Myth: Wearing makeup causes acne breakouts

Acne breakouts caused by makeup and other skin care products, known as acne cosmetica, typically resolve when patients stop using pore-clogging products; however, the overall impact of cosmetics on the development of acne lesions is considered to be negligible. Many cosmetics are not inherently comedogenic and can be used safely by patients in combination with proper skin care techniques.

Although dermatologists may be inclined to discourage makeup use during acne treatment or breakouts due to its potential to aggravate the patient’s condition, research has shown that treatment results and quality of life (QoL) scores associated with makeup use in acne patients may improve when patients receive instruction on how to use skin care products and cosmetics effectively. In one study of 50 female acne patients, 25 participants were instructed on how to use skin care products and cosmetics, and the other 25 participants received no specific instructions from dermatologists. After 4 weeks of treatment with conventional topical and/or oral acne medications, the investigators concluded that use of skin care products did not negatively impact acne treatment, and the group that received application instructions showed more notable improvements in QoL scores versus those who did not. In another study, the overall number of acne eruptions decreased over a 2- to 4-week period in female acne patients who were trained by a makeup artist to apply cosmetics while undergoing acne treatment. These results suggest that acne patients who wear makeup may benefit from a conversation with their dermatologist about what products and skin care techniques they can use to minimize exacerbation of or even improve their condition.

When choosing makeup that will not cause or exacerbate acne breakouts, patients should look for packaging that indicates the product will not clog pores and is oil-free, noncomedogenic, and/or nonacnegenic. Some makeup products are specifically formulated to help camouflage redness and pimples, which can help improve quality of life and self-esteem in acne patients who otherwise may be self-conscious about their appearance. Mineral-based cosmetics containing powdered formulas of silica, titanium dioxide, and zinc oxide can be used to absorb oil, camouflage redness, and prevent irritation. Anti-inflammatory ingredients and antioxidants also are used in some makeup products to reduce skin irritation and promote barrier repair. Additional cosmetic ingredients that can affect the mechanisms of acne pathogenesis and may contribute to a decrease in acne lesions include nicotinamide, lactic acid, triethyl acetate/ethyllineolate, and prebiotic plant extracts.

Makeup should be applied gently to avoid irritating the skin. It also is important to remind patients not to share their makeup brushes and applicators and to clean them weekly to ensure that bacteria, dead skin cells, and oil are not spread to the skin, which can lead to new breakouts. Although patients may be compelled to scrub the skin to remove makeup, a mild cleanser should be gently applied using the fingertips and rinsed off with lukewarm water to minimize skin irritation. Any makeup remaining on the skin after washing should be gently removed with an oil-free makeup remover.
 

Myth: Wearing makeup causes acne breakouts

Acne breakouts caused by makeup and other skin care products, known as acne cosmetica, typically resolve when patients stop using pore-clogging products; however, the overall impact of cosmetics on the development of acne lesions is considered to be negligible. Many cosmetics are not inherently comedogenic and can be used safely by patients in combination with proper skin care techniques.

Although dermatologists may be inclined to discourage makeup use during acne treatment or breakouts due to its potential to aggravate the patient’s condition, research has shown that treatment results and quality of life (QoL) scores associated with makeup use in acne patients may improve when patients receive instruction on how to use skin care products and cosmetics effectively. In one study of 50 female acne patients, 25 participants were instructed on how to use skin care products and cosmetics, and the other 25 participants received no specific instructions from dermatologists. After 4 weeks of treatment with conventional topical and/or oral acne medications, the investigators concluded that use of skin care products did not negatively impact acne treatment, and the group that received application instructions showed more notable improvements in QoL scores versus those who did not. In another study, the overall number of acne eruptions decreased over a 2- to 4-week period in female acne patients who were trained by a makeup artist to apply cosmetics while undergoing acne treatment. These results suggest that acne patients who wear makeup may benefit from a conversation with their dermatologist about what products and skin care techniques they can use to minimize exacerbation of or even improve their condition.

When choosing makeup that will not cause or exacerbate acne breakouts, patients should look for packaging that indicates the product will not clog pores and is oil-free, noncomedogenic, and/or nonacnegenic. Some makeup products are specifically formulated to help camouflage redness and pimples, which can help improve quality of life and self-esteem in acne patients who otherwise may be self-conscious about their appearance. Mineral-based cosmetics containing powdered formulas of silica, titanium dioxide, and zinc oxide can be used to absorb oil, camouflage redness, and prevent irritation. Anti-inflammatory ingredients and antioxidants also are used in some makeup products to reduce skin irritation and promote barrier repair. Additional cosmetic ingredients that can affect the mechanisms of acne pathogenesis and may contribute to a decrease in acne lesions include nicotinamide, lactic acid, triethyl acetate/ethyllineolate, and prebiotic plant extracts.

Makeup should be applied gently to avoid irritating the skin. It also is important to remind patients not to share their makeup brushes and applicators and to clean them weekly to ensure that bacteria, dead skin cells, and oil are not spread to the skin, which can lead to new breakouts. Although patients may be compelled to scrub the skin to remove makeup, a mild cleanser should be gently applied using the fingertips and rinsed off with lukewarm water to minimize skin irritation. Any makeup remaining on the skin after washing should be gently removed with an oil-free makeup remover.
 

Myth: Wearing makeup causes acne breakouts

Acne breakouts caused by makeup and other skin care products, known as acne cosmetica, typically resolve when patients stop using pore-clogging products; however, the overall impact of cosmetics on the development of acne lesions is considered to be negligible. Many cosmetics are not inherently comedogenic and can be used safely by patients in combination with proper skin care techniques.

Although dermatologists may be inclined to discourage makeup use during acne treatment or breakouts due to its potential to aggravate the patient’s condition, research has shown that treatment results and quality of life (QoL) scores associated with makeup use in acne patients may improve when patients receive instruction on how to use skin care products and cosmetics effectively. In one study of 50 female acne patients, 25 participants were instructed on how to use skin care products and cosmetics, and the other 25 participants received no specific instructions from dermatologists. After 4 weeks of treatment with conventional topical and/or oral acne medications, the investigators concluded that use of skin care products did not negatively impact acne treatment, and the group that received application instructions showed more notable improvements in QoL scores versus those who did not. In another study, the overall number of acne eruptions decreased over a 2- to 4-week period in female acne patients who were trained by a makeup artist to apply cosmetics while undergoing acne treatment. These results suggest that acne patients who wear makeup may benefit from a conversation with their dermatologist about what products and skin care techniques they can use to minimize exacerbation of or even improve their condition.

When choosing makeup that will not cause or exacerbate acne breakouts, patients should look for packaging that indicates the product will not clog pores and is oil-free, noncomedogenic, and/or nonacnegenic. Some makeup products are specifically formulated to help camouflage redness and pimples, which can help improve quality of life and self-esteem in acne patients who otherwise may be self-conscious about their appearance. Mineral-based cosmetics containing powdered formulas of silica, titanium dioxide, and zinc oxide can be used to absorb oil, camouflage redness, and prevent irritation. Anti-inflammatory ingredients and antioxidants also are used in some makeup products to reduce skin irritation and promote barrier repair. Additional cosmetic ingredients that can affect the mechanisms of acne pathogenesis and may contribute to a decrease in acne lesions include nicotinamide, lactic acid, triethyl acetate/ethyllineolate, and prebiotic plant extracts.

Makeup should be applied gently to avoid irritating the skin. It also is important to remind patients not to share their makeup brushes and applicators and to clean them weekly to ensure that bacteria, dead skin cells, and oil are not spread to the skin, which can lead to new breakouts. Although patients may be compelled to scrub the skin to remove makeup, a mild cleanser should be gently applied using the fingertips and rinsed off with lukewarm water to minimize skin irritation. Any makeup remaining on the skin after washing should be gently removed with an oil-free makeup remover.
 

The chance of developing major depressive disorder (MDD) is much higher in patients who have acne, according to a retrospective cohort analysis published as a research letter.

“The onset of acne, when patients present for treatment because of active disease, is associated with a greater risk of developing depression” wrote Isabelle A. Vallerand, an MD/PhD student at the University of Calgary (Alta.), and her associates. “Although the severity of acne was not assessed directly in the current study, this finding suggests a potential dose/response relationship such that more active disease may lead to a greater risk of depression.”

© Ocskay Bence/Fotolia.com

[email protected]

SOURCE: Vallerand I et al. Br J Dermatol. 2018 Feb 7. doi: 10.1111/bjd.16099.

The chance of developing major depressive disorder (MDD) is much higher in patients who have acne, according to a retrospective cohort analysis published as a research letter.

“The onset of acne, when patients present for treatment because of active disease, is associated with a greater risk of developing depression” wrote Isabelle A. Vallerand, an MD/PhD student at the University of Calgary (Alta.), and her associates. “Although the severity of acne was not assessed directly in the current study, this finding suggests a potential dose/response relationship such that more active disease may lead to a greater risk of depression.”

© Ocskay Bence/Fotolia.com

[email protected]

SOURCE: Vallerand I et al. Br J Dermatol. 2018 Feb 7. doi: 10.1111/bjd.16099.

The chance of developing major depressive disorder (MDD) is much higher in patients who have acne, according to a retrospective cohort analysis published as a research letter.

“The onset of acne, when patients present for treatment because of active disease, is associated with a greater risk of developing depression” wrote Isabelle A. Vallerand, an MD/PhD student at the University of Calgary (Alta.), and her associates. “Although the severity of acne was not assessed directly in the current study, this finding suggests a potential dose/response relationship such that more active disease may lead to a greater risk of depression.”

© Ocskay Bence/Fotolia.com

[email protected]

SOURCE: Vallerand I et al. Br J Dermatol. 2018 Feb 7. doi: 10.1111/bjd.16099.

How did the experience of office visits get to be so frustrating for both patients and doctors? Let’s put it under the microscope and examine it.

To medicine’s credit, it realized the value of looking for diseases before symptoms occurred, such as using mammograms to detect breast cancer and controlling blood pressure and blood sugar to avert comorbidities.

