Originally published September 2016
It’s estimated that up to half of all prescriptions for antibiotics in Canada and the United States are inappropriate.1–3 Because overuse is linked to antibiotic-resistant infections, healthcare organizations are focusing on educating patients and providers about the need to reduce unnecessary prescribing. For example, in 2012 Accreditation Canada made antibiotic stewardship a required organizational practice,4 and the Choosing Wisely Canada5 campaign has raised awareness of overuse of antibiotics.
In this article, antibiotic prescribing issues include:
- inappropriate ordering (e.g. wrong choice of drug)
- unnecessary prescribing, (e.g. prescribing an antibiotic at the request of a patient)
- inadequate monitoring or follow-up of patients on antibiotics
For more information on CMPA cases related to physicians missing or failing to appreciate the severity of a bacterial infection, members are encouraged to read the CMPA articles on sepsis and meningitis.6,7
The CMPA reviewed 150 medical-legal cases (closed between 2011 and 2015) that involved issues with antibiotic prescriptions. The analysis provides insight into where improvements can be made, particularly in patient assessment, communication, and monitoring and follow-up.
Most inappropriate prescriptions in the CMPA cases reviewed resulted from either incomplete patient assessment or poor clinical judgment. The most common issue was not performing a focused history and physical examination before prescribing. In cases where history taking was deficient, it most often meant patients were not asked about allergies, patients’ allergy information was not verified in the medical records, or both. In a few cases, physicians relied on incomplete documentation in the medical record and did not verify allergy information with the patient.
There were some cases in which empiric treatment was appropriate, but in other cases physicians were found by peer experts to have prescribed too early. These types of issues occurred both in the community and in the emergency department.
Knowledge gaps were apparent when the prescribed antibiotic was found in retrospect to be the wrong choice for the clinical presentation or the patient (e.g. patient’s age), or was contraindicated for its potential to interact with another drug the patient was known to be taking. Other issues included not appreciating co-morbidities that would warrant more aggressive treatment or a decreased dosage. In a few cases, peer experts were of the opinion that consultation with an infectious disease specialist was warranted.
A few of these inappropriate prescriptions were identified by pharmacists before being filled, while others were not. In terms of professional liability, both physicians and pharmacists are considered independent providers, each owing a separate duty to the patient for care that falls within their individual scopes of practice. Other errors might have been prevented had additional checks been in place and followed (e.g. electronic health record warnings for providers).
Patient requests for antibiotics
An infrequent, but noteworthy, issue in the CMPA cases was patients requesting an antibiotic, but physicians not prescribing it as they didn’t believe it was necessary. These requests are common in practice and can result in conflict between physicians and patients. They also highlight the need for physicians to have communication strategies that reinforce sound clinical decision-making.
Case example: Unnecessary prescription influenced by patient demand
A young man visits a walk-in clinic complaining of a persistent dry cough that has lasted for more than one month. He has no other symptoms. He does not have a fever and his chest is clear on examination.
The family physician (FP) assessing the patient believes he has a post-viral cough or possibly a reactive airway. The FP offers the patient a trial of prescription cough syrup or a bronchodilator puffer, but the patient declines both, insisting on antibiotics. After unsuccessfully trying to explain the rationale for his decision, the FP relents and prescribes a 10-day course of antibiotics. He documents in the medical record that the prescription was written on the patient’s insistence.
The patient files a medical regulatory authority (College) complaint alleging that the physician was dismissive of his concerns and reluctant to prescribe the requested treatment. The committee is critical of the FP’s decision to prescribe the antibiotic without medical justification.
The College’s decision in this case reinforces that physicians are expected to use their clinical judgment to determine whether the medication is necessary and whether the potential benefits outweigh the potential harms. Also, for an encounter to be successful, physicians should discuss their clinical opinion with patients, which are not always easy conversations.
Strategies to support appropriate prescribing
- Obtain an adequate history, including current medications and medication history; consider comorbidities; and conduct an appropriate examination before prescribing a medication.
- Consider whether the prescribed medication has any absolute or relative contraindications, such as patient allergies, and the possibility of multi-drug allergy syndrome.
- Formalize how your office manages communication with pharmacists to ensure that requests for information can be responded to appropriately and efficiently.
