Avoiding Antibiotic Resistance – What to Tell Your Patients

  1. What are you teaching your patients about antibiotic resistance? How do you deal with patients who are dissatisfied with their care because they expected to receive a prescription for an antibiotic… and didn’t?

    Avoiding Antibiotic Resistance – What to Tell Your Patients

    Antibiotic resistance is an ongoing problem in healthcare. Many of our institutional quality assurance and performance improvement measures are linked to infection control and different forms of reducing antibiotic resistance. And that's a great place to start. But I can't help thinking we can do more to prevent antibiotic resistance, especially when it comes to patient education.

    All too often, the things that seem obvious to us as nurses with all our specialized training, can seem like babble in a foreign language to a patient. We see this all the time if we're paying attention: The patient's eyes glaze over while we're talking to them. They nod knowingly, but the lesson gets lost in mid-air, and the desired outcome never materializes.

    A revealing 2018 study published in JAMA Internal Medicine analyzed thousands of telemedicine visits, to show that patients tend to consider their visits successful when they receive prescriptions for antibiotics, whether the medication is medically necessary or not. When you consider the power of patients' expectations paired with heavy institutional emphasis on patient satisfaction scores, prescribers have a strong disincentive for prescribing antibiotics appropriately.

    This study made me think about the difference between patient expectations and patient education. Do patients truly understand the problem of antibiotic resistance? My musings seem to be in line with the CDC's public education materials on antibiotic resistance prevention, which suggest that patients do not fully understand what antibiotic resistance is, or how they might be contributing to the problem by expecting, demanding, and taking antibiotics when they don't really need them. Note: The CDC's educational brochure, "Antibiotics Aren't Always the Answer" is free to download here.

    Targeted, specific, patient education helps patients and healthcare professionals partner together to reduce antibiotic resistance. Here are some thoughts for nurses at all levels on improving patient education about antibiotic resistance.

    Four Key Concepts

    Patients must understand at least four key concepts in order to understand antibiotic resistance. First, not all diseases are caused by bacteria. Second, not all bacteria are bad. Third, antibiotic resistance happens in bacterial cells, not in the human body's cells. And fourth, the overuse of antibiotics will render them ineffective over time.

    First, patients must understand there are many other types of disease-causing microbes besides bacteria- such as viruses, parasites and protozoa just to name a few. This distinction matters in the world of antibiotic resistance because antibiotics are specifically designed to target bacteria-not other microbes. So if the patient's illness is being caused by something other than bacteria, an antibiotic won't work, and the patient shouldn't be taking one.

    Second, not all bacteria are bad. Help patients understand the human body requires good bacteria to survive and function properly. It's the "bad" or pathogenic bacteria that cause infections and illnesses. Resistant bacteria are like pathogenic or "bad" bacteria with superpowers.

    Third, clarify that the resistance part of antibiotic resistance is something that happens in the cells of the bacteria, not the cells of the human body. Patients who have familiarity with the concept of drug tolerance may mistakenly conflate this concept with the idea with antibiotic resistance. Helping the patient understand that antibiotic resistance is all about the bacteria's own drive to survive in the presence of the antibiotic that's trying to kill it can help the patient see the problem in a new light. When patients realize how taking antibiotics makes them a part of the "war on bugs" rather than the "war on drugs," they become more motivated to take the full course of antibiotics as prescribed.

    Fourth, the overuse of antibiotics, including using them when they're not necessary, means more bacteria have more time and opportunity to develop resistance. New antibiotics aren't being developed as quickly as bacteria develop resistance, which means the antibiotics we have now could eventually become useless. Using antibiotics judiciously and appropriately is necessary if we want to continue using them.

    Managing Patient Expectations

    If antibiotics are NOT prescribed, it's important to say the right things to reassure the patient that their needs are being met. A speaker at the American Association of Nurse Practitioners (AANP) conference in 2015, Kim McGinn-Perryman, DNP, shared the acronym, PEARLS, as a strategy for managing patient disappointment when expectations and appropriate antibiotic use practices don't match. While this acronym is especially useful for NPs who find themselves in the position of NOT prescribing antibiotics to someone who is expecting them, all nurses can use aspects of this approach to reinforce their patient education messages throughout the workflow in clinics or any environment where oral antibiotics are prescribed.