Today, a doctor looks at the computer screen and checks off when a mammogram was done and whether blood pressure and blood sugar are controlled. “Authorities” believe that good health is achieved by performing positive checkoffs to questions like this. This definition of quality care is, in reality, “quantity care” and can be tied to physician compensation. Physicians who did not adequately meet Physician Quality Reporting System requirements have received letters informing them that their Medicare Part B payments for 2018 will be reduced by 3%.

Many seasoned clinicians recognize that practicing good medicine involves more than following a computer printout of tests and treatments based on the patient’s symptoms, more than plugging into the diagnostic and prescription mills that are part of today’s managed care system. Making the correct diagnosis requires a carefully taken history, listening to the patients’ stories of their journeys into and through illness, and using a bio-psychosocial-spiritual approach.

Getting to know the patient as a person requires that the doctor and patient take a journey together. In that journey, when the doctor empathizes with the patient and understands what makes the patient tick, the doctor can empower the patient – giving the patient a fuller understanding of their medical conditions, greater participation in the diagnostic work-up and in treatments, and hope for success – all leading to better outcomes.

Doctors are frustrated with the current medical assembly-line system. A study has shown that physicians spend 2 hours on electronic health records and clerical work for every hour they provide direct patient care (Ann Intern Med. 2016;165[11]:753-60). Nearly half of physicians now report that they are “burned out” by the demand to achieve the quantitative requirements on the one hand and their inability to minister to the needs of their patients on the other hand. Patients are also frustrated by the system as they cope with health insurance and costs, with the short time allocated for office visits, and with a fragmented and impersonal medical system. Patients feel that they are little more than a source of information for boxes to be checked off by the physician whose eyes are forced to be on the computer and the clock.

How can we begin to integrate these measures of quality into “quantity medicine” and make the experience of medical visits less frustrating for doctors and patients? How can we reward the skills that recognize that the course of an illness is influenced by patients’ emotions and thoughts related to their problems, their supportive or stressful relationships with others, and the context within which they conceptualize their lives – particularly their religious and spiritual beliefs about life’s purpose and challenges and attitudes toward death?

Caring for patients requires a more sophisticated approach than seeing patients as computer checkoffs. Office visits need to focus on the patient who has the symptoms, not just the symptoms the patient has.

Isn’t it time to make patient-centered care a reality and not just a slogan? If this speaks to you, then what should you do? Even though solutions may not be simple, we should not be deterred from finding patient-centered systems since patients and doctors are unhappy with today’s system. Why not have patients grade their office visits?

While this approach has its shortcomings, and isn’t the only solution, it does place the patient at the center of the process, answering questions about whether the doctor listened to them, heard their concerns, and presented a reasonable plan to help them get better.

In addition, all those involved with medical care should be involved in the process to replace today’s deficient system. The nation’s main organizations representing physicians should propose solutions to support patient-centered care. Individual physicians should become involved, speaking up and sending articles and letters to medical journals and the lay press.

Patients should be empowered to open up a public discussion – in print and broadcast media – on how they want to improve their own medical experiences and the quality of their health care.

It’s worth it. It’s our health.
 

Dr. Banner is a practicing internist in Philadelphia and chair emeritus of the Albert Einstein Medical Center Medical Ethics Committee. Dr. Benor is a psychiatric psychotherapist in the United States and a wholistic psychotherapist in Canada. Dr. Reiser is adjunct professor, University of Texas School of Public Health, Austin, and the UT Austin Plan II Honors Program, and teaches medical history, medical ethics, and public policy. The authors are indebted to Benjamin Sharfman, PhD, and Jane Brown, PhD, for their important roles in creating this article.
 

How did the experience of office visits get to be so frustrating for both patients and doctors? Let’s put it under the microscope and examine it.

To medicine’s credit, it realized the value of looking for diseases before symptoms occurred, such as using mammograms to detect breast cancer and controlling blood pressure and blood sugar to avert comorbidities.

Today, a doctor looks at the computer screen and checks off when a mammogram was done and whether blood pressure and blood sugar are controlled. “Authorities” believe that good health is achieved by performing positive checkoffs to questions like this. This definition of quality care is, in reality, “quantity care” and can be tied to physician compensation. Physicians who did not adequately meet Physician Quality Reporting System requirements have received letters informing them that their Medicare Part B payments for 2018 will be reduced by 3%.

Many seasoned clinicians recognize that practicing good medicine involves more than following a computer printout of tests and treatments based on the patient’s symptoms, more than plugging into the diagnostic and prescription mills that are part of today’s managed care system. Making the correct diagnosis requires a carefully taken history, listening to the patients’ stories of their journeys into and through illness, and using a bio-psychosocial-spiritual approach.

Getting to know the patient as a person requires that the doctor and patient take a journey together. In that journey, when the doctor empathizes with the patient and understands what makes the patient tick, the doctor can empower the patient – giving the patient a fuller understanding of their medical conditions, greater participation in the diagnostic work-up and in treatments, and hope for success – all leading to better outcomes.

Doctors are frustrated with the current medical assembly-line system. A study has shown that physicians spend 2 hours on electronic health records and clerical work for every hour they provide direct patient care (Ann Intern Med. 2016;165[11]:753-60). Nearly half of physicians now report that they are “burned out” by the demand to achieve the quantitative requirements on the one hand and their inability to minister to the needs of their patients on the other hand. Patients are also frustrated by the system as they cope with health insurance and costs, with the short time allocated for office visits, and with a fragmented and impersonal medical system. Patients feel that they are little more than a source of information for boxes to be checked off by the physician whose eyes are forced to be on the computer and the clock.

How can we begin to integrate these measures of quality into “quantity medicine” and make the experience of medical visits less frustrating for doctors and patients? How can we reward the skills that recognize that the course of an illness is influenced by patients’ emotions and thoughts related to their problems, their supportive or stressful relationships with others, and the context within which they conceptualize their lives – particularly their religious and spiritual beliefs about life’s purpose and challenges and attitudes toward death?

Caring for patients requires a more sophisticated approach than seeing patients as computer checkoffs. Office visits need to focus on the patient who has the symptoms, not just the symptoms the patient has.

Isn’t it time to make patient-centered care a reality and not just a slogan? If this speaks to you, then what should you do? Even though solutions may not be simple, we should not be deterred from finding patient-centered systems since patients and doctors are unhappy with today’s system. Why not have patients grade their office visits?

While this approach has its shortcomings, and isn’t the only solution, it does place the patient at the center of the process, answering questions about whether the doctor listened to them, heard their concerns, and presented a reasonable plan to help them get better.

In addition, all those involved with medical care should be involved in the process to replace today’s deficient system. The nation’s main organizations representing physicians should propose solutions to support patient-centered care. Individual physicians should become involved, speaking up and sending articles and letters to medical journals and the lay press.

Patients should be empowered to open up a public discussion – in print and broadcast media – on how they want to improve their own medical experiences and the quality of their health care.

It’s worth it. It’s our health.
 

Dr. Banner is a practicing internist in Philadelphia and chair emeritus of the Albert Einstein Medical Center Medical Ethics Committee. Dr. Benor is a psychiatric psychotherapist in the United States and a wholistic psychotherapist in Canada. Dr. Reiser is adjunct professor, University of Texas School of Public Health, Austin, and the UT Austin Plan II Honors Program, and teaches medical history, medical ethics, and public policy. The authors are indebted to Benjamin Sharfman, PhD, and Jane Brown, PhD, for their important roles in creating this article.
 

How did the experience of office visits get to be so frustrating for both patients and doctors? Let’s put it under the microscope and examine it.

To medicine’s credit, it realized the value of looking for diseases before symptoms occurred, such as using mammograms to detect breast cancer and controlling blood pressure and blood sugar to avert comorbidities.

Today, a doctor looks at the computer screen and checks off when a mammogram was done and whether blood pressure and blood sugar are controlled. “Authorities” believe that good health is achieved by performing positive checkoffs to questions like this. This definition of quality care is, in reality, “quantity care” and can be tied to physician compensation. Physicians who did not adequately meet Physician Quality Reporting System requirements have received letters informing them that their Medicare Part B payments for 2018 will be reduced by 3%.

Many seasoned clinicians recognize that practicing good medicine involves more than following a computer printout of tests and treatments based on the patient’s symptoms, more than plugging into the diagnostic and prescription mills that are part of today’s managed care system. Making the correct diagnosis requires a carefully taken history, listening to the patients’ stories of their journeys into and through illness, and using a bio-psychosocial-spiritual approach.

Getting to know the patient as a person requires that the doctor and patient take a journey together. In that journey, when the doctor empathizes with the patient and understands what makes the patient tick, the doctor can empower the patient – giving the patient a fuller understanding of their medical conditions, greater participation in the diagnostic work-up and in treatments, and hope for success – all leading to better outcomes.

Doctors are frustrated with the current medical assembly-line system. A study has shown that physicians spend 2 hours on electronic health records and clerical work for every hour they provide direct patient care (Ann Intern Med. 2016;165[11]:753-60). Nearly half of physicians now report that they are “burned out” by the demand to achieve the quantitative requirements on the one hand and their inability to minister to the needs of their patients on the other hand. Patients are also frustrated by the system as they cope with health insurance and costs, with the short time allocated for office visits, and with a fragmented and impersonal medical system. Patients feel that they are little more than a source of information for boxes to be checked off by the physician whose eyes are forced to be on the computer and the clock.

How can we begin to integrate these measures of quality into “quantity medicine” and make the experience of medical visits less frustrating for doctors and patients? How can we reward the skills that recognize that the course of an illness is influenced by patients’ emotions and thoughts related to their problems, their supportive or stressful relationships with others, and the context within which they conceptualize their lives – particularly their religious and spiritual beliefs about life’s purpose and challenges and attitudes toward death?

Caring for patients requires a more sophisticated approach than seeing patients as computer checkoffs. Office visits need to focus on the patient who has the symptoms, not just the symptoms the patient has.

