Are Your Antibiotic Prescriptions In Line With Evidence-Based Medicine?

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Continuing Education Course #130 — May 2005

I am pleased to introduce the latest article, “Are Your Antibiotic Prescriptions In Line With Evidence-Based Medicine?” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

Many leading experts cite the overuse of antibiotics as a major contributing factor to the increased prevalence of antibiotic resistant bacteria. With this in mind, Ann C. Anderson, DPM, and John S. Steinberg, DPM, discuss key factors that lead to misuse of antibiotics and review the literature for appropriate indications and use of antibiotic management.

At the end of this article, you’ll find a 10-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 76 and successfully answering the questions on pg. 82. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Drs. Anderson and Steinberg have disclosed that they have no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of their presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists.
RELEASE DATE: May 2005.
EXPIRATION DATE: May 31, 2006.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• cite factors that can lead to the overprescribing of antibiotics;
• recognize when prophylactic antibiotics are appropriate;
• discuss key considerations in antibiotic management of hospitalized patients;
• discuss the appropriate use of topical antimicrobial agents; and
• describe the clinical rationale for using antibiotic beads.

Sponsored by the North American Center for Continuing Medical Education.

Here is an acute deep space abscess in a patient who has diabetes. This infection will likely require a combination of aggressive surgical management and systemic antibiotic agents.
This large plantar neuropathic ulceration has no clinical signs of infection. While this site would benefit from a course of topical antimicrobials, it does not need systemic antibiotic therapy.
Here one can see neglected onychocryptosis with reactive soft tissue. Although antibiotics are often prescribed for this condition, the primary nail avulsion will likely be a sufficient treatment.
Here one can see the placement of PMMA antibiotic beads after a partial calcanectomy. This temporary local placement of antibiotic works synergistically with the systemic antibiotic therapy prescribed.
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Author(s): 
By Ann C. Anderson, DPM, and John S. Steinberg, DPM

   Many of the treatment decisions made on a daily basis in medicine are not founded on or confirmed by the best available science. Some of these decisions are based on historic clinical standards and teachings yet to be scientifically proven while other decisions are made out of habit or sometimes a lack of appropriate information.

   The questions raised in this discussion are not intended to imply that every treatment decision must be based on randomized controlled trials. However, we do hope to point out many clinical misconceptions regarding the prescribing and usage of antibiotics.

   This article will raise some very controversial points about the practice of antibiotic prescriptions. We are not seeking to establish a new standard of care or question the way one practices. We are simply facilitating discussion regarding the evidence-based practice of medicine and how it might relate to the antibiotic prescriptions we write on a daily basis.

Why DPMs Overprescribe Antibiotics

   In close similarity to the entire medical profession, podiatrists are often guilty of overprescribing antibiotics. There are certainly many reasons for this practice, not the least of which is a fear of being found negligent in a potential legal action. When faced with a dilemma of whether or not to prescribe, the physician will likely decide that he or she can minimize the risk of potential legal action by including an antibiotic prescription in the treatment plan.

   While clinicians should not withhold antibiotics if there is reasonable concern for an infection, they should not generally give antibiotics as part of a shotgun approach to an unknown problem. Performing a thorough patient examination and evaluation should enable one to determine whether there is an infection and pursue an appropriate course of treatment.

   Patient expectation is another key factor that drives unnecessary antibiotic prescriptions. Just as patients go to their primary care doctor for antibiotics when they have a simple cold virus, patients expect to visit their podiatrists and receive prescription medication to cure their ailments. Many patients do not feel they have received proper attention until they get a prescription from their doctor. Additionally, patients with wounds often do not understand the difference between a chronic wound contamination and an acute wound infection. At the most, one would treat chronic wound contamination with simple topical management whereas an acute wound infection would require oral or parenteral antibiotic management.

   As with many medical decisions, proper documentation is essential. When clinicians decide an antibiotic is not medically necessary, they should document that decision and provide an explanation. Conversely, when one decides to prescribe an antibiotic, he or she should discuss the clinical findings of infection in the treatment note for that date in order to justify the risk/benefit ratio of the decision.

   Additionally, the local standard of care often drives antibiotic prescriptions. No physician wants to be cited as deviating from the standard of care and therefore is easily swayed by the prescribing habits of the local podiatric community. This overprescribing can lead to the proliferation of resistant organisms and can contribute to gastrointestinal complications and secondary infections from the altered homeostasis, which can result from unnecessary antibiotic prescribing.

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