Antibiotic Over-Prescription

Antibiotics are hailed as the greatest medical advance, and yet recent conditions of participation set by Medicare ask care facilities to break their antibiotic prescription habit as part of infection control policy.

Contradictory? Not entirely.

It’s estimated that between 50-80% of antibiotic use in the United States is either inappropriate or unnecessary. Lazy prescribing is contributing to the rise of antibiotic-resistant “superbugs,” which effects 2 million people and kills an estimated 35,000 yearly. These superbugs are more difficult to kill because of evolutionary resistance developed after repeat antibiotic exposure, which renders the neutralizing effect instrumental in their demise as ineffective.The CDC anticipates antibiotic resistance to be one of the largest threats to the US healthcare system, which is why Uncle Sam wants YOU to join the fight against resistance.

Long-term care (LTC) facilities are particularly vulnerable to these bacterial "supervillain" invasions due to close communal setting, high antibiotic prescription and staff turnover rate, which is associated with poorer hand washing technique. In hospice especially, quality of life supersedes medical treatment if the two are contraindicated. Studies on hospice patients and antibiotic use demonstrate longer, but a lower quality of life when compared with patients who refused treatment. This decrease in quality of life is partly explained by the uncomfortable, alternative medication administration routes required for many hospice patients.  This initial discomfort is then exacerbated by undesirable side effects from antibiotic use such as diarrhea, upset stomach and skin rash. A patient once confided to me that while the antibiotic course resolved her urinary urgency related to an infection, she still frequented the bathroom for the other type of urgency as a side effect from the medication.

Oftentimes monitoring antibiotic use can be costly and invasive to patients by requiring follow-up blood draws, cultures and/or imaging. Around 27% of hospice patients pass away within 7 days of receiving an antibiotic, which puts their questioning into use, when we know they often negatively impact quality of life. Declining treatment may be difficult for some healthcare professionals to grasp, who throughout their careers developed an ingrained "Quick! They have an infection, let’s treat it!" mentality, but this kind of autopilot thinking can do more harm than good in palliative care. 

One of the ways hospice facilities can reduce antibiotic prescription is to be more diligent identifying asymptomatic bacteriuria (ASB) vs. urinary tract infection (UTI). A positive urinalysis does not indicate infection, especially if the patient exhibits no other UTI symptoms. True symptoms of a urinary tract infection include burning and pain with urination, fever/chills and increased urgency and frequency. Bacteriuria is particularly common in the elderly. Between 15-50% of patients in LTC facilities have this condition (with greater predominance among women).Treating ASB does not decrease the occurrence of true UTI nor does it improve quality of life OR survival rate. It does inconvenience the patient however, and cause potential harm of organ system damage. The takeaway is that when tempted to treat ASB, just say no to drugs! If bacteriuria is the result of a UTI, more indicative symptoms will manifest soon enough. At the very least, culture the urine first before prescribing antibiotics. Even if the result is positive, weigh the pros and cons of initiating treatment, especially if the patient remains asymptomatic. Think before you prescribe!

Dame Sally Davies, a prominent medical doctor and academic administrator in the U.K, recently compared the existential threat of antibiotic resistance to that of climate change and demanded a similar political activist response from the public. As healthcare professionals, we must be on the forefront of this movement in order to set in motion the change required to not only save future generations, but to provide better comfort for our end-of-life patients in their last days. 

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