Isn’t it time to make patient-centered care a reality and not just a slogan? If this speaks to you, then what should you do? Even though solutions may not be simple, we should not be deterred from finding patient-centered systems since patients and doctors are unhappy with today’s system. Why not have patients grade their office visits?

While this approach has its shortcomings, and isn’t the only solution, it does place the patient at the center of the process, answering questions about whether the doctor listened to them, heard their concerns, and presented a reasonable plan to help them get better.

In addition, all those involved with medical care should be involved in the process to replace today’s deficient system. The nation’s main organizations representing physicians should propose solutions to support patient-centered care. Individual physicians should become involved, speaking up and sending articles and letters to medical journals and the lay press.

Patients should be empowered to open up a public discussion – in print and broadcast media – on how they want to improve their own medical experiences and the quality of their health care.

It’s worth it. It’s our health.
 

Dr. Banner is a practicing internist in Philadelphia and chair emeritus of the Albert Einstein Medical Center Medical Ethics Committee. Dr. Benor is a psychiatric psychotherapist in the United States and a wholistic psychotherapist in Canada. Dr. Reiser is adjunct professor, University of Texas School of Public Health, Austin, and the UT Austin Plan II Honors Program, and teaches medical history, medical ethics, and public policy. The authors are indebted to Benjamin Sharfman, PhD, and Jane Brown, PhD, for their important roles in creating this article.
 

Does obstructive sleep apnea protect the heart? Just say no to routine ovarian cancer screening, why MS patients miss out in primary care, and how malpractice claims mark middle age.

Listen to the MDedge Daily News podcast for all the details on today’s top news.

Does obstructive sleep apnea protect the heart? Just say no to routine ovarian cancer screening, why MS patients miss out in primary care, and how malpractice claims mark middle age.

Listen to the MDedge Daily News podcast for all the details on today’s top news.

Does obstructive sleep apnea protect the heart? Just say no to routine ovarian cancer screening, why MS patients miss out in primary care, and how malpractice claims mark middle age.

Listen to the MDedge Daily News podcast for all the details on today’s top news.

The facts are dire: In 2014, people diagnosed with schizophrenia or mood disorders made 10.8 million visits to emergency departments (EDs). Between 2006 and 2014, the rate of ED visits related to mental health/substance abuse jumped 44%. The suicide rate among people with serious emotional disturbances (SEDs) is 25 times higher than that in the general population. Two million people with serious mental illness (SMI) are jailed annually, but only about 1 in 3 is currently receiving any treatment.

However, early intervention for SMI can help many people stay out of EDs and jails. That is the focus of The Way Forward: Federal Action for a System That Works for All People Living With SMI and SED and Their Families and Caregivers, a report recently released by the Substance Abuse and Mental Health Services Administration (SAMHSA).

“The emergency room is not a place for people that are experiencing exacerbations of mental health conditions,” says Elinore McCance-Katz, MD, PhD, assistant secretary for mental health and substance use at SAMHSA and chair of the Interdepartmental Serious Mental Illness Coordinating Committee, which produced the report.

In the report, the committee cited the 2003 President’s New Freedom Commission on Mental Health, which concluded that America’s mental health service delivery system was “in shambles,” with “fragmented, disconnected and often inadequate” mental health services and supports. Yet a number of the commission’s recommendations still have not been implemented or only “partially realized,” the committee notes.

In an interview with MedPageToday.com, McCance-Katz says the solution is a “national system of crisis intervention services”—a continuum of care with outpatient services as alternatives to inpatient care. Most states report insufficient psychiatric crisis response capacity, as well as insufficient numbers of inpatient psychiatric hospital beds. If the right system, one that includes community interventions and adequate resources, were in place, McCance-Katz says, “we might not need so many beds.”

The facts are dire: In 2014, people diagnosed with schizophrenia or mood disorders made 10.8 million visits to emergency departments (EDs). Between 2006 and 2014, the rate of ED visits related to mental health/substance abuse jumped 44%. The suicide rate among people with serious emotional disturbances (SEDs) is 25 times higher than that in the general population. Two million people with serious mental illness (SMI) are jailed annually, but only about 1 in 3 is currently receiving any treatment.

However, early intervention for SMI can help many people stay out of EDs and jails. That is the focus of The Way Forward: Federal Action for a System That Works for All People Living With SMI and SED and Their Families and Caregivers, a report recently released by the Substance Abuse and Mental Health Services Administration (SAMHSA).

“The emergency room is not a place for people that are experiencing exacerbations of mental health conditions,” says Elinore McCance-Katz, MD, PhD, assistant secretary for mental health and substance use at SAMHSA and chair of the Interdepartmental Serious Mental Illness Coordinating Committee, which produced the report.

In the report, the committee cited the 2003 President’s New Freedom Commission on Mental Health, which concluded that America’s mental health service delivery system was “in shambles,” with “fragmented, disconnected and often inadequate” mental health services and supports. Yet a number of the commission’s recommendations still have not been implemented or only “partially realized,” the committee notes.

In an interview with MedPageToday.com, McCance-Katz says the solution is a “national system of crisis intervention services”—a continuum of care with outpatient services as alternatives to inpatient care. Most states report insufficient psychiatric crisis response capacity, as well as insufficient numbers of inpatient psychiatric hospital beds. If the right system, one that includes community interventions and adequate resources, were in place, McCance-Katz says, “we might not need so many beds.”

The facts are dire: In 2014, people diagnosed with schizophrenia or mood disorders made 10.8 million visits to emergency departments (EDs). Between 2006 and 2014, the rate of ED visits related to mental health/substance abuse jumped 44%. The suicide rate among people with serious emotional disturbances (SEDs) is 25 times higher than that in the general population. Two million people with serious mental illness (SMI) are jailed annually, but only about 1 in 3 is currently receiving any treatment.

However, early intervention for SMI can help many people stay out of EDs and jails. That is the focus of The Way Forward: Federal Action for a System That Works for All People Living With SMI and SED and Their Families and Caregivers, a report recently released by the Substance Abuse and Mental Health Services Administration (SAMHSA).

“The emergency room is not a place for people that are experiencing exacerbations of mental health conditions,” says Elinore McCance-Katz, MD, PhD, assistant secretary for mental health and substance use at SAMHSA and chair of the Interdepartmental Serious Mental Illness Coordinating Committee, which produced the report.

In the report, the committee cited the 2003 President’s New Freedom Commission on Mental Health, which concluded that America’s mental health service delivery system was “in shambles,” with “fragmented, disconnected and often inadequate” mental health services and supports. Yet a number of the commission’s recommendations still have not been implemented or only “partially realized,” the committee notes.

In an interview with MedPageToday.com, McCance-Katz says the solution is a “national system of crisis intervention services”—a continuum of care with outpatient services as alternatives to inpatient care. Most states report insufficient psychiatric crisis response capacity, as well as insufficient numbers of inpatient psychiatric hospital beds. If the right system, one that includes community interventions and adequate resources, were in place, McCance-Katz says, “we might not need so many beds.”

Children’s Research Hospital

Many young children with sickle cell anemia (SCA) may not be taking the recommended antibiotics to prevent invasive pneumococcal disease (IPD), according to research published in Pediatrics.

Results of a previous study indicated that daily treatment with penicillin could reduce the risk of IPD by 84% in young children with SCA.

In the current study, only 18% of young SCA patients received daily penicillin or an equivalent antibiotic as IPD prophylaxis.

“Most children with sickle cell anemia are not getting the antibiotics they should be to adequately protect against potentially deadly infections,” said study author Sarah Reeves, PhD, of the University of Michigan Medical School in Ann Arbor.

“Long-standing recommendations say children with sickle cell anemia should take antibiotics daily for their first 5 years of life. It can be life-saving.”

For this study, Dr Reeves and her colleagues analyzed data on 2821 SCA patients, ages 3 months to 5 years, living in Florida, Illinois, Louisiana, Michigan, South Carolina, and Texas.

The patients were continuously enrolled in the Medicaid program for at least 1 calendar year between 2005 and 2012. The researchers evaluated the receipt of antibiotics through the insurance claims for filled prescriptions.

The team found that, overall, 18% of patients received at least 300 days of antibiotics.

Sixteen percent of patients received at least 300 days of penicillin; 16% received at least 300 days of penicillin or erythromycin; 18% received at least 300 days of penicillin, erythromycin, or amoxicillin; and 22% received at least 300 days of any antibiotic to prevent Streptococcus pneumoniae.

On average, patients received 162 days of penicillin; 164 days of penicillin or erythromycin; 178 days of penicillin, erythromycin, or amoxicillin; and 193 days of any antibiotic to prevent S pneumoniae.

Multivariable analysis suggested that medical visits and a patient’s state of residence were associated with receiving at least 300 days of antibiotics.

The researchers said that each additional SCA-related outpatient visit and well-child visit was associated with incrementally increased odds of receiving at least 300 days of antibiotics. The odds ratio (OR) was 1.01 for SCA-related outpatient visits and 1.08 for well-child visits (P<0.05 for both).

Patients in Florida (OR=0.51, P<0.05), Louisiana (OR=0.57, P<0.05), Michigan (OR=0.60, P<0.05), and South Carolina (OR=0.62, P<0.05) had lower odds of receiving at least 300 days of antibiotics than patients in Illinois (OR=1.00) or Texas (OR=1.01).

The researchers did not investigate why children were not receiving recommended antibiotics, but Dr Reeves identified possible barriers to compliance. She noted that caregiver challenges include picking up prescriptions every 2 weeks from a pharmacy as well as remembering to administer an antibiotic to a young, healthy-appearing child twice a day.

“The types of challenges involved in making sure children get the recommended dose of antibiotics is exacerbated by the substantial burden of care already experienced by families to help control the symptoms of this disease,” Dr Reeves said.

She added that future studies should more deeply explore barriers preventing families from getting antibiotics and potential interventions to improve the rate of children receiving recommended prescriptions.

“Interventions to improve the receipt of antibiotics among children with sickle cell anemia should include enhanced collaboration between healthcare providers, pharmacists, and families,” Dr Reeves said.

