Samantha Magnus

Abstract

The inappropriate use of antibiotics is an important issue around the world. Not only can the use of antibiotics for viral infections or over use of antibiotics promote antibiotic resistance but it can also increase the likelihood of preventable drug-related adverse events. Inappropriate use of antibiotics can be linked to two main sources; the prescriber (the physician) and the user (the patient). The antibiotic seeking and taking behaviors of the patients can promote antibiotic resistance within the community. On the other hand the inappropriate antibiotic prescribing behaviors in physicians can also promote antibiotic resistance. This literature reviews common antibiotic seeking and taking behaviors in patients and prescribing behaviors in physicians which promote antibiotic resistance while offering advice on how to avoid and change these behaviors.

Introduction

When antibiotics became easy for the public to access, a dilemma was created by the popular view that antibiotics were a ‘miracle drug’ or a ‘cure-all’ for the illness of the time. This view of antibiotics is still present today and is also one of the reasons why antibiotic resistance forms at the rates it does today. Because of this view antibiotics are often misused and abused not only by the public but sometimes by those in the medical profession as well. The more education that can be provided to the public about antibiotics, the more effectively we will be able to deter the misuse of antibiotics and also deter antibiotic resistance. Misuse of antibiotics cannot be isolated to one side or the other of the patient/physician relationship; instead the blame lies on both sides with the patient and with the physician.

Many times patients develop inaccurate ideas relating to antibiotics similar to the idea that antibiotics are a ‘miracle drug.’ When patients have these misconceptions they often develop behaviors which can be destructive to antibiotic use. Entering into a physician’s office with the idea that you already need an antibiotic can cause patients to pressure physicians for antibiotics when they are not needed. In fact some patients out right demand antibiotics though the antibiotics will do no good due to a viral infection. On the other hand, there are many patients who go into their physicians merely with the hope of feeling better and they end up being prescribed antibiotics. Of this group of individuals there is a large number who have developed bad habits of taking their antibiotics such as forgetting to take them or ceasing to take them as soon as they feel a bit better. By developing these behaviors without the proper knowledge about antibiotics patients are promoting antibiotic misuse and antibiotic resistance.

Physicians also have bad habits when it comes to antibiotics, however their habits don’t tend to stem from lack of education but instead from lack of concern or from extreme pressure from patients and their practice. When patients go to see their physician they trust that they are being prescribed what they need to feel better, and so it is very important that physicians prescribe antibiotics correctly. However there are still a large number of physicians who inappropriately prescribe antibiotics because they have developed certain attitudes towards antibiotics and antibiotic resistance, they give into the pressure of patients asking for antibiotics, or because they have a high volume of patients and just wish to get them in and out of the office quickly. These behaviors are destructive not only to the patients, who are receiving medicine they often do not need, but also to the community because inappropriate prescription of antibiotics promotes antibiotic resistance.

This literature review will provide an overview of common antibiotic seeking and taking behaviors in patients and prescribing behaviors in physicians which promote antibiotic resistance. By reviewing a variety of articles this review will not only help point out destructive behaviors involving antibiotics but will also recommend and offer advice on how to avoid and changes these behaviors.

Antibiotic Seeking Behaviors

Normally when patients seek the help of their physician, they enter their physician’s office with only the intention to find a way to feel better. However there are occasions when patients enter a physician’s office seeking more than to feel better; in fact, they are seeking specific courses of prescriptions such as antibiotics. By having certain goals in mind before entering a physician’s office, patients are opening themselves up to becoming one-sided and to refusing the proper treatment by demanding specific prescriptions. This insistence can not only be dangerous for the patient but can also be dangerous for the physician and for the community.

Haltiwanger et al (2001) present a study of college aged individuals which reflects the trends in antibiotic seeking behaviors of all ages in the general populace. These trends also surface in Swahala (2008), Hawkings (2008), Berzanskyte et al (2006), and Aronson’s (2006) various studies. Haltiwanger et al (2001) administered a questionnaire throughout a total of three months at a health center serving a body of about 15,000 students. The survey consisted of two parts, part one was completed before the students saw the clinician it addressed the students general knowledge of antibiotics and their understanding of their illness. Part two was completed after their visit to the clinician and assessed the student’s satisfaction about their visit and learned about their past antibiotic use. From this survey a trend can be found in the antibiotic seeking behaviors of patients. Of the sample of 129 students, 85 students believed they needed medication before they visited the clinician; of those 85 students, 71 believed they needed an antibiotic, 8 a decongestant, 1 some cough medicine, and 5 said other (Haltiwanger et al 2001). In other words, 66% believed they needed medicine before they met their clinician and 55% of the total participants believed they needed an antibiotic before talking to their clinician. These statistics show a very serious trend in patients, an antibiotic seeking trend.