Monitoring and follow-up issues
The majority of the cases related to the monitoring or follow-up of antibiotics involved the prolonged use of aminoglycosides (mostly gentamicin) without adequate monitoring, resulting in permanent renal or oto-vestibular injury. As these prescriptions originated in hospitals, pharmacists often shared criticism for poor monitoring.
Other follow-up issues stemmed from failure to recognize the need for closer monitoring of some patients, inadequate monitoring processes and protocols, or poor coordination of care among physicians or with other healthcare providers.
Case example: Follow-up issues due to inadequate system
A middle-aged woman presents to her family physician’s office with symptoms suggestive of a urinary tract infection. The FP prescribes a broad-spectrum antibiotic and orders a urine culture. The patient returns three days later as her symptoms have not improved. The office assistant calls for the lab results, but they are not yet available. The FP changes the prescription to another type of broad-spectrum antibiotic. The patient’s results arrive the next day. They are reviewed by the FP, who plans to reconcile them with the drugs prescribed later that day. However, a staff member enters the results into the record before this can occur. A few days later, the patient attends the practice’s walk-in clinic, and sees a colleague of the FP. This physician reviews the test results and discovers that the infection is caused by bacteria that are resistant to both antibiotics that had been previously prescribed. The patient leaves with a new prescription for the appropriate antibiotic.
The patient files a College complaint that alleges her FP failed to provide appropriate care and adequate follow-up. The FP implements a new office system to ensure that test results are properly managed.
Strategies for better monitoring
- Identify the need for monitoring.
- Communicate the need for ongoing monitoring to the patient and to the healthcare provider who is responsible for the follow-up.
- Ensure there is a reliable system in place to facilitate the timely receipt, effective review, and appropriate management and follow-up of tests.
The bottom line
Inappropriate antibiotic prescribing negatively impacts public health. It contributes to antimicrobial resistance, is potentially harmful to patients, and poses medical-legal risks for physicians. Physicians can minimize medical-legal risks associated with antibiotic prescribing by speaking with patients about appropriate treatment options for their health concerns, planning appropriate monitoring and follow-up, and working with other healthcare providers and administrators to create effective systems for the care of patients requiring antibiotics.
- Glass-Kaastra SK, Finley R, Hutchinson J, Patrick DM, Weiss K, Conly J. Variation in outpatient oral antimicrobial use patterns among Canadian provinces, 2000 to 2010. Can J Infect Dis Med Microbiol [Internet]. 2014 Mar – Apr [cited 2016 May 20];25(2):95-8. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4028675/
- United States Centers for Disease Control. Antibiotic resistance threats in the United States, 2013 [Internet]. Atlanta (GA): United States Centres for Disease Control; 2013 [cited 2016 May 20].114 p. Available from: http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf
- Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864-73.
- Accreditation Canada. Safety in Canadian health care organizations: A focus on transitions in care and Required Organizational Practices [Internet]. Ottawa (ON): Accreditation Canada, 2013 [cited 2016 May 20]. Available at: https://accreditation.ca/sites/default/files/char-2013-en.pdf
- Public Health Agency of Canada. “Choosing Wisely Canada” and antimicrobial stewardship: A shared focus on reducing unnecessary care. Canada Communicable Disease Report (CCDR):Volume 41 S-4, June 18, 2015. Ottawa (ON):Public Health Agency of Canada;2015 Jun 18. Available from: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/15vol41/dr-rm41s-4/overview-apercu_02-eng.php
- The Canadian Medical Protective Association. Sepsis can be difficult to recognize, but early diagnosis and treatment is essential. CMPA Perspective [Internet]. 2015 June [cited 2016 May 20];7(3):14-16. Available from: https://www.cmpa-acpm.ca/en/safety/-/asset_publisher/N6oEDMrzRbCC/content/sepsis-can-be-difficult-to-recognize-but-early-diagnosis-and-treatment-is-essential
- The Canadian Medical Protective Association. Meningitis — Understanding the vulnerabilities. CMPA Perspective [Internet]. 2015 December [cited 2016 May 20];7(5):7-9. Available from: https://www.cmpa-acpm.ca/en/safety/-/asset_publisher/N6oEDMrzRbCC/content/meningitis-understanding-the-vulnerabilities