“Doctors need to repeatedly discuss the importance of taking antibiotics with families of children with sickle cell anemia. Social factors that may impact receiving filled prescriptions should also be considered, such as the availability of transportation and time to travel to pharmacies to pick up the prescriptions.”

Children’s Research Hospital

Many young children with sickle cell anemia (SCA) may not be taking the recommended antibiotics to prevent invasive pneumococcal disease (IPD), according to research published in Pediatrics.

Results of a previous study indicated that daily treatment with penicillin could reduce the risk of IPD by 84% in young children with SCA.

In the current study, only 18% of young SCA patients received daily penicillin or an equivalent antibiotic as IPD prophylaxis.

“Most children with sickle cell anemia are not getting the antibiotics they should be to adequately protect against potentially deadly infections,” said study author Sarah Reeves, PhD, of the University of Michigan Medical School in Ann Arbor.

“Long-standing recommendations say children with sickle cell anemia should take antibiotics daily for their first 5 years of life. It can be life-saving.”

For this study, Dr Reeves and her colleagues analyzed data on 2821 SCA patients, ages 3 months to 5 years, living in Florida, Illinois, Louisiana, Michigan, South Carolina, and Texas.

The patients were continuously enrolled in the Medicaid program for at least 1 calendar year between 2005 and 2012. The researchers evaluated the receipt of antibiotics through the insurance claims for filled prescriptions.

The team found that, overall, 18% of patients received at least 300 days of antibiotics.

Sixteen percent of patients received at least 300 days of penicillin; 16% received at least 300 days of penicillin or erythromycin; 18% received at least 300 days of penicillin, erythromycin, or amoxicillin; and 22% received at least 300 days of any antibiotic to prevent Streptococcus pneumoniae.

On average, patients received 162 days of penicillin; 164 days of penicillin or erythromycin; 178 days of penicillin, erythromycin, or amoxicillin; and 193 days of any antibiotic to prevent S pneumoniae.

Multivariable analysis suggested that medical visits and a patient’s state of residence were associated with receiving at least 300 days of antibiotics.

The researchers said that each additional SCA-related outpatient visit and well-child visit was associated with incrementally increased odds of receiving at least 300 days of antibiotics. The odds ratio (OR) was 1.01 for SCA-related outpatient visits and 1.08 for well-child visits (P<0.05 for both).

Patients in Florida (OR=0.51, P<0.05), Louisiana (OR=0.57, P<0.05), Michigan (OR=0.60, P<0.05), and South Carolina (OR=0.62, P<0.05) had lower odds of receiving at least 300 days of antibiotics than patients in Illinois (OR=1.00) or Texas (OR=1.01).

The researchers did not investigate why children were not receiving recommended antibiotics, but Dr Reeves identified possible barriers to compliance. She noted that caregiver challenges include picking up prescriptions every 2 weeks from a pharmacy as well as remembering to administer an antibiotic to a young, healthy-appearing child twice a day.

“The types of challenges involved in making sure children get the recommended dose of antibiotics is exacerbated by the substantial burden of care already experienced by families to help control the symptoms of this disease,” Dr Reeves said.

She added that future studies should more deeply explore barriers preventing families from getting antibiotics and potential interventions to improve the rate of children receiving recommended prescriptions.

“Interventions to improve the receipt of antibiotics among children with sickle cell anemia should include enhanced collaboration between healthcare providers, pharmacists, and families,” Dr Reeves said.

“Doctors need to repeatedly discuss the importance of taking antibiotics with families of children with sickle cell anemia. Social factors that may impact receiving filled prescriptions should also be considered, such as the availability of transportation and time to travel to pharmacies to pick up the prescriptions.”

Children’s Research Hospital

Many young children with sickle cell anemia (SCA) may not be taking the recommended antibiotics to prevent invasive pneumococcal disease (IPD), according to research published in Pediatrics.

Results of a previous study indicated that daily treatment with penicillin could reduce the risk of IPD by 84% in young children with SCA.

In the current study, only 18% of young SCA patients received daily penicillin or an equivalent antibiotic as IPD prophylaxis.

“Most children with sickle cell anemia are not getting the antibiotics they should be to adequately protect against potentially deadly infections,” said study author Sarah Reeves, PhD, of the University of Michigan Medical School in Ann Arbor.

“Long-standing recommendations say children with sickle cell anemia should take antibiotics daily for their first 5 years of life. It can be life-saving.”

For this study, Dr Reeves and her colleagues analyzed data on 2821 SCA patients, ages 3 months to 5 years, living in Florida, Illinois, Louisiana, Michigan, South Carolina, and Texas.

The patients were continuously enrolled in the Medicaid program for at least 1 calendar year between 2005 and 2012. The researchers evaluated the receipt of antibiotics through the insurance claims for filled prescriptions.

The team found that, overall, 18% of patients received at least 300 days of antibiotics.

Sixteen percent of patients received at least 300 days of penicillin; 16% received at least 300 days of penicillin or erythromycin; 18% received at least 300 days of penicillin, erythromycin, or amoxicillin; and 22% received at least 300 days of any antibiotic to prevent Streptococcus pneumoniae.

On average, patients received 162 days of penicillin; 164 days of penicillin or erythromycin; 178 days of penicillin, erythromycin, or amoxicillin; and 193 days of any antibiotic to prevent S pneumoniae.

Multivariable analysis suggested that medical visits and a patient’s state of residence were associated with receiving at least 300 days of antibiotics.

The researchers said that each additional SCA-related outpatient visit and well-child visit was associated with incrementally increased odds of receiving at least 300 days of antibiotics. The odds ratio (OR) was 1.01 for SCA-related outpatient visits and 1.08 for well-child visits (P<0.05 for both).

Patients in Florida (OR=0.51, P<0.05), Louisiana (OR=0.57, P<0.05), Michigan (OR=0.60, P<0.05), and South Carolina (OR=0.62, P<0.05) had lower odds of receiving at least 300 days of antibiotics than patients in Illinois (OR=1.00) or Texas (OR=1.01).

The researchers did not investigate why children were not receiving recommended antibiotics, but Dr Reeves identified possible barriers to compliance. She noted that caregiver challenges include picking up prescriptions every 2 weeks from a pharmacy as well as remembering to administer an antibiotic to a young, healthy-appearing child twice a day.

“The types of challenges involved in making sure children get the recommended dose of antibiotics is exacerbated by the substantial burden of care already experienced by families to help control the symptoms of this disease,” Dr Reeves said.

She added that future studies should more deeply explore barriers preventing families from getting antibiotics and potential interventions to improve the rate of children receiving recommended prescriptions.

“Interventions to improve the receipt of antibiotics among children with sickle cell anemia should include enhanced collaboration between healthcare providers, pharmacists, and families,” Dr Reeves said.

“Doctors need to repeatedly discuss the importance of taking antibiotics with families of children with sickle cell anemia. Social factors that may impact receiving filled prescriptions should also be considered, such as the availability of transportation and time to travel to pharmacies to pick up the prescriptions.”

Image from PLOS ONE

Preclinical research suggests that targeting JAK2 can reduce the risk of graft-versus-host disease (GVHD) in transplant recipients.

Researchers found that genetic ablation of JAK2 on donor T cells or inhibition of JAK2 via treatment with pacritinib reduced GVHD in mice without compromising graft-versus-leukemia (GVL) activity.

“An effort to identify selective immune suppression whereby GVHD is reduced and the antitumor activity of the graft is preserved is key to improving the success of blood and marrow transplantation,” said Brian C. Betts, MD, of Moffitt Cancer Center in Tampa, Florida.

Dr Betts and his colleagues conducted this research and recounted their findings in PNAS.

In experiments with mice, the researchers found that donor T cells with JAK2 deletion were less likely than wild-type donor T cells to induce GVHD. However, JAK2 deletion did not impair the GVL effect.

Mice that received JAK2^−/− T cells had longer survival, higher body weights, and less GVHD than control mice.

The researchers said targeting JAK2 may reduce GVHD, in part, by limiting Th1 differentiation and the migratory capacity of alloreactive T cells. However, targeting JAK2 promotes beneficial regulatory-T-cell and Th2 differentiation as well.

The researchers also tested the effects of JAK2 inhibition with pacritinib. Mice received allografts and were treated with pacritinib or vehicle control for 3 weeks.

As before, JAK2 inhibition reduced acute GVHD mortality while preserving the GVL effect.

The team also discovered that pacritinib could protect mice from tissue graft rejection, suggesting the drug could be used to prevent kidney or liver transplant rejection.

Now, the researchers are working on a phase 1/2 trial designed to determine if pacritinib and standard immune suppression can prevent acute GVHD after hematopoietic stem cell transplant (NCT02891603).

Image from PLOS ONE

Preclinical research suggests that targeting JAK2 can reduce the risk of graft-versus-host disease (GVHD) in transplant recipients.

Researchers found that genetic ablation of JAK2 on donor T cells or inhibition of JAK2 via treatment with pacritinib reduced GVHD in mice without compromising graft-versus-leukemia (GVL) activity.

“An effort to identify selective immune suppression whereby GVHD is reduced and the antitumor activity of the graft is preserved is key to improving the success of blood and marrow transplantation,” said Brian C. Betts, MD, of Moffitt Cancer Center in Tampa, Florida.

Dr Betts and his colleagues conducted this research and recounted their findings in PNAS.

In experiments with mice, the researchers found that donor T cells with JAK2 deletion were less likely than wild-type donor T cells to induce GVHD. However, JAK2 deletion did not impair the GVL effect.

Mice that received JAK2^−/− T cells had longer survival, higher body weights, and less GVHD than control mice.

The researchers said targeting JAK2 may reduce GVHD, in part, by limiting Th1 differentiation and the migratory capacity of alloreactive T cells. However, targeting JAK2 promotes beneficial regulatory-T-cell and Th2 differentiation as well.

The researchers also tested the effects of JAK2 inhibition with pacritinib. Mice received allografts and were treated with pacritinib or vehicle control for 3 weeks.