Antibiotic Seeking Behaviors and Illness

Students who felt they had certain infections tended to associate more with antibiotic seeking behaviors. In fact, ninety percent of the individuals who sought antibiotics believed they had a viral infection while on the other hand, forty percent of individuals who believed they had a viral infection sought antibiotics (Haltiwanger et al 2001). Of the 129 students who participated in Haltiwanger et al’s (2001) study, 106 believed that antibiotics could cure a bacterial infection and of these 129 students, 90 students correctly believed that antibiotics would not cure a viral infection. The frightening part about these 90 students is that despite 90 of them knowing antibiotics would not cure a viral infection, three still believed they needed an antibiotic even though they thought they had a viral infection (Haltiwanger et al 2001).

 Even though some students knew antibiotics would not cure their illness, they still believed they needed antibiotics. In fact, of the 71 students who believed they needed an antibiotic, 14 students had a specific antibiotic in mind.  None of these students were medical students and, therefore, none of these students would have the capability to know which antibiotic would best suit their illness, if an antibiotic was appropriate in the first place. By seeking antibiotics, without proper knowledge and education concerning antibiotics, the general population can not only endanger themselves by taking incorrect antibiotics but they can also endanger others by promoting antibiotic resistance.

Common Behaviors Associated with Patients Taking Antibiotics

The most common theme in the literature reporting studies of antibiotic seeking behaviors involved the patients’ perception of antibiotics. Almost all of the patients who participated in the various studies had no concerns about the efficiency of antibiotics or the effectiveness. Instead, patients commonly believed that antibiotics were more effective than they truly are and would treat many illnesses which they are ineffective against. Why so many people have a ‘miracle drug’ perception of antibiotics may have occurred due to many reasons, such as flawed education about antibiotics or a mistaken personal perception.  Common misconceptions about antibiotics can be blamed as the cause for many of the flawed behaviors associated with antibiotic seeking patients.  Within the multitude of research articles there were other themes present in relation to antibiotic seeking behaviors, and although some stem from the belief that antibiotics perform like a ‘miracle drug’ other behaviors stem from various other beliefs. Overall patients fell into five categories which described not only the patients’ antibiotic seeking and taking behaviors but also the beliefs and actions behind these behaviors.

The Patient Takes Antibiotics as Prescribed

Unfortunately many individuals do not take all of the antibiotics as they are prescribed by their clinicians as there should be. In multiple studies, the percentage of patients who adhered to the antibiotic regimen prescribed to them was lower than 50% of all patients included in the study. In the study run by Hawkings et al (2008), only 17 out of the 46 participants adhered to the antibiotic regimen prescribed to them and not surprisingly the typical respondent in this group was between the ages of 36 and 89, with the average age being 56. Also the study run by Sawalha (2008) shows similar results to Hawkings et al (2008) with only 129 patients taking antibiotics as prescribed out of 1039 patients who fully participated in the study. In Sawalha’s (2008) study the average age of patients who took antibiotics only as prescribed was 39 years ± 9.7 years.

These two studies specifically illustrate the trend of a low percentage of individuals taking antibiotics as prescribed by their clinician and they also illustrate a trend concerning the age of the patients who take antibiotics as prescribed. Overall the average age of patients taking antibiotics as prescribed puts them into the middle aged category. Their age presents the notion that these individuals may have more experience and knowledge pertaining to antibiotics and so they tend to take antibiotics as prescribed due to this knowledge and experience. This also presents the notion that if more individuals were better educated about the effects and the proper usage of antibiotics there would be less abuse of antibiotics and more individuals taking antibiotics as they are prescribed by their clinicians. However, the truth of the matter is that at this point in time there is still a small percentage of individuals who take antibiotics as prescribed and a larger percentage of individuals who exhibit other destructive behaviors.

