: Fueling Fire with Fire
Since the Situated Learning Theory shows how physicians learn from "doing", their peers, and their adaptations to their environmental norms, this theory can also be used to counter current practices and beliefs. In many studies, physicians have expressed the need for effective dissemination and the need for more direct guidance, due to the fact that many do not perceive particular diseases or medical practices as growing problems. Physicians have commented how they comprehend the significance of a problem, but continue to aim their focus on other more immediate health issues such as myocardial infarctions (9). It is difficult to emphasize antibiotic resistance and enforce good practice particularly when it tends to lead to adverse effects on people other than the immediate recipient of the drugs (10).
Other physicians have emphasized a combination of their learning, and that their held beliefs about what are "major" issues in the medical world are strongly emphasized in their medical training and over many years in practice (9). In order to address these belief differences it is important to try and make the beliefs of pressing health problems as universal as possible, which can first try to be accomplished during medical training and developing core values. Following medical training it is up to the environment of the health care institution to effectively develop a well-rounded set of beliefs and practices surrounding antibiotic prescriptions and limiting resistance. This will make it easier for physicians to express medical knowledge and culture to patients effectively while still maintaining a strong patient-provider relationship.
Critique 3: Antibiotic resistance interventions are implemented at specific levels of the health care hierarchy and not as a concerted effort between patients, providers and policy-makers.
The American Medical Association (AMA), World Health Organization (WHO), Infectious Disease Society of America (IDSA), Centers for Disease Control (CDC), Food and Drug Administration (FDA), United States Department of Agriculture (USDA) and countless other organizations have blatantly recognized, and many have developed, recommendations, guidelines, and a vast array of materials designated to reduce antibiotic resistance both in hospitals and community settings. Many healthcare institutions currently have antibiotic resistance guidelines in place that their health professionals are assumed to appropriately adhere to, while completely disregarding economic, pharmaceutical, patient, and social norm pressures to act otherwise (11).
Guidelines are in place in many hospital settings that address prescribing antibiotics to patients, however guidelines are just that, they guide physicians when making decisions. As noted in critique 2, physicians, particularly older physicians, have difficulty adapting and forming new habits, particularly in an area that has remained stagnant and relatively consistent for many years. The CDC could update recommendations every 6-months with the newest evidence-based research, however without enforcement and concerted effort there will never be progress.
Currently the U.S. does not systematically gather data on antibiotic prescriptions and use that can be utilized to understand the manner and the degree to which antibiotics are used (1). Surveillance is also important to determine antibiotic resistance trends for a wide range of infections and pathogens, as well as the type/quantity of antibiotics most commonly used in patient care. It is considered inappropriate use when physicians prescribe broad spectrum antibiotics to a patient with an infection that must be attacked by a narrow spectrum antibiotic and vice versa. Developing trends observed by these surveillance systems, would offer support to physicians when making decisions about which antibiotics to use (if any) and relaying this information to patients (1).
Physicians and patients can do their part to reduce antibiotic resistance by prescribing appropriate antibiotics (or no antibiotics for viral infections) and adhere to antibiotic regimens, respectively. Unfortunately, these actions merely slow the emergence and transmission of resistance so the focus must also be on policy-makers and the government to keep up with resistance.
Pharmaceutical companies have placed antibiotic development on the back burner. Five new antibiotics were approved between 2003-2007, compared to 16 new antibiotics between 1983-1987 (12). In 2008, only 15 antibiotics of 167 under development had a totally new mechanism of action to tackle multidrug resistance (13). Since the 1960s only four new classes of antibiotics have been introduced and most of the new antibiotics are simply chemical derivatives of these basic scaffolds (14). Pharmaceutical companies have little incentive to develop new antibiotics due to high failure rates in clinical trials, as well as poor return on investment since they are taken for only a short period of time (13).
Another area of government regulation is antibiotic use in livestock. The largest use of antibiotics worldwide is in the production of animals for human consumption and secondly, as additives in animal feeds over long-term, low-level use (prime conditions for microbes to mutate and spread resistant strains) (15). While this is great for the producers seeking to produce large, healthy animals to sell to consumers, it is dangerous in regard to increasing antibiotic resistance. The same antibiotics used in the feed and to stimulate growth are also those used by humans to treat infections. The European Union (EU) is years ahead of the United States, and officially banned the use of antibiotics for animal growth in 2006 (16). Again, recommendations have been made by the IDSA and other organizations to ban non-judicious antibiotic use in animals, plants and marine environments; however these recommendations are not viewed as urgent problems.
The lack of new antibiotics for the future and antibiotic use in livestock production are incredibly dense, multifaceted topics that could be addressed more in depth in extended interventions. They are discussed briefly here to illustrate the depth and magnitude of the emergence of antibiotic resistant microbes and to point out that current intervention strategies do nothing to change them.
Intervention 3: Utilizing the Diffusion of Innovations Theory to initiate change

