Christine E Kistler MD MASc Associate Professor Department of Family Medicine University of North Carolina at Chapel Hill Conflicts of Interest I have no financial conflicts of interest to disclose ID: 915763
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Slide1
Novel Strategies for Reducing Unnecessary Antibiotic Use
Christine E. Kistler, MD,
MASc
Associate Professor
Department of Family MedicineUniversity of North Carolina at Chapel Hill
Slide2Conflicts of Interest
I have no financial conflicts of interest to disclose.
Slide3Tversky and Kahneman. Judgment under Uncertainty: Heuristics and Biases. Science. 1974
Ariely, D. Predictably Irrational. Harper Collins. 2008
People are predictably irrational. The basic wiring of our brains makes us return to the same mistakes again and again.
This work has been enunciated by Kahneman and Tversky, Dan Ariely, and others.
People are susceptible to natural decision-making bias and the use of heuristics, through a dual process of decision-makingHow do people make decisions?
Slide4How are antibiotic prescribing decisions made?
Factors Influencing Antibiotic Prescribing Decisions
Nursing
Homes and
StaffHealth Care
Providers
Patients
and
Families
Clinical Situation
Prescribing Decision
Slide5How individual nurses and providers make antibiotic prescribing decisions?
Clinical event requiring an antibiotic-related decision
Evaluation of information to initiate a call/ antibiotic
Preference Construction-
“What matters most about this decision?”
Decision to call
provider
/ decision to prescribe
Nurse and Provider Usual Care
Intuitive Thinking
- quick judgments based on implicit beliefs or cognitive biases; influenced by heuristics such as attribute substitution for clinical symptoms of infection- increased during time pressures and unfamiliarity
Deliberative Thinking
- slow, analytical judgments that explicitly weigh options, e.g., perceived balance of likelihood of
an
infection versus
other source of symptoms
; may include emotional or cognitive values but weighed against the evidence for an active infection.
Enhanced Decision-Making
Antibiotic-related decisions not based on evidence
Evidence-based antibiotic prescribing
Nursing Home Characteristics: overall rates of prescribing, types of nurses, providers and patients, residents with dementia
Rates of appropriate antibiotic prescribing and rates of sepsis and hospitalization
DUAL PROCESS THEORY OF DECISION MAKING
Slide6Stumbling Blocks
Complexity Stumbling BlocksClinical picture doesn’t fit patternLack of full informationSocial and emotional pressuresCognitive Stumbling BlocksPremature closure of clinical reasoningMisattribution biasRisk aversion
Islam R, et al. BMC Med Info & Dec
Mak
2015
Slide7Current Research
Kistler CE J Am Geriatr
Soc. 2017Brown M J Am Med Dir Assoc 2016Feldstein D
J Am Dir Assoc. 2017
We conducted several chart-based studies of nursing home infections as part of a larger dissemination trial of an antibiotic stewardship project in 31 nursing homes in North Carolina. We randomly sampled charts and abstracted relevant data. Urinary tract infection (UTI) study: 260 participants with antibiotic prescriptions for UTIRespiratory study: 226 participants with chest radiographs Skin and soft tissue infection (SSTI) study: 161 participants with antibiotic prescriptions for SSTI
Slide8Urinary Tract Infections
Common heuristics and stumbling blocks:Anchoring bias: “Any symptom” can indicate a UTIChoice-supportive bias: Initial use of broad spectrum antibiotics (typically fluoroquinolone) and no narrowing or discontinuation of antibiotics in the face of cultures
Confirmation bias: +LE must be an infection
Context effect: Overlying long-prescribing duration
Kistler CE, et al. J Am Geriatr Soc. 2017
Slide9Urinary Tract Infections
Enhanced Decision Making Techniques:Use a structured evaluation and know prescribing criteria: SBAR, etc.
