Antibiotic stewardship and the coming microbial apocalypse: cognitive factors driving overuse

Here’s an editorial in the Annals of Internal Medicine.

Is this a “tragedy of the commons?” This is not a conflict between the needs of the individual patient and the good of the commons. There are potential harms to the individual patient from excessive use. From the article:

Our chief moral duty as clinicians is to our individual patients, in defense of physicians who seem to disregard the commons. However, clinicians and patients may be underestimating the individual harms and overestimating the benefits of antibiotics. Although the effects of antibiotics on the host's microbiota are often invisible, evidence that the impact is more deleterious than previously suspected is accumulating (8). Such findings may eventually change our attitude toward individual antibiotic risk to a greater degree than the threat of resistant infections alone. Using antibiotics only when needed is in the best interest of our patients as well as our communities.

According to the editorial, adoption of best practice in the area of overusage is slower than in many other areas of medicine. Why? More from the article:

Long-standing habits are hard to break. Analogous to birth cohort effects, training cohorts may exhibit stable similarities in social practice norms, which are affected by cultural attitudes toward antibiotic benefits versus harms, patient–clinician communication, or perceived expectations, and may result in different thresholds for antibiotic use. Learned practices that are shared, especially between attending physicians and trainees, resist change even when there is no evidence to support the practice. However, physicians are also influenced by their contemporary social networks—the system and social context within which they practice, including the attitudes and behaviors of their surrounding colleagues (10). These networks can be a powerful motivator for change.

Putting it together, accurate weighing of the true risks and benefits of antibiotic prescribing will help to make prudent use more justifiable on a rational level. However, physicians also need to feel that judicious prescribing is the right thing to do on an emotional or intuitive level, which often requires social cues and accountability. Interventions must also be designed with the reality of time pressure in mind, and caution must be taken with procedures that require an expenditure of time or cognitive resources. The correlation in Silverman and coworkers' study between high patient volume and antibiotic prescribing is consistent with the notion that physicians seeing patients with acute respiratory infections are practicing under extremely busy circumstances, which often require rapid decision making and intuition as opposed to deliberate, rational thought.

The last sentence points to a major barrier in the pursuit of evidence based medicine.