Since it is difficult to promote health behavior change and initiate new guidelines and policies that physicians and providers will ultimately follow, a new overall approach must be used. The Diffusion of Innovations theory is an excellent theory for addressing changes in health behavior at the group level. The framework specifically addresses innovation, style of communication, steps in decision making and the social context. According to Ralph Linton, diffusion include three distinct processes, "presentation of the new culture element or elements to the society, acceptance by the society, and the integration of the acceptance by the society, and the integration of the accepted element or elements into the preexisting culture" (17).
An intervention developed using the Diffusion of Innovations Theory addresses all of the drawbacks of current antibiotic resistance campaigns and approaches. The innovation is the new culture of healthcare institutions recognizing antibiotic resistance as a major health concern and physician's appropriately using antibiotics to cure bacterial infections and effectively communicate with patients. It will also include individuals within the institutions that will make sure physician's are judiciously prescribing antibiotics and will include a surveillance method as described earlier. The next aspect is the relative advantage, or the degree to which the innovation is perceived as better than prior interventions (i.e. effectiveness and cost efficiency). Reducing the emergence of multidrug resistant infections, will reduce the cost per patient within the hospital setting since multidrug resistant infections tend to resort to more expensive, last resort regimens (10).
The intervention will then address the complexity of the issue. Incorporating active learning sessions for physicians and health care professionals within a hospital will teach and reinforce the issues and implemented guidelines. There will also be bulleted reminders posted within the hospital to serve as reminders, including important facts to convey to patients.
It will be the hope that early adopters will already share the belief that antibiotic resistance is a major problem, and begin to implement changes within their institutions. It has been shown that the more charismatic and well-known particular individuals or institutions implementing the change are, the more likely others will be influenced to follow (18). Current interventions include utilizing many different modes of communication to get the word out to patients. While these modes are easy to access, they provide a plethora of conflicting opinion from source to source, and studies have shown that face-to-face exchange, specifically between a person regarded as highly professional and knowledgeable communicating with a patient, will result in a desired change of attitude. Lastly, the process can be summarized by the following:
1. Researchers gather knowledge about the growing problem and resulting effects of antibiotic resistance at the patient, physician, and health care system/economic levels.
2. The healthcare institutions and physicians are persuaded about advantages of the proposed innovation (i.e. reduce per patient costs, reduce length of stay in hospitals, reduce/slow antibiotic resistance)
3. The institutions and physicians engage in active learning activities (i.e. workshops, communication strategies, communicating with professionals about innovation) that will lead to choosing and adopting the innovation
4. The innovation is incorporated into the institution and daily practice of the physician which will be monitored
5. Reinforcement of the innovation will be achieved via discussion groups, seminars between nearby hospitals, and presentation of evidence-based findings (18).


1. Infectious Diseases Society of America (IDSA) Combating Antimicrobial Resistance: Policy Recommendations to Save Lives. Clinical Infectious Diseases 2011; 52(S5):S397-S428.
2. Gould, I.M. Coping with antibiotic resistance: the impending crisis. International J of Antimicrobial Agents 2010; 36:S1-S2.
3. Ranji SR, Steinman MA, Shojania KG, Sundaram V, Lewis R, Arnold S, Gonzales R.
Antibiotic Prescribing Behavior. Vol. 4 of: Shojania KG, McDonald KM, Wachter RM, OwensDK, editors. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9 (Prepared by the Stanford University-UCSF Evidence-based Practice Center under Contract No. 290-02-0017). Agency for Healthcare Research and Quality 2006. AHRQ Publication No. 04(06)-0051-4.
4. Sharma, M., Romas, J.A. Chapter 4: Health Belief Model. In: Theoretical Foundations of Health Education and Health Promotion. Sudbury, MA: Jones & Bartlett. pgs 31-44.
5. Centers for Disease Control (CDC). Get Smart: Know When Antibiotics Work Campaign. 2011.
6. Hmelo, C.E., Evenson, D.H. Introduction: Problem-Based Learning: Gaining Insights on Learning Interactions through Multiple Methods of Inquiry (pgs. 1-19). In: Hmelo, C.E., Evenson, D.H., ed. Problem-Based Learning: A Research Perspective on Learning Interactions. Mahwah, NJ: Lawrence Erlbaum Associates, Inc., 2000.
7. Brown, J. S., Collins, A., & Dugid, P. (1989). Situated cognition and the culture of learning. Educational Researcher, 18, 32-42.
8. Jain, Rajiv, Kralovic, S.M., Evans, M.E., Ambrose, M.,Simbartl, L.A., Obrosky, S., Render, M.L., Freyberg, M.S., Jernigan, J.A., Muder, R.R., Miller, L.J., and Roselle, G.A. Veterans Affairs Initiative to Prevent Methicillin-Resistant Staphylococcus aureus Infections. N Engl J Med 2011; 364:15.
9. Barlow, G., Nathwani, D., Myers, E., Sullivan, F., Stevens, N., Duffy, R., Davey, P. Identifying Barriers to the Rapid Administration of Appropriate Antibiotics in Community-Acquired Pneumonia. J of Antimicrobial Chemotherapy 2008; 61:442-451.
10. ReAct - Action on Antibiotic Resistance: Economic Aspects of Antibiotic Resistance.
11. University of Pennsylvania Medical Center Guidelines for Antimicrobial Therapy. 2011. Accessed from /table%20of%20contents.htm.

12. Stubbings, William and Labishiniski, H. New Antibiotics for antibiotic-resistant bacteria. Biology Reports 2009; I:40.
13. Fischbach, M.A., Walsh, C.T. Antibiotic for Emerging Pathogens. Science 2009; 325: 1089-1093.
14. Braine, Theresa. Race Against Time to Develop New Antibiotics. Bull World Health Organization 2011; 89:88-89.
15. Silbergeld, E.K., Graham, J., Price, L.B. Industrial Food Animal Production, Antimicrobial Resistance and Human Health. Annual Review of Public Health 2008; 29:151-169.
16. Smith DL, Dushoff J, Morris G Jr (2005) Agricultural antibiotics and human health. PLoS Med 2(8): e232.
17. Dearing, J.D. Applying Diffusion of Innovations Theory to Intervention Development. Res Soc Work Pract 2009: 19:503-518.
18. Sanson-Fisher, R. W. Diffusion of Innovation Theory for Clinical Change. MJA 2004; 180: S55-56.

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