As before, JAK2 inhibition reduced acute GVHD mortality while preserving the GVL effect.

The team also discovered that pacritinib could protect mice from tissue graft rejection, suggesting the drug could be used to prevent kidney or liver transplant rejection.

Now, the researchers are working on a phase 1/2 trial designed to determine if pacritinib and standard immune suppression can prevent acute GVHD after hematopoietic stem cell transplant (NCT02891603).

Image from PLOS ONE

Preclinical research suggests that targeting JAK2 can reduce the risk of graft-versus-host disease (GVHD) in transplant recipients.

Researchers found that genetic ablation of JAK2 on donor T cells or inhibition of JAK2 via treatment with pacritinib reduced GVHD in mice without compromising graft-versus-leukemia (GVL) activity.

“An effort to identify selective immune suppression whereby GVHD is reduced and the antitumor activity of the graft is preserved is key to improving the success of blood and marrow transplantation,” said Brian C. Betts, MD, of Moffitt Cancer Center in Tampa, Florida.

Dr Betts and his colleagues conducted this research and recounted their findings in PNAS.

In experiments with mice, the researchers found that donor T cells with JAK2 deletion were less likely than wild-type donor T cells to induce GVHD. However, JAK2 deletion did not impair the GVL effect.

Mice that received JAK2^−/− T cells had longer survival, higher body weights, and less GVHD than control mice.

The researchers said targeting JAK2 may reduce GVHD, in part, by limiting Th1 differentiation and the migratory capacity of alloreactive T cells. However, targeting JAK2 promotes beneficial regulatory-T-cell and Th2 differentiation as well.

The researchers also tested the effects of JAK2 inhibition with pacritinib. Mice received allografts and were treated with pacritinib or vehicle control for 3 weeks.

As before, JAK2 inhibition reduced acute GVHD mortality while preserving the GVL effect.

The team also discovered that pacritinib could protect mice from tissue graft rejection, suggesting the drug could be used to prevent kidney or liver transplant rejection.

Now, the researchers are working on a phase 1/2 trial designed to determine if pacritinib and standard immune suppression can prevent acute GVHD after hematopoietic stem cell transplant (NCT02891603).

Photo by Bill Branson

A study conducted in Sweden revealed that social benefits can ease financial burdens for parents of children recently diagnosed with cancer.

However, the study also showed that mothers experienced persistently lower income after benefits diminished.

Ayako Hiyoshi, PhD, of Örebro University in Örebro, Sweden, and her colleagues detailed these findings in Cancer.

The researchers gathered information from Swedish national registers and examined the trajectories of parents’ income from different sources.

Parents of children with cancer diagnosed between 2004 and 2009 were identified and matched with parents of children without cancer (reference parents).

In total, 20,091 families were followed from the year before cancer diagnosis to a maximum of 8 years.

The researchers noted that, around the time of a child’s cancer diagnosis, total income (from all sources) was, on average, higher in mothers of children with cancer than in reference mothers.

The ratio of mean total income for mothers of children with cancer, compared to reference mothers, was 1.032 at 1 year prior to the child’s diagnosis and 1.064 the year of diagnosis.

For fathers of children with cancer, total income was slightly lower than reference fathers’ income. The ratios were 0.987 at 1 year prior to diagnosis and 0.995 the year of diagnosis.

The researchers also noted that parents’ income from work was at its lowest around the time of a child’s cancer diagnosis but increased with time.

At cancer diagnosis, the ratio of mean income from work was 0.642 for mothers and 0.858 for fathers. One year later, the ratios were 0.786 and 0.956, respectively. At 3 years, the ratios were 0.876 and 0.986, respectively. At 6 years, the ratios were 0.856 and 1.058, respectively.

The researchers pointed out that sickness and childcare-related benefits, which compensated for income loss, were greater for parents of children with cancer than for reference parents. However, social benefits diminished over time.

One year prior to cancer diagnosis, the ratio of sickness benefits was 3.495 for mothers and 5.213 for fathers. The year of diagnosis, the ratios were 4.785 and 5.795, respectively. At 3 years, the ratios were 1.404 and 1.339, respectively. And at 6 years, the ratios were 0.931 and 1.421, respectively.

One year prior to cancer diagnosis, the ratio of childcare-related benefits was 2.830 for mothers and 3.514 for fathers. The year of diagnosis, the ratios were 4.553 and 4.930, respectively. At 3 years, the ratios were 2.225 and 1.948, respectively. And at 6 years, the ratios were 1.272 and 1.095, respectively.

The decline of social benefits over time meant that cancer mothers’ total income became lower than that of reference mothers, and this difference persisted over the period studied. This was not the case for cancer fathers, however.

The ratio of income from all sources for cancer mothers compared to reference mothers was 1.064 the year of diagnosis, 0.985 at 2 years, 0.966 at 4 years, and 0.934 at 6 years.

The ratio of income from all sources for cancer fathers compared to reference fathers was 0.995 the year of diagnosis, 0.993 at 2 years, 0.998 at 4 years, and 1.029 at 6 years.

“A significant and unexpected finding was that, although income from employment stayed lower for several years for mothers, total income was higher for mothers of children with cancer around the time of the child’s cancer diagnosis when the compensation from social benefits were included,” Dr Hiyoshi said.

“The persistently lower income from employment for mothers of children with cancer compared with mothers of cancer-free children implies potential long-term consequences for the mothers of children with cancer, including their career and future pension in old age.”

Photo by Bill Branson

A study conducted in Sweden revealed that social benefits can ease financial burdens for parents of children recently diagnosed with cancer.

However, the study also showed that mothers experienced persistently lower income after benefits diminished.

Ayako Hiyoshi, PhD, of Örebro University in Örebro, Sweden, and her colleagues detailed these findings in Cancer.

The researchers gathered information from Swedish national registers and examined the trajectories of parents’ income from different sources.

Parents of children with cancer diagnosed between 2004 and 2009 were identified and matched with parents of children without cancer (reference parents).

In total, 20,091 families were followed from the year before cancer diagnosis to a maximum of 8 years.

The researchers noted that, around the time of a child’s cancer diagnosis, total income (from all sources) was, on average, higher in mothers of children with cancer than in reference mothers.

The ratio of mean total income for mothers of children with cancer, compared to reference mothers, was 1.032 at 1 year prior to the child’s diagnosis and 1.064 the year of diagnosis.

For fathers of children with cancer, total income was slightly lower than reference fathers’ income. The ratios were 0.987 at 1 year prior to diagnosis and 0.995 the year of diagnosis.

The researchers also noted that parents’ income from work was at its lowest around the time of a child’s cancer diagnosis but increased with time.

At cancer diagnosis, the ratio of mean income from work was 0.642 for mothers and 0.858 for fathers. One year later, the ratios were 0.786 and 0.956, respectively. At 3 years, the ratios were 0.876 and 0.986, respectively. At 6 years, the ratios were 0.856 and 1.058, respectively.

The researchers pointed out that sickness and childcare-related benefits, which compensated for income loss, were greater for parents of children with cancer than for reference parents. However, social benefits diminished over time.

One year prior to cancer diagnosis, the ratio of sickness benefits was 3.495 for mothers and 5.213 for fathers. The year of diagnosis, the ratios were 4.785 and 5.795, respectively. At 3 years, the ratios were 1.404 and 1.339, respectively. And at 6 years, the ratios were 0.931 and 1.421, respectively.

One year prior to cancer diagnosis, the ratio of childcare-related benefits was 2.830 for mothers and 3.514 for fathers. The year of diagnosis, the ratios were 4.553 and 4.930, respectively. At 3 years, the ratios were 2.225 and 1.948, respectively. And at 6 years, the ratios were 1.272 and 1.095, respectively.

The decline of social benefits over time meant that cancer mothers’ total income became lower than that of reference mothers, and this difference persisted over the period studied. This was not the case for cancer fathers, however.

The ratio of income from all sources for cancer mothers compared to reference mothers was 1.064 the year of diagnosis, 0.985 at 2 years, 0.966 at 4 years, and 0.934 at 6 years.

The ratio of income from all sources for cancer fathers compared to reference fathers was 0.995 the year of diagnosis, 0.993 at 2 years, 0.998 at 4 years, and 1.029 at 6 years.

“A significant and unexpected finding was that, although income from employment stayed lower for several years for mothers, total income was higher for mothers of children with cancer around the time of the child’s cancer diagnosis when the compensation from social benefits were included,” Dr Hiyoshi said.

“The persistently lower income from employment for mothers of children with cancer compared with mothers of cancer-free children implies potential long-term consequences for the mothers of children with cancer, including their career and future pension in old age.”

Photo by Bill Branson

A study conducted in Sweden revealed that social benefits can ease financial burdens for parents of children recently diagnosed with cancer.

However, the study also showed that mothers experienced persistently lower income after benefits diminished.

Ayako Hiyoshi, PhD, of Örebro University in Örebro, Sweden, and her colleagues detailed these findings in Cancer.

The researchers gathered information from Swedish national registers and examined the trajectories of parents’ income from different sources.

Parents of children with cancer diagnosed between 2004 and 2009 were identified and matched with parents of children without cancer (reference parents).

In total, 20,091 families were followed from the year before cancer diagnosis to a maximum of 8 years.

The researchers noted that, around the time of a child’s cancer diagnosis, total income (from all sources) was, on average, higher in mothers of children with cancer than in reference mothers.

The ratio of mean total income for mothers of children with cancer, compared to reference mothers, was 1.032 at 1 year prior to the child’s diagnosis and 1.064 the year of diagnosis.

For fathers of children with cancer, total income was slightly lower than reference fathers’ income. The ratios were 0.987 at 1 year prior to diagnosis and 0.995 the year of diagnosis.

The researchers also noted that parents’ income from work was at its lowest around the time of a child’s cancer diagnosis but increased with time.

At cancer diagnosis, the ratio of mean income from work was 0.642 for mothers and 0.858 for fathers. One year later, the ratios were 0.786 and 0.956, respectively. At 3 years, the ratios were 0.876 and 0.986, respectively. At 6 years, the ratios were 0.856 and 1.058, respectively.