    P - Partnership. Acknowledge that you are working in partnership with the patient, toward a goal of resolving the problem. Example: "Part of my job is to help you manage this."

    E - Empathy. Express empathy for the patient's situation. Example: "I understand you're feeling terrible."

    A - Apology. Offer an apology. Example: "I'm very sorry you're not feeling well." If you know the patient is upset about not receiving antibiotics, you might consider taking the conversation a step farther so the patient can sort out their feelings with you instead of taking out their frustration in a rating system or on social media. "I'm sorry you're not getting a prescription for antibiotics today. Do you understand our explanation on why?"

    R - Respect. Show respect for the patient, including their beliefs, intentions, goals, and actions: "You did the right thing coming in to get this checked out today."

    L - Legitimize. Legitimize the patient's thought process: "I can definitely see how you might think an antibiotic would help your symptoms."

    S - Support. Offer actionable support. "I know you want to feel better as soon as possible. Let me give you some treatment suggestions you can use instead of antibiotics."
    The bottom line is that nurses at all levels must work with their patients to provide adequate patient education about appropriate antibiotic use. It's not enough to simply direct a patient to take their antibiotics as prescribed. They won't if they don't appreciate why it matters. We must use our patient education skills to ensure they have a clear understanding of antibiotic resistance.

    Sources and Resources:

    Antibiotics Aren't Always the Answer

    Association Between Antibiotic Prescribing for Respiratory Tract Infections and Patient Satisfaction in Direct-to-Consumer Telemedicine | Infectious Diseases | JAMA Internal Medicine | JAMA Network

    Patient Satisfaction Ratings May Be A Factor In Doctors' Prescribing Behavior : Shots - Health News : NPR

    Using PEARLS to reduce unnecessary antibiotics - The Clinical Advisor
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    9 Comments

  3. by   ruby_jane
    No argument about any of that. And I salute you nurse practitioners who take the time to manage those expectations. Unfortunately there are a large group of folks who simply will not have their expectations managed. When they run into someone who tells them what they don't want to hear they'll go to another practice where someone will give them a Zpack.
  4. by   JKL33
    Good tips for managing expectations. I also don't think it's unreasonable to provide information even before the patient has experienced (what is to them) a disappointing recommendation. As appropriate, I try to set the stage a little (not over-stepping my bounds); for example: "Oh wow, it sounds like you've been feeling really terrible - - we'll be happy to try and help figure out whether you need an antibiotic or whether this might be a virus that kind of has to run its course...." People are totally receptive to this, and when the provider informs them that they have a viral illness, they don't immediately jump to the conclusion that the provider is just another uncaring quack refusing to help them. Just the fact that it's already the second time they've heard the information can help them consider that it might be true.

    One of the big mysteries of recent years is why we don't emphasize education more if we are going to be so concerned about patient satisfaction. To educate professionally is to respect that the patient 1) has a right to the information 2) is capable of understanding. People know when they are being respected and when they aren't.
  5. by   Robmoo
    It is difficult to get people to take antibiotic overuse seriously when it is used regularly in cattle and chicken feed. Overuse?

    Sunday I took my daughter to a local urgent care of a children's hospital in my area. They sent us home saying that is just a viral illness and bring her back if she is not better in 2-3 days, for another $100 co-pay and 2 lost days of work of course. The next day she is even worse with higher fevers so we get a work in appointment Monday with our family docotor and he finds an ear infection. 36 hours and several doses of antibiotics later she is fever free and back to being herself. After a complete course of antibiotics the illness doesn't return. Guess where I will never be taking my kids? Can you blame me? Most people after paying $150 plus and missing a day of work most people would make the same decision.

    There has to be a better way or the public will never take antibiotic overuse seriously.
  6. by   JKL33
    Unfortunately, frequent use of empiric antibiotics for minor conditions that haven't declared/distinguished themselves is not the better way. Healthcare providers are not in control of antibiotics being fed to animals.

