Overprescribing: In addition to overdiagnosis, the pressure to increase patient satisfaction in the context of patients requesting or demanding a prescription also contributes to overprescribing. In community settings, for example, where patient contact time is particularly affected, it may be faster just to prescribe than to explain why antibiotics are not necessary. Last, again, lack of education of clinicians contributes to overprescribing.

Not prescribing first-line antibiotics per current guidelines: Current guidelines recommend using community antibiotic nomograms, as well as [considering] comorbidities and risk factors for drug-resistant Streptococcus pneumoniae, to guide decision-making regarding choice of antibiotics in both the inpatient/emergency department and outpatient settings.6

Dr Dela Cruz: Currently there is no clear clinical biomarker that allows a provider to determine when to appropriately use antibiotics and when to stop antibiotics for patients with lung infections. 

Pulmonology Advisor: What are some challenges and potential solutions regarding efforts to reduce antibiotic overuse in this setting?

Dr Forest: [We need to] change the focus of care from efficiency to effectiveness to decrease the pressure on prescribers to please patients and increase productivity at the cost of effective care.

[Healthcare systems should] imbed [electronic health record] tools, such as the Choose Wisely program and other best practices in electronic health records, to help prescribers abide by current guidelines for pneumonia along with those for bronchitis, upper respiratory infection, etc. A key concept is that overprescribing antibiotics for upper respiratory infection, bronchitis, otitis media, and viral syndromes also leads to antibiotic resistance.

Dr Dela Cruz: We need better tools to help us distinguish viral causes of pneumonia from bacterial causes. Patients with symptoms of lung infections are often looking for medications to help them get better, and frequently are given antibiotics even when the cause is a respiratory virus. There is always a concern that patients with viral lung infections can subsequently develop a bacterial superinfection. What we need is a way to reassure both patients and medical providers that [a bacterial infection is not present in a given situation], and that it is okay to not give antibiotics. Currently, we do not have a clear way to determine this, and this is an active area of research.

Pulmonology Advisor: What specific recommendations would you offer to clinicians?

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Dr Niederman: Identify risks for specific pathogens in specific patient populations to optimize therapy without overusing our most effective antibiotics. Choosing the most narrow-spectrum therapy that is likely to be effective, based on patient risk factors for specific pathogens, can lead to effective therapy without overuse.

Dr Forest: Only start antibiotics if the patient case meets clinical, laboratory, and radiological criteria for antibiotic use. For example, get the X-ray for pneumonia, and do not prescribe antibiotics for [infections such as] viral upper respiratory infection or simple bronchitis.