The Patient is Unable to take Antibiotics as Prescribed Due to Social Constraints

There is a fraction of the population who intends to take antibiotics as they are prescribed to them but due to some outlying factor, normally a social factor such as work or school, they are unable to complete their antibiotic regimen as prescribed. In Hawkings et al (2008) study this fraction of the population is represented by 12% of the participants within his study. These participants tended to be between the ages of 21 and 38 with the average age of 32.5 years. As well these participants had a high percentage, 75%, of individuals with children or a child in school/ nursery. Aronson (2006) also found a similar group of participants who were unable to maintain their antibiotic regimens due to social constraints. Out of the 34 participants in Aronson’s study only 6, or 16%, admitting to skipping or missing a dose to due social constraints. The average age of participants in her study were between 18 and 22 making it difficult to asses a trend in relation to age and the effects of social constraints on adhering to an antibiotic regimen. There will always be a measure of human error when it comes to anything involving humans; as such, the fraction of individuals who intended to adhere to their antibiotic regimen but due to a social constraint could not, will always be present.

The Patient Frequently Forgets to Take Antibiotics

The most common reason individuals list, in multiple studies, for not completing their antibiotic regimen as prescribed is forgetfulness and often times the participants blame their forgetfulness on busy lifestyles (Hawkings 2008). In Hawkings’ (2008) study 19 participants, or 41%, said they didn’t finish their antibiotic regimen due to forgetfulness. In Aronson’s (2006) study, 4 participants out of 34, or 12%, did not finish their regimen due to forgetfulness as well. Many of the patients in both of these studies cited reasons such as having a busy life as the root of their forgetfulness. Upon further analysis there was a common trend amongst individuals who forgot to take their antibiotics; the individuals did not have a set routine to follow.

There are many methods to help the percentage of the population who routinely forget to take their antibiotics as prescribed. One method is to attempt to find one part of a busy schedule that usually remains the same, such as the time you arrive at work or when you eat a specific meal, and take the antibiotics right before you have to go to work or whenever you eat a specific meal. Another method to attempt to take antibiotics as prescribed is to either set an alarm on your phone or your clock to go off every day at the same time so you remember to take your antibiotics. Lastly, another method that can help individuals to help remember to take their antibiotics is to get a family member or friend to help remind you everyday to take your antibiotics.

The Patient Stops Antibiotic Use Due to Feeling Better

The key to ensuring antibiotics are being entirely effective is to follow your regimen as prescribed by your clinician and to not stop taking the antibiotics as soon as you start feeling better. Unfortunately there is a percentage of individuals who do stop taking antibiotics as soon as they start feeling better. In Hawkings’ (2008) study 11 participants, 24%, ceased taking antibiotics as soon as they were feeling better. Their mean age was 28.5 years old with a range from 18 to 34 years of age. In Aronson’s (2006) study 2 participants, 6%, ceased taking antibiotics due to the fact that they were feeling better.

The common problem ,which presents the behavior of ceasing antibiotic regimens do to feeling better instead of completing the regimens, can be associated with lack of education pertaining to antibiotics. By providing the proper education about how antibiotics function and about the importance of following antibiotic regimens as prescribed, the percentage of individuals who cease taking antibiotics only due to feeling better can be effectively lowered. However despite the problems which can arise due to stopping an antibiotic regimen early, such as promotion of antibiotic resistance, there are more dangerous behaviors associated with patients taking antibiotics.

The Patient Deliberately Ceases Antibiotic Use Early to Maintain a Supply

Perhaps the most dangerous behavior, when it comes to taking antibiotics, is ceasing your regimen early so you will have a supply of antibiotics for a later time period. Not only does this put the patient at risk by potentially taking expired antibiotics, some of which turn toxic, but it also puts the community at risk by promoting antibiotic resistance when the antibiotics are used inappropriately by the patients at later times. In Hawkings’ (2008) study only 3 participants, 7%, ceased taking antibiotics early to maintain a supply. Their average age was 19 with a range of 18 to 21 years of age. In Sawhala’s (2008) study 11.4% of individuals were self medicating with antibiotics that they had saved from previous prescriptions; their average age was 39.4 ±9.5 years.

The age spread of individuals who exhibit this dangerous antibiotic taking behavior is rather diverse which indicates that this behavior may also be due to lack of education pertaining to antibiotics. This behavior is very serious and education about the effects of self medicating antibiotics needs to be more available to the public. By taking antibiotics when patients feel they are needed versus when a clinician prescribes them, patients are putting themselves at risk not only to dose incorrectly or to take expired antibiotics which could potentially be toxic, but by also promoting antibiotic resistance in their community by introducing more bacteria to antibiotics which could be being used in ineffective or inappropriate amounts.