    Also unfortunately, the improvement of an illness while taking an antibiotic doesn't independently prove the infection was bacterial or that the antibiotic was needed for that illness. It's the classic, repeatedly-seen course of events: Viral URI that has been going on for a few days is very likely to improve during the course of time that the antibiotic is being taken. Patient makes a connection and believes this proves that they needed the antibiotic.

    I've also seen antibiotics Rx'd mostly based on the fact that it was someone's second visit and they're irritated. They've verbalized their dissatisfaction with the initial provider's recommendations. Personally I would never want my child to be given an antibiotic for that reason.

    I understand your position of concern with a little one who doesn't feel well, and also the inconvenience of having to attend to the illness. But, completely separate from your child's case/situation, the above things still remain true according to current knowledge.

    Ear Infection | Community | Antibiotic Use | CDC
  7. by   traumaRUs
    Agree with all of the above. I work with an immunocompromised population where I order aminoglycosides daily. However, I also instruct my pts that while THEY might need antibiotics for their illness, it doesn't mean their entire family who are not immunocompromised need antibiotics.
  8. by   Jedrnurse
    Maybe there needs to be stricter prescriptive guidelines? I mean, running out of effective treatment options or creating "superbugs" has the potential to outpace the opioid crisis as a public health menace. It certainly seems like practitioners can't prescribe those "like they used to".
  9. by   KatieMI
    Quote from Jedrnurse
    Maybe there needs to be stricter prescriptive guidelines? I mean, running out of effective treatment options or creating "superbugs" has the potential to outpace the opioid crisis as a public health menace. It certainly seems like practitioners can't prescribe those "like they used to".
    The guidelines are pretty strict already. The problem is, like 9 out of 10 patients do not care about any of them. They do not care about very possible event of shutting down a single office for 50 miles around due to their constant demands to get "somethin' good for my pain, my anxiety, my fear and my sleep" (meaning you know what type of stuff). And this is a REAL possibility. Do you think they suddenly will care for one more issue?

    The thing is, WE providers created this and other problems. WE made patients "customers" who behave toward health care providers like toward waitressing staff in quick order diner. Now, of course, we are not happy with it, but now it is again up to us to change it, and that will be WAY more difficult.

    With patients I have developed trust, I do not throw scripts. I spend quite more time (which greatly reduces my "productivity") to explain them that sneezing in cold weather is normal, for one example. Sometimes I even give them script for Zpack and tell not to fill it till if they do not get better in 3 to 4 days. They accept it because they trust me to begin with.

    For that reason, I hate urgent care. Zpacks and Medrols and Claritins fly there like confetti. If I won't give all that to them, they will just go to another urgent care.

    And, yeah, what Robmoo wrote is just the truth. Not many families nowadays have housemaker mom who has time to shattle sheezy and feverish kid around the appointments and stay home with him or her, not mentioning $$ question.
  10. by   ruby_jane
    Quote from KatieMI

    With patients I have developed trust, I do not throw scripts. I spend quite more time (which greatly reduces my "productivity") to explain them that sneezing in cold weather is normal, for one example. Sometimes I even give them script for Zpack and tell not to fill it till if they do not get better in 3 to 4 days. They accept it because they trust me to begin with.

    For that reason, I hate urgent care. Zpacks and Medrols and Claritins fly there like confetti. If I won't give all that to them, they will just go to another urgent care.
    .
    Amen to all that, Katie!
  11. by   Elaine M
    Quote from Robmoo
    It is difficult to get people to take antibiotic overuse seriously when it is used regularly in cattle and chicken feed. Overuse?

    Sunday I took my daughter to a local urgent care of a children's hospital in my area. They sent us home saying that is just a viral illness and bring her back if she is not better in 2-3 days, for another $100 co-pay and 2 lost days of work of course. The next day she is even worse with higher fevers so we get a work in appointment Monday with our family docotor and he finds an ear infection. 36 hours and several doses of antibiotics later she is fever free and back to being herself. After a complete course of antibiotics the illness doesn't return. Guess where I will never be taking my kids? Can you blame me? Most people after paying $150 plus and missing a day of work most people would make the same decision.

    There has to be a better way or the public will never take antibiotic overuse seriously.
    You do realize there could have been no physical signs of an ear infection on Sunday though, right?

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