Watchful waiting and periodic re-evaluation (once cultures result): await culture results and de-prescribeUse guidelines and first line agents: TMP/SMX, Nitrofurantoin, Fosfomycin, or
pivmecillinam (and NOT
fluoroquniolones) Only prescribe for 3-5 daysKistler CE, et al. J Am Geriatr Soc. 2017
Slide10Respiratory Tract Infections
Common heuristics and stumbling blocks:Illusion of validity: symptoms/signs of cough and upper respiratory infections often seen as part of pneumonia
Probability neglect: discount the prevalence of other common chest conditions: COPD, arthritis, CHFLoss aversion in the face of uncertain radiographic findings
Brown M, et al.
J Am Med Dir Assoc 2016
Slide11Respiratory Tract Infections
Enhanced Decision Making Techniques:Use a structured evaluation and know when to prescribe and when not to:
a head cold or chest cold do not need antibioticsCOPD is best treated with steroids
CHF is best treated with diuretics Deprescribe in the face of a low-risk chest x-ray
Be tolerant of ambiguity and don’t over-value technologyBrown M, et al. J Am Med Dir Assoc 2016
Slide12Skin and Soft Tissue Infections
Common heuristics and stumbling blocks:Misattribution of signs/symptoms: redness and ulcersSunk Cost Commitment: Use broad-spectrum antibiotics where narrow-spectrum may suffice, e.g.
doxycline (and NOT cephalosporin), aka, an assumption of MRSA
Feldstein D, et al.
J Am Dir Assoc. 2017
Slide13Skin and Soft Tissue Infections
Enhanced Decision Making Techniques:Mark the wound and follow over timeTreat superficial infections (e.g. impetigo, mild wound infections) with topical antibiotics
Treat small abscesses with I&D (though recent
NEJM showed benefit with oral abx
treatment)Treat for only 5-7 days and know your antibiogram : consider Cephalexin or Penicillin, or ClindamycinFeldstein D, et al. J Am Dir Assoc. 2017
Slide14Conclusions: Improve Your Decision-Making
Know the evidence-based signs and symptoms of infections: Fever is 1.2°F above baseline (usually around 99 °F -99.5 °F)Avoid premature closure of the diagnostic and treatment pathways: use all optionsUse watchful waiting and re-evaluation
Prescribe first-line agents and the lowest appropriate duration
Sloane PD, et al.
N C Med J. 2016Sloane PD, et al. J Am Geriatr Soc. 2014
Slide15Implications
We are only human! We need help overcoming our own natural bias. De-biasing techniques and systems-based interventions can help!
Slide16Downloadable Condition-Specific SBARS
Slide17Home
Medical Providers
Nurses
Nursing Assistants
Residents and FamiliesContact Us
Promoting Wise Antibiotic Use in Nursing Homes
Why is this important?
Health and well-being of nursing home residents is the goal of care.
Inappropriate overuse of antibiotics leads to serious complications.
We need to change our thinking from “just in case” to “only when needed”
What you can do
Nurses
Click here
to complete our 10-module antibiotic stewardship training course and obtain up to 2 hours of CE credit.
Medical providers
Click here
to download our ”Infection Management in Nursing Homes”
audiocasts
, available for CME credit.
Residents and Families
Click here
to
download our educational brochure and fact sheet about antibiotic use in nursing homes.
Facts about Antibiotic Overuse in Nursing Homes
Adverse effects such as clostridium difficile infection are increasing.
Between 25-75% prescriptions do not meet clinical guidelines.
Few new antibiotics are being developed; so we need to preserve what we have.
https://nursinghomeinfections.unc.edu/
Slide18Thank You!
Thanks to the UNC Department of Family Medicine and our IMAS team:
Sheryl Zimmerman, PhDPhil Sloane, MD, MPH
Mallory Brown, MDDiane Feldstein, MD
Kimberly Ward, BADavid Reed, PhDDavid Weber, MDKezia Scales, PhDAnd all of our nursing homes and medical providers!