Common patterns in college students

College students present a unique group of individuals, they are young usually ranging from the age of 18-22 but they are also becoming educated through their college years. Because of this many expect to find less destructive antibiotic seeking behaviors and more constructive antibiotic seeking behaviors amongst college students. In both Aronson (2006) and Haltiwanger et al’s (2001) study their participants are college students and in both studies the majority of students had constructive behaviors when it came to antibiotics. They took their regimen as prescribed and they understood when antibiotics were applicable and not applicable to their illness. However there was a percentage of individuals who did not follow their regimen or who participated in other destructive antibiotic seeking behaviors.

The most common destructive behavior when it came to antibiotics and college students was forgetting to take their antibiotics as prescribed by their clinicians. This usually resulted due to a change in schedule, like going for a weekday to a weekend, or from a hectic schedule to a patterned schedule (Aronson 2006). The other destructive behavior exhibited by college students was actively seeking a prescription for an antibiotic either in general or by name. By going into the clinicians with a goal in mind of receiving antibiotics, despite knowledge of their illness and knowledge of the effectiveness of antibiotic against certain illness, college aged students are promoting bad habits and behaviors when it comes to antibiotics. The best way to solve these two problems is to provide the proper education to the students either during their clinician visit or by teaching the students in either a class or presenting them with the materials needed to educate them on antibiotics. By arming them with the proper knowledge the students can develop or readjust their habits so they are more beneficial and so they do not promote antibiotic resistance.

Antibiotic Prescribing Behaviors

The patient cannot be the only one to blame when it comes to the promotion of antibiotic resistance, in fact the physician may also play a large part in antibiotic promotion. One of the keys to preventing antibiotic resistance from occurring at a heightened pace is correct prescription of antibiotics by physicians. Surprisingly there are many physicians who inappropriately prescribe antibiotics or who take a stance or attitude towards antibiotics which either unintentionally or blatantly promotes antibiotic resistance. One way to help prevent being prescribed antibiotics inappropriately is to be educated on common attitudes towards antibiotic prescription and common indicators that a physician will inappropriately prescribe antibiotics.

Attitudes Towards Antibiotic Prescription

Each physician will take a certain stance on antibiotics which could be influenced by their patient population or even by previous training. These attitudes can affect the way physicians prescribe antibiotics to their patients. A study presented by Metlay et al (2002), consisting of a questionnaire sent out to 800 generalists and 800 infections disease specialists, presents some very interesting attitudes towards antibiotic prescription within the medical profession. This study found that there were four underlying domains of concern relating to physicians' practice of prescribing antibiotics and their concerns related toantibiotic resistance.

Domain One

Domain one reflects an overall concern about the societal impact of drug resistance by the medical professionals.  Almost all statements that fall within domain one were specifically endorsed by many of the infectious disease specialists and generalists. There are five questions that fall within this domain from the questionnaire given in Metlay et al’s (2002) study.  Physicians who made statements that fall into this domain believe that antibiotic resistance is a major public health concern and that overprescribing antibiotics is a major cause of resistance. Physicians who responded positivley to this domain also believe that each decision to prescribe antibiotics will have an impact on resistance and because of this each time before prescribing an antibiotic the medical member must weigh the pros and cons of the effects of antibiotic prescription (Metlay et al 2002).

Domain Two

Domain two reflects the belief that the responsibility, when it comes to antibiotic resistance, does not reside with the physician. Physicians whose answers fell into this domain evidently believe it is the physician’s job to weigh the needs of each patient and to only consider what each individual patient needs.  Individuals who fell into domain two tended to emphasize non-physician factors when it came to antibiotic resistance. They also were confident about the rate of creating new drugs and that this rate will keep pace with the rate of antibiotic resistance. Another common belief of individuals in this category was physicians should move to new antibiotics when bacteria begins to show resistance to old antibiotics and that the patients actions play a large part in antibiotic resistance (Metlay et al2002).

Domain Three

Domain three also focuses on societal impacts of antibiotic resistance, just as domain one; however unlike domain one, domain three also focuses on how physicians can balance patient and society needs. Physicians who fell into this category held the common belief that new antibiotics should not be used as soon as they are introduced. Instead new antibiotics should be kept in reserve for patients who are infected with bacteria resistant to the old antibiotics.  They also believe that the milder the infection the patient has the more the physician will be willing to use an older antibiotic which already has some reported resistance (Metlay et al2002).

Domain Four

Last there is domain four, quite easily the most dangerous domain when it comes to physician beliefs and habits concerning antibiotic prescription and antibiotic resistance. This domain shows the trend of antibiotic overuse amongst physicians. Within this domain, physicians admitted to believing that they prescribe antibiotics more often than needed to their patients. They also admitted that patient demand is a major reason as to why they will unnecessarily prescribe antibiotics to their patients. This domain reflects not only the issue of overprescribing antibiotics but also the issue of inappropriate prescription of antibiotics (Metlay et al2002).

