June 21, 2002

VUMC team studies overuse of antibiotics

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Dr. Marie R. Griffin

VUMC team studies overuse of antibiotics

A collaborative study, among Vanderbilt University Medical Center, the Tennessee Department of Health, the Knox County Health Department and the Centers for Disease Control and Prevention, has shown a reduction in the prescription of antibiotics in Knox County after a community-wide intervention campaign. The study was published Wednesday in the Journal of the American Medical Association.

“There’s good evidence that because we use so many antibiotics, many bacteria are becoming resistant,” said Dr. Marie R. Griffin, professor of Preventive Medicine. “There is high use of antibiotics in Tennessee and a very high antibiotic resistance rate in Streptococcus pneumoniae bacteria which causes serious diseases in children and adults.”

Vanderbilt participants in the JAMA study include Griffin, Dr. William Schaffner, professor and chair of Preventive Medicine, and Edward Mitchel, data analyst in the department of Preventive Medicine. Dr. Allen S. Craig, Tennessee State Epidemiologist and assistant clinical professor of Preventive Medicine, also participated in the study.

The Knox County Health Department led a multifaceted yearlong campaign (May 1997-April 1998) aimed at decreasing unnecessary antibiotic use among children. The campaign was spurred by an outbreak of meningitis in a nearby community in which four children in a day-care center had an antibiotic-resistant form of meningitis. “That episode was very scary and caught the attention of the community as well as public health officials,” Griffin said.

Vanderbilt’s role was to help evaluate the effectiveness of the Knox County intervention program. The children, TennCare patients, were younger than 15 and were all seen in physicians’ offices for outpatient visits. The prescribing data were compared between the intervention county and control counties (Davidson, Hamilton and Shelby counties) during the 12-month periods before, during and after the intervention.

“We wanted to know if the Knox County campaign did more than just the general message that doctors were getting anyway,” Griffin said. “We wanted to compare what happened in Knox County during that intervention year and the following year to what happened in the three other large, urban counties in Tennessee that did not have a special ongoing, targeted campaign.”

The investigators found that there was an 11 percent greater decline in antibiotic use in Knox County than in Davidson, Hamilton and Shelby counties.

“What we found was that antibiotic use was declining slowly in all four counties, but it was declining statistically, significantly more in Knox County than in the other three counties,” Griffin said.

Antibiotic resistance began to receive national attention at about the same time Knox County began its campaigns to encourage physicians to become more conservative about prescribing antibiotics.

The collaboration among the groups involved in the intervention was a “model episode,” Schaffner said. “Without the involvement of Vanderbilt and the CDC, the health departments would not have been able to assess whether this special intervention in Knoxville had a distinctive impact or not.”

It was important to get the message to pediatricians and parents that antibiotics are not necessary for all respiratory infections, Griffin said.

“Many respiratory infections in children are due to viruses and antibiotics don’t really help, but when a child goes in with a respiratory tract infection, there’s an 80 to 90 percent probability that he or she is going to get an antibiotic prescription.”

“Clearly that’s a place where change has to happen, and that’s indeed the place where change did happen in Knox County,” Griffin said. “The number of visits didn’t change, but there were fewer prescriptions given per visit.”

The Knox County campaign, aided by materials developed by the CDC, included grand rounds for pediatricians, and pamphlets and educational materials were made available to the parents bringing newborns and young children to the pediatrician’s office.

“We need parents to know when it’s appropriate to bring their child in to the doctor. A virus can make a child very ill, but you can have a very ill child who doesn’t necessarily need an antibiotic,” Griffin said.

The national data show that antibiotics are being given for illnesses that do not warrant the use of antibiotics. There is also room for improvement in the type of antibiotics prescribed.

“For illnesses like middle ear infections, the most common reason an antibiotic is prescribed in children, a penicillin-type antibiotic will be just fine. We don’t need to give the more broad spectrum antibiotics,” Griffin said.

The Knox County initiative took the national message one step further, Schaffner said.

“What the folks in Knox County did was quite distinctive and noteworthy,” he said. “Most previous attempts to influence the use of antimicrobials were aimed at providers. But the folks in Knox County figured out, they, of course, had to speak to doctors, but they also had to speak to the parents of these young children. Then they made a third effort, to reach the general public so grandmothers, aunts, uncles, neighbors, and friends at church were all getting the same message in hopes that they could reinforce each other.”

Schaffner said that parents are often disappointed when they take their ill child to a doctor and leave without an antibiotic prescription.

“They want the doctor to do something and do something quickly. In the parent’s mind, that usually means getting an antibiotic. What we hope is for a change in expectations. Now, when the parent brings a child in, getting a prescription is a triumph. What we’d really like is for the doctor to say the child really doesn’t need an antibiotic, and the parent to say ‘oh good.’ That would be a huge change.”

Schaffner said there must be ongoing attention to the problem of antibiotic resistance.

“Doctors as well as patients all over the United States are into this for the duration,” he said. “This is not something that will yield to a quick fix.”