Antibiotics were once regarded as magical pills, saving millions. But unfortunately, antibiotic resistance is eroding their efficacy. One of the main drivers of this resistance is the very high use of antibiotics in primary care.
To understand part of the problem, consider this: have you ever taken an antibiotic for an acute respiratory infection such as a sore throat, acute cough or middle ear infection? You likely said yes: more than half of patients with an acute respiratory infection receive an antibiotic prescription.
Yet the main benefit of taking antibiotics for these conditions is small; the decrease in the duration of sore throat is about 16 hours compared to not taking antibiotics. You could be one of the people who will have problems from taking antibiotics, like vomiting, diarrhea, thrush or rash. Other downsides include cost, remembering to take them, and the risk of antibiotic resistance, which could threaten successful treatment of any really serious future infection (such as meningitis, community acquired pneumonia).
There are many reasons for the high rate of antibiotic use for acute respiratory infections. One can be the imperative for clinicians wanting to support their patients with acute respiratory infections and ‘do something’, perhaps in the belief that any benefit from antibiotics (however minimal) is better than none.
Another reason might be that clinicians, believing their patients want antibiotics, prescribed them to maintain a good therapeutic relationship. Some patients may even ask for antibiotics (often because they over-estimate their benefits, and do not realize they have harms).
Shared decision making
Part of improving the appropriateness of antibiotic use for infections like these is improving the communication between doctors and patients about the need for antibiotics and their benefits and harms. Better still, enabling clinicians and patients to jointly participate in making the decision to use antibiotics or not, after discussing the options, benefits and harms, and patients’ values and preferences.
This is a process known as shared decision making. We know this can help with reducing unnecessary antibiotic prescribing, the question is: how much does it currently occur within consultations between doctors and patients with acute respiratory infections?
Our study addressed this question, along with how antibiotic benefits and harms, including antibiotic resistance, are discussed during routine clinical consultations and what happens to the conversation when decision aids (tools designed to encourage shared decision making and include the benefits and harms of using or not using antibiotics) are used.
This research was part of a larger study in southeast Queensland, Australia – a randomized controlled trial of decision aids for the most common acute respiratory infections (sore throat, middle ear infection, acute cough) that antibiotics are prescribed for, to see if providing decision aids this reduces antibiotic prescribing.
How common is shared decision making?
When clinicians who had been provided with a patient decision aid used it, the discussion about antibiotic benefits and harms, including talking about antibiotic resistance, was better.
We audio-recorded 36 consultations with patients who had acute respiratory infection, and afterwards asked the patients about their involvement in the treatment decision and confidence in the decision. Ideally, we would have recorded all the consultations in the randomized trial – but doing so would have been prohibitively expensive and difficult.
We found that the extent to which shared decision making occurred in consultations was quite low. Even simple communication about antibiotic benefits and harms was not common: it was rare in consultations when decision aids were not used, and antibiotic resistance was never mentioned as a harm. However, when clinicians who had been provided with a patient decision aid used it, the discussion about antibiotic benefits and harms, including talking about antibiotic resistance, was better.
Surprisingly, patients thought that they were highly involved in the decision, even when they were not. Perhaps this comes from low expectations: patients who have never experienced shared decision making will have no idea what it is like.
Our current study suggests that using decision aids might improve the way primary care doctors communicate antibiotic benefits and harms in routine consultations for acute respiratory infection – and this is important so that patients can make an informed health decision. The next time you visit your primary care doctor with one of these infections, ask some questions such as: what will happen if you wait and watch? How much benefit is there from antibiotics? And how much harm is there?