The researchers pointed out that sickness and childcare-related benefits, which compensated for income loss, were greater for parents of children with cancer than for reference parents. However, social benefits diminished over time.

One year prior to cancer diagnosis, the ratio of sickness benefits was 3.495 for mothers and 5.213 for fathers. The year of diagnosis, the ratios were 4.785 and 5.795, respectively. At 3 years, the ratios were 1.404 and 1.339, respectively. And at 6 years, the ratios were 0.931 and 1.421, respectively.

One year prior to cancer diagnosis, the ratio of childcare-related benefits was 2.830 for mothers and 3.514 for fathers. The year of diagnosis, the ratios were 4.553 and 4.930, respectively. At 3 years, the ratios were 2.225 and 1.948, respectively. And at 6 years, the ratios were 1.272 and 1.095, respectively.

The decline of social benefits over time meant that cancer mothers’ total income became lower than that of reference mothers, and this difference persisted over the period studied. This was not the case for cancer fathers, however.

The ratio of income from all sources for cancer mothers compared to reference mothers was 1.064 the year of diagnosis, 0.985 at 2 years, 0.966 at 4 years, and 0.934 at 6 years.

The ratio of income from all sources for cancer fathers compared to reference fathers was 0.995 the year of diagnosis, 0.993 at 2 years, 0.998 at 4 years, and 1.029 at 6 years.

“A significant and unexpected finding was that, although income from employment stayed lower for several years for mothers, total income was higher for mothers of children with cancer around the time of the child’s cancer diagnosis when the compensation from social benefits were included,” Dr Hiyoshi said.

“The persistently lower income from employment for mothers of children with cancer compared with mothers of cancer-free children implies potential long-term consequences for the mothers of children with cancer, including their career and future pension in old age.”

Despite universal agreement that antibiotic overprescribing is a problem, the practice continues to vex us. Antibiotic use—whether appropriate or not—has been linked to rising rates of antimicrobial resistance, disruption of the gut microbiome leading to Clostridium difficile infections (CDI), allergic reactions, and increased health care costs (see Table 1).^1-6 And yet, clinicians continue to overprescribe this class of medication.

A 2016 report from the CDC estimates that at least 30% of antibiotics prescribed in US outpatient settings are unnecessary.⁷ Another report cites a slightly higher figure across a variety of health care settings.⁸ Pair these findings with the fact that there are currently few new drugs in development to target resistant bacteria, and you have the potential for a postantibiotic era in which common infections could become lethal.⁷

In 2003, the CDC launched its “Get Smart: Know When Antibiotics Work” program (now known as “Be Antibiotics Aware”), focused on decreasing inappropriate antibiotic use in the outpatient setting.⁹ In 2015, the White House released the National Action Plan for Combating Antibiotic-Resistant Bacteria, with a goal of decreasing inappropriate outpatient antibiotic use by 50% and inappropriate inpatient use by 20% by 2020.¹⁰ And, on an international level, the World Health Organization (WHO) in 2015 developed a five-year strategic framework for implementing its Global Action Plan on Antimicrobial Resistance.¹¹

Family practitioners are on the front lines of this battle. Here’s what we can do now.

WHEN AND WHERE ARE ANTIBIOTICS MOST OFTEN INAPPROPRIATELY PRESCRIBED?

The diagnosis leading to the most frequent inappropriate prescribing of antibiotics is acute respiratory tract infection (ARTI), which includes bronchitis, otitis media, pharyngitis, sinusitis, tonsillitis, the common cold, and pneumonia. Up to 40% of antibiotic prescriptions for these conditions are unnecessary.^8,12 Bronchitis is the most common ARTI diagnosis associated with inappropriate antibiotic prescriptions, while sinusitis, suppurative otitis media, and pharyngitis are the diagnoses associated with the lion’s share of all (appropriate and inappropriate) antibiotic prescriptions within the ARTI category.^8,9,12,13 Refer to national clinical guidelines, which delineate when antibiotic treatment is appropriate for these conditions.^14-16

With respect to setting, there are conflicting findings as to whether antibiotic prescribing differs in office-based versus emergency department (ED) settings.

• One study found a higher rate of antibiotic prescribing during ED visits than office visits (21% vs 9%), even though, between 2007 and 2009, more antibiotic prescriptions were written for adults in primary care offices than in either outpatient hospital clinics or EDs.¹⁷
• In a cross-sectional study using data from 2005 to 2010 National Ambulatory Medical Care Surveys (NAMCS) and National Hospital Ambulatory Medical Care Surveys (NHAMCS), more than half of patients with uncomplicated acute rhinosinu­sitis received a prescription for antibiotics, but there was no overall difference in antibiotic prescriptions between primary care and ED presentation.¹⁸
• A retrospective analysis found that between 2006 and 2010, outpatient hospital practices (56%) and community-practice offices (60%) prescribed more antibiotics for ARTIs than EDs did (51%).¹²

STICK TO NARROW-SPECTRUM AGENTS WHEN POSSIBLE

Using broad-spectrum antibiotics, such as quinolones or imipenem, firstline, contributes more to the problem of antibiotic resistance than does prescribing narrow-spectrum antibiotics such as amoxicillin, cephalexin, or trimethoprim-sulfamethoxazole.⁷ Yet between 2007 and 2009, broad-spectrum agents were prescribed for 61% of outpatient adult visits in which patients received an antibiotic prescription.¹⁷ Quinolones (25%), macrolides (20%), and aminopenicillins (12%) were most commonly prescribed, and antibiotic prescriptions were most often written for respiratory conditions, such as bronchitis, for which we now know antibiotics are rarely indicated.¹⁷

Between 2006 and 2008, pediatric patients who received antibiotic prescriptions were given broad-spectrum agents 50% of the time, of which macrolides were the class most commonly prescribed.¹³

More recently, researchers examined the frequency with which clinicians prescribe narrow-spectrum, firstline antibiotics for otitis media, sinusitis, and pharyngitis using 2010 to 2011 NAMCS/NHAMCS data. They found that providers used firstline agents recommended by professional guidelines 52% of the time, although it was estimated that they would have been appropriate in 80% of cases; pediatric patients were more likely to receive appropriate firstline antibiotics than adult patients.¹⁹ Macrolides, especially azithromycin, were the most common non-firstline antibiotics prescribed.^19,20 The bottom line is that when antibiotics are indicated for upper respiratory infections (otitis media, sinusitis, and pharyngitis), clinicians should prescribe a narrow-spectrum antibiotic first.

ANTIBIOTIC OVERPRESCIBING AFFECTS THE GUT AND BEYOND

The human intestinal microbiome is composed of a diverse array of bacteria, viruses, and parasites.²¹ The main functions of the gut microbiome include interacting with the immune system and participating in biochemical reactions in the gut, such as absorption of fat-soluble vitamins and the production of vitamin K.

As we know, antibiotics decrease the diversity of gut bacteria, which, in turn, can cause less efficient nutrient extraction, as well as vulnerability to enteric infections.²¹ It is well known, for example, that the bacterial gut microbiome can either inhibit or promote diarrheal illnesses such as those caused by CDI. CDI is now the most common health care-related infection, accounting for about a half-million health care facility infections per year.²² It extends hospital stays an average of almost 10 days and is estimated to cost the health care system $6.3 billion annually.²³

Antibiotics can also eliminate antibiotic-susceptible organisms, allowing resistant organisms to proliferate.⁴ They also promote the transmission of genes for antibiotic resistance between gut bacteria.⁴

Beyond the gut

Less well known is that gut bacteria can promote or inhibit extraintestinal infections.

Gut bacteria and HIV. In early HIV infections, for example, gut populations of Lactobacillus and Bifidobacteria are reduced, and the gut barrier becomes compromised.²⁴ Increasing translocation of bacterial products is associated with HIV disease progression. Preservation of Lactobacillus populations in the gut is associated with markers predictive of better HIV outcomes, including a higher CD4 count, a lower viral load, and less evidence of gut microbial translocation.²⁴ This underscores the importance of maintaining healthy gut flora in patients with HIV, using such steps as avoiding unnecessary antibiotics.

Gut bacteria and stress, depression. Antibiotics directly induce the expression of key genes that affect the stress response.²⁵ While causative studies are lacking, there is a growing body of evidence suggesting that the gut microbiome is involved in two-way communication with the brain and can affect, and be affected by, stress and depression.^21,26-30 Diseases and conditions that seem to have a putative connection to a disordered microbiome (dysbiosis) include depression, anxiety, Crohn disease, type 2 diabetes, and obesity. (For a discussion of the relationship between the gut microbiome and diabetes, see Endocrine Consult: The Gut Microbiome in Type 2 Diabetes.)

Gut bacteria and childhood obesity. Repeated use of broader-spectrum antibiotics in children younger than 24 months of age increases the risk for childhood obesity.^1,6 One theory for the association is that the effects of broad-spectrum antibiotics on the intestinal flora of young children may alter long-term energy homeostasis, resulting in a higher risk for obesity.¹

Gut bacteria and asthma. Studies demonstrate differences in the gut microbiomes of asthmatic and nonasthmatic patients. These differences affect the activities of helper T-cell subsets (Th1 and Th2), which in turn affect the development of immune tolerance.³¹

Although additional studies are needed to confirm these findings, the evidence collected thus far should make us all pause before prescribing drugs that can alter our microbiome in complex and only partially understood ways.

WHAT CAN WE DO RIGHT NOW?

The issues created by the inappropriate prescribing of antibiotics have been known for decades, and multiple attempts have been made to find solutions and implement change. Although some small successes have occurred, little overall progress has been made in reducing antibiotic prescribing in the general population. A historical review of why clinicians prescribe antibiotics inappropriately and the interventions that have successfully reduced this prescribing may prove valuable as we continue to look for new, effective answers.