Predictors of Inappropriate Antibiotic Prescription

Probing physicians' attitude towards antibiotics may be the easiest way to determine whether they are likely to inappropriately prescribe antibiotics; however, it may not be very easy to determine what a single physician’s attitude happens to be. As such, there are various other predictors of the likelihood of a physician to inappropriately prescribe antibiotics. A study performed by Cadieux et al (2007) describes predictors of inappropriate prescription of antibiotics by physicians. Their study focuses on four main hypotheses which state inappropriate antibiotic prescription is due to a lack of physician knowledge, a lack of time in practice, a lack in physician training environment, and avoidance behavior of timely patient education, or patient traffic. Of these four hypotheses two proved to be significant predicators of inappropriate antibiotic prescription; time in practice and avoidance of behavior of timely patient education, or patient traffic.

Physician’s Time in Practice as an Indicator

Cadieux et al (2007) found that physicians who had been in practice longer were astonishingly more likely to inappropriately prescribe antibiotics. This behaviour may be due to the physicians adjusting to the culture’s views of antibiotic prescription or this may be due to various other factors as well (Cadieux et al 2007). The fact that the longer a physician is in practice the more likely they are to inappropriately prescribe antibiotics is a bit shocking considering most people believe that physicians who are in practice longer are more reliable on their subject and less likely to inappropriately prescribe or diagnose anything.

Physician’s Patient Traffic as an Indicator

Cadieux et al (2007) also found that physicians who have a high traffic flow are more likely to inappropriately prescribe antibiotics. One reason physicians with hight traffic may be more likely to prescribe antibiotics is that they are probably more eager to get their patients in and out the door and, therefore, they are more likely to rush and inappropriately prescribe antibiotics to their patients. Also these physicians may also be less likely to want to tolerate patient pressure when it comes to prescribing antibiotics and therefore they may give into their patients’ antibiotic seeking pressure. This also relates to physicians with more time in practice because individuals tend to seek out experienced physicians creating a larger patient traffic flow for physicians with more in practice.

Conclusion

Antibiotic resistance is a major concern and so it is important to be educated about antibiotics and their proper use. By knowing common errors patients present when seeking antibiotics and by knowing common errors physicians present when prescribing antibiotics, we can start combating antibiotic resistance one step at a time. There is no one group of individuals to blame for antibiotic resistance, instead the blame rests equally on everyone. By seeking antibiotics without the proper knowledge of their use and effects individuals are promoting antibiotic resistance within themselves and their community. However by prescribing antibiotics without properly diagnosing an illness or without properly weighting the consequences of the antibiotics physicians are promoting antibiotic resistance in their patients and communities as well. There are many studies which present common behaviors found both in patients and physicians which promote antibiotic resistance, each of these studies presents a unique view which can help educate the population about antibiotic resistance and can help to prevent the population from increasing the rate of antibiotic resistance.

 

References

Aronson, B. (2006). Antibiotic-taking experiences of undergraduate college students. Journal of the American Academy of Nurse Practitioners, 18(12), 591-598. doi:10.1111/j.1745-7599.2006.00184.x.

Cadieux, G., Tamblyn, R., Dauphinee, D., & Libman, M. (2007). Predictors of inappropriate antibiotic prescribing among primary care physicians. Canadian Medical Association Journal, 177(8), 877-883. doi:10.1503/cmaj.070151.

Haltiwanger, K., Hayden, G., Weber, T., Evans, B., & Possner, A. (2001). Antibiotic-seeking behavior in college students: What do they really expect? Journal of American College Health, 50(1), 9-13. doi:10.1080/07448480109595705.

Hawkings, N., Butler, C., & Wood, F. (2008). Antibiotics in the community: A typology of user behaviours. Patient Education and Counseling, 73(1), 146-152. doi:10.1016/j.pec.2008.05.025.

Metlay, J., Shea, J., Crossette, L., & Asch, D. (2002). Tensions in Antibiotic Prescribing: Pitting Social Concerns Against the Interests of Individual Patients. Journal of General Internal Medicine, 17(2), 87-94. doi:10.1046/j.1525-1497.2002.10711.x.

Sawalha, A. (2008). Self-medication with antibiotics: A study in Palestine. International Journal of Risk & Safety in Medicine, 20(4), 213-222. Retrieved from PsycINFO database.