Why do we overprescribe antibiotics? A 2015 systematic literature review found that patient demand, pharmaceutical company marketing activities, limited up-to-date information sources, and fear of losing patients are major reasons providers cite for prescribing antibiotics.³²

In a separate study that explored antibiotic prescribing habits for acute bronchitis, clinicians cited “patient demand” as the major reason for prescribing antibiotics. Respondents also reported that “other physicians were responsible for inappropriate antibiotic prescribing.”³³

Strategies that work

Some early intervention programs directed at reducing antibiotic prescribing demonstrated success (see Table 2).^34-36

One example comes from a 1996-1998 study of four primary care practices.³⁴ Researchers evaluated the impact of a multidimensional intervention effort targeted at clinicians and patients and aimed at lowering the use of antimicrobial agents for acute uncomplicated bronchitis in adults. It incorporated multiple elements, including office-based and household patient educational materials and a clinician intervention involving education, practice profiling, and academic detailing. Clinicians in this program reduced their rates of antibiotic prescribing for uncomplicated bronchitis from 74% to 48%.³⁴

Employing EMRs. A more recent study focused on use of electronic medical rec­ords (EMRs) and communications to modify clinician antibiotic prescribing.³⁵ By sending clinicians monthly emails comparing their prescribing patterns to those of peers and “typical top performers,” inappropriate antibiotic prescriptions for ARTIs went from 19.9% to 3.7%.³⁵

In another effort, the same researchers modified providers’ EMRs to detect when potentially inappropriate antibiotics were prescribed. The system then prompted the clinician to provide an “antibiotic justification note,” which remained visible in the patient’s chart. This approach, which encouraged providers to follow prescribing guidelines by capitalizing on their concerns about their reputations, produced a 77% reduction in antibiotic prescribing.³⁵

Focusing on the public. Studies have also examined the effectiveness of educating the public about when antibiotics are not likely to be helpful and of the harms of unnecessary antibiotics.

Studies conducted in Tennessee and Wisconsin that combined prescriber and community education about unnecessary antibiotics for children found that the intervention reduced antibiotic prescribing in both locations by about 19%, compared with about a 9% reduction in the control groups.^36,37

DOES PRESCRIBING ANTIBIOTICS AFFECT PATIENT SATISFACTION?

The results are mixed as to whether prescribing antibiotics affects patient satisfaction. Two studies in the early 2000s found that both patients and parents reported higher satisfaction with clinicians who explained why antibiotics were not indicated versus those who simply prescribed them—and that such explanations do not need to take a lot of time (see Table 3 for patient care tips).^37,38

A more recent study found that higher antibiotic prescribing practices in Britain were associated with modestly higher patient satisfaction ratings.³⁹ The authors of this study noted, however, that reduced antibiotic prescribing may be a proxy for other practice patterns that affected satisfaction ratings.

REDUCING ANTIBIOTIC PRESCRIBING REDUCES RESISTANCE

There is also strong evidence that when clinicians decrease antibiotic prescribing, antimicrobial resistance follows suit. One of the earlier landmark studies to demonstrate this was a Finnish study published in 1997.⁴⁰ The authors found that a reduction of macrolide antibiotic consumption in Finland led to a reduction in streptococci macrolide resistance from 16.5% to 8.6%.⁴⁰

Multiple studies have since demonstrated similar results for both respiratory and urinary tract infections.^41,42 A 2017 meta-analysis of 32 studies found that antibiotic stewardship programs reduced the incidence of infections and colonization with multidrug-resistant Gram-negative bacteria (by 51%), extended-spectrum beta-lactamase–producing Gram-negative bacteria (48%), and methicillin-resistant Staphylococcus aureus (37%). There was also a reduction in the incidence of CDI (32%).⁴³

Despite universal agreement that antibiotic overprescribing is a problem, the practice continues to vex us. Antibiotic use—whether appropriate or not—has been linked to rising rates of antimicrobial resistance, disruption of the gut microbiome leading to Clostridium difficile infections (CDI), allergic reactions, and increased health care costs (see Table 1).^1-6 And yet, clinicians continue to overprescribe this class of medication.

A 2016 report from the CDC estimates that at least 30% of antibiotics prescribed in US outpatient settings are unnecessary.⁷ Another report cites a slightly higher figure across a variety of health care settings.⁸ Pair these findings with the fact that there are currently few new drugs in development to target resistant bacteria, and you have the potential for a postantibiotic era in which common infections could become lethal.⁷

In 2003, the CDC launched its “Get Smart: Know When Antibiotics Work” program (now known as “Be Antibiotics Aware”), focused on decreasing inappropriate antibiotic use in the outpatient setting.⁹ In 2015, the White House released the National Action Plan for Combating Antibiotic-Resistant Bacteria, with a goal of decreasing inappropriate outpatient antibiotic use by 50% and inappropriate inpatient use by 20% by 2020.¹⁰ And, on an international level, the World Health Organization (WHO) in 2015 developed a five-year strategic framework for implementing its Global Action Plan on Antimicrobial Resistance.¹¹

Family practitioners are on the front lines of this battle. Here’s what we can do now.

WHEN AND WHERE ARE ANTIBIOTICS MOST OFTEN INAPPROPRIATELY PRESCRIBED?

The diagnosis leading to the most frequent inappropriate prescribing of antibiotics is acute respiratory tract infection (ARTI), which includes bronchitis, otitis media, pharyngitis, sinusitis, tonsillitis, the common cold, and pneumonia. Up to 40% of antibiotic prescriptions for these conditions are unnecessary.^8,12 Bronchitis is the most common ARTI diagnosis associated with inappropriate antibiotic prescriptions, while sinusitis, suppurative otitis media, and pharyngitis are the diagnoses associated with the lion’s share of all (appropriate and inappropriate) antibiotic prescriptions within the ARTI category.^8,9,12,13 Refer to national clinical guidelines, which delineate when antibiotic treatment is appropriate for these conditions.^14-16

With respect to setting, there are conflicting findings as to whether antibiotic prescribing differs in office-based versus emergency department (ED) settings.

• One study found a higher rate of antibiotic prescribing during ED visits than office visits (21% vs 9%), even though, between 2007 and 2009, more antibiotic prescriptions were written for adults in primary care offices than in either outpatient hospital clinics or EDs.¹⁷
• In a cross-sectional study using data from 2005 to 2010 National Ambulatory Medical Care Surveys (NAMCS) and National Hospital Ambulatory Medical Care Surveys (NHAMCS), more than half of patients with uncomplicated acute rhinosinu­sitis received a prescription for antibiotics, but there was no overall difference in antibiotic prescriptions between primary care and ED presentation.¹⁸
• A retrospective analysis found that between 2006 and 2010, outpatient hospital practices (56%) and community-practice offices (60%) prescribed more antibiotics for ARTIs than EDs did (51%).¹²

STICK TO NARROW-SPECTRUM AGENTS WHEN POSSIBLE

Using broad-spectrum antibiotics, such as quinolones or imipenem, firstline, contributes more to the problem of antibiotic resistance than does prescribing narrow-spectrum antibiotics such as amoxicillin, cephalexin, or trimethoprim-sulfamethoxazole.⁷ Yet between 2007 and 2009, broad-spectrum agents were prescribed for 61% of outpatient adult visits in which patients received an antibiotic prescription.¹⁷ Quinolones (25%), macrolides (20%), and aminopenicillins (12%) were most commonly prescribed, and antibiotic prescriptions were most often written for respiratory conditions, such as bronchitis, for which we now know antibiotics are rarely indicated.¹⁷

Between 2006 and 2008, pediatric patients who received antibiotic prescriptions were given broad-spectrum agents 50% of the time, of which macrolides were the class most commonly prescribed.¹³

More recently, researchers examined the frequency with which clinicians prescribe narrow-spectrum, firstline antibiotics for otitis media, sinusitis, and pharyngitis using 2010 to 2011 NAMCS/NHAMCS data. They found that providers used firstline agents recommended by professional guidelines 52% of the time, although it was estimated that they would have been appropriate in 80% of cases; pediatric patients were more likely to receive appropriate firstline antibiotics than adult patients.¹⁹ Macrolides, especially azithromycin, were the most common non-firstline antibiotics prescribed.^19,20 The bottom line is that when antibiotics are indicated for upper respiratory infections (otitis media, sinusitis, and pharyngitis), clinicians should prescribe a narrow-spectrum antibiotic first.

ANTIBIOTIC OVERPRESCIBING AFFECTS THE GUT AND BEYOND

The human intestinal microbiome is composed of a diverse array of bacteria, viruses, and parasites.²¹ The main functions of the gut microbiome include interacting with the immune system and participating in biochemical reactions in the gut, such as absorption of fat-soluble vitamins and the production of vitamin K.

As we know, antibiotics decrease the diversity of gut bacteria, which, in turn, can cause less efficient nutrient extraction, as well as vulnerability to enteric infections.²¹ It is well known, for example, that the bacterial gut microbiome can either inhibit or promote diarrheal illnesses such as those caused by CDI. CDI is now the most common health care-related infection, accounting for about a half-million health care facility infections per year.²² It extends hospital stays an average of almost 10 days and is estimated to cost the health care system $6.3 billion annually.²³

Antibiotics can also eliminate antibiotic-susceptible organisms, allowing resistant organisms to proliferate.⁴ They also promote the transmission of genes for antibiotic resistance between gut bacteria.⁴

Beyond the gut

Less well known is that gut bacteria can promote or inhibit extraintestinal infections.

Gut bacteria and HIV. In early HIV infections, for example, gut populations of Lactobacillus and Bifidobacteria are reduced, and the gut barrier becomes compromised.²⁴ Increasing translocation of bacterial products is associated with HIV disease progression. Preservation of Lactobacillus populations in the gut is associated with markers predictive of better HIV outcomes, including a higher CD4 count, a lower viral load, and less evidence of gut microbial translocation.²⁴ This underscores the importance of maintaining healthy gut flora in patients with HIV, using such steps as avoiding unnecessary antibiotics.

Gut bacteria and stress, depression. Antibiotics directly induce the expression of key genes that affect the stress response.²⁵ While causative studies are lacking, there is a growing body of evidence suggesting that the gut microbiome is involved in two-way communication with the brain and can affect, and be affected by, stress and depression.^21,26-30 Diseases and conditions that seem to have a putative connection to a disordered microbiome (dysbiosis) include depression, anxiety, Crohn disease, type 2 diabetes, and obesity. (For a discussion of the relationship between the gut microbiome and diabetes, see Endocrine Consult: The Gut Microbiome in Type 2 Diabetes.)

Gut bacteria and childhood obesity. Repeated use of broader-spectrum antibiotics in children younger than 24 months of age increases the risk for childhood obesity.^1,6 One theory for the association is that the effects of broad-spectrum antibiotics on the intestinal flora of young children may alter long-term energy homeostasis, resulting in a higher risk for obesity.¹

Gut bacteria and asthma. Studies demonstrate differences in the gut microbiomes of asthmatic and nonasthmatic patients. These differences affect the activities of helper T-cell subsets (Th1 and Th2), which in turn affect the development of immune tolerance.³¹

Although additional studies are needed to confirm these findings, the evidence collected thus far should make us all pause before prescribing drugs that can alter our microbiome in complex and only partially understood ways.

WHAT CAN WE DO RIGHT NOW?

The issues created by the inappropriate prescribing of antibiotics have been known for decades, and multiple attempts have been made to find solutions and implement change. Although some small successes have occurred, little overall progress has been made in reducing antibiotic prescribing in the general population. A historical review of why clinicians prescribe antibiotics inappropriately and the interventions that have successfully reduced this prescribing may prove valuable as we continue to look for new, effective answers.

Why do we overprescribe antibiotics? A 2015 systematic literature review found that patient demand, pharmaceutical company marketing activities, limited up-to-date information sources, and fear of losing patients are major reasons providers cite for prescribing antibiotics.³²

In a separate study that explored antibiotic prescribing habits for acute bronchitis, clinicians cited “patient demand” as the major reason for prescribing antibiotics. Respondents also reported that “other physicians were responsible for inappropriate antibiotic prescribing.”³³

Strategies that work

Some early intervention programs directed at reducing antibiotic prescribing demonstrated success (see Table 2).^34-36

One example comes from a 1996-1998 study of four primary care practices.³⁴ Researchers evaluated the impact of a multidimensional intervention effort targeted at clinicians and patients and aimed at lowering the use of antimicrobial agents for acute uncomplicated bronchitis in adults. It incorporated multiple elements, including office-based and household patient educational materials and a clinician intervention involving education, practice profiling, and academic detailing. Clinicians in this program reduced their rates of antibiotic prescribing for uncomplicated bronchitis from 74% to 48%.³⁴

Employing EMRs. A more recent study focused on use of electronic medical rec­ords (EMRs) and communications to modify clinician antibiotic prescribing.³⁵ By sending clinicians monthly emails comparing their prescribing patterns to those of peers and “typical top performers,” inappropriate antibiotic prescriptions for ARTIs went from 19.9% to 3.7%.³⁵

In another effort, the same researchers modified providers’ EMRs to detect when potentially inappropriate antibiotics were prescribed. The system then prompted the clinician to provide an “antibiotic justification note,” which remained visible in the patient’s chart. This approach, which encouraged providers to follow prescribing guidelines by capitalizing on their concerns about their reputations, produced a 77% reduction in antibiotic prescribing.³⁵

Focusing on the public. Studies have also examined the effectiveness of educating the public about when antibiotics are not likely to be helpful and of the harms of unnecessary antibiotics.

Studies conducted in Tennessee and Wisconsin that combined prescriber and community education about unnecessary antibiotics for children found that the intervention reduced antibiotic prescribing in both locations by about 19%, compared with about a 9% reduction in the control groups.^36,37

DOES PRESCRIBING ANTIBIOTICS AFFECT PATIENT SATISFACTION?

The results are mixed as to whether prescribing antibiotics affects patient satisfaction. Two studies in the early 2000s found that both patients and parents reported higher satisfaction with clinicians who explained why antibiotics were not indicated versus those who simply prescribed them—and that such explanations do not need to take a lot of time (see Table 3 for patient care tips).^37,38

A more recent study found that higher antibiotic prescribing practices in Britain were associated with modestly higher patient satisfaction ratings.³⁹ The authors of this study noted, however, that reduced antibiotic prescribing may be a proxy for other practice patterns that affected satisfaction ratings.

REDUCING ANTIBIOTIC PRESCRIBING REDUCES RESISTANCE

There is also strong evidence that when clinicians decrease antibiotic prescribing, antimicrobial resistance follows suit. One of the earlier landmark studies to demonstrate this was a Finnish study published in 1997.⁴⁰ The authors found that a reduction of macrolide antibiotic consumption in Finland led to a reduction in streptococci macrolide resistance from 16.5% to 8.6%.⁴⁰

Multiple studies have since demonstrated similar results for both respiratory and urinary tract infections.^41,42 A 2017 meta-analysis of 32 studies found that antibiotic stewardship programs reduced the incidence of infections and colonization with multidrug-resistant Gram-negative bacteria (by 51%), extended-spectrum beta-lactamase–producing Gram-negative bacteria (48%), and methicillin-resistant Staphylococcus aureus (37%). There was also a reduction in the incidence of CDI (32%).⁴³

Despite universal agreement that antibiotic overprescribing is a problem, the practice continues to vex us. Antibiotic use—whether appropriate or not—has been linked to rising rates of antimicrobial resistance, disruption of the gut microbiome leading to Clostridium difficile infections (CDI), allergic reactions, and increased health care costs (see Table 1).^1-6 And yet, clinicians continue to overprescribe this class of medication.

A 2016 report from the CDC estimates that at least 30% of antibiotics prescribed in US outpatient settings are unnecessary.⁷ Another report cites a slightly higher figure across a variety of health care settings.⁸ Pair these findings with the fact that there are currently few new drugs in development to target resistant bacteria, and you have the potential for a postantibiotic era in which common infections could become lethal.⁷

In 2003, the CDC launched its “Get Smart: Know When Antibiotics Work” program (now known as “Be Antibiotics Aware”), focused on decreasing inappropriate antibiotic use in the outpatient setting.⁹ In 2015, the White House released the National Action Plan for Combating Antibiotic-Resistant Bacteria, with a goal of decreasing inappropriate outpatient antibiotic use by 50% and inappropriate inpatient use by 20% by 2020.¹⁰ And, on an international level, the World Health Organization (WHO) in 2015 developed a five-year strategic framework for implementing its Global Action Plan on Antimicrobial Resistance.¹¹

Family practitioners are on the front lines of this battle. Here’s what we can do now.

WHEN AND WHERE ARE ANTIBIOTICS MOST OFTEN INAPPROPRIATELY PRESCRIBED?

The diagnosis leading to the most frequent inappropriate prescribing of antibiotics is acute respiratory tract infection (ARTI), which includes bronchitis, otitis media, pharyngitis, sinusitis, tonsillitis, the common cold, and pneumonia. Up to 40% of antibiotic prescriptions for these conditions are unnecessary.^8,12 Bronchitis is the most common ARTI diagnosis associated with inappropriate antibiotic prescriptions, while sinusitis, suppurative otitis media, and pharyngitis are the diagnoses associated with the lion’s share of all (appropriate and inappropriate) antibiotic prescriptions within the ARTI category.^8,9,12,13 Refer to national clinical guidelines, which delineate when antibiotic treatment is appropriate for these conditions.^14-16

With respect to setting, there are conflicting findings as to whether antibiotic prescribing differs in office-based versus emergency department (ED) settings.

• One study found a higher rate of antibiotic prescribing during ED visits than office visits (21% vs 9%), even though, between 2007 and 2009, more antibiotic prescriptions were written for adults in primary care offices than in either outpatient hospital clinics or EDs.¹⁷
• In a cross-sectional study using data from 2005 to 2010 National Ambulatory Medical Care Surveys (NAMCS) and National Hospital Ambulatory Medical Care Surveys (NHAMCS), more than half of patients with uncomplicated acute rhinosinu­sitis received a prescription for antibiotics, but there was no overall difference in antibiotic prescriptions between primary care and ED presentation.¹⁸
• A retrospective analysis found that between 2006 and 2010, outpatient hospital practices (56%) and community-practice offices (60%) prescribed more antibiotics for ARTIs than EDs did (51%).¹²

STICK TO NARROW-SPECTRUM AGENTS WHEN POSSIBLE

Using broad-spectrum antibiotics, such as quinolones or imipenem, firstline, contributes more to the problem of antibiotic resistance than does prescribing narrow-spectrum antibiotics such as amoxicillin, cephalexin, or trimethoprim-sulfamethoxazole.⁷ Yet between 2007 and 2009, broad-spectrum agents were prescribed for 61% of outpatient adult visits in which patients received an antibiotic prescription.¹⁷ Quinolones (25%), macrolides (20%), and aminopenicillins (12%) were most commonly prescribed, and antibiotic prescriptions were most often written for respiratory conditions, such as bronchitis, for which we now know antibiotics are rarely indicated.¹⁷

Between 2006 and 2008, pediatric patients who received antibiotic prescriptions were given broad-spectrum agents 50% of the time, of which macrolides were the class most commonly prescribed.¹³

More recently, researchers examined the frequency with which clinicians prescribe narrow-spectrum, firstline antibiotics for otitis media, sinusitis, and pharyngitis using 2010 to 2011 NAMCS/NHAMCS data. They found that providers used firstline agents recommended by professional guidelines 52% of the time, although it was estimated that they would have been appropriate in 80% of cases; pediatric patients were more likely to receive appropriate firstline antibiotics than adult patients.¹⁹ Macrolides, especially azithromycin, were the most common non-firstline antibiotics prescribed.^19,20 The bottom line is that when antibiotics are indicated for upper respiratory infections (otitis media, sinusitis, and pharyngitis), clinicians should prescribe a narrow-spectrum antibiotic first.

ANTIBIOTIC OVERPRESCIBING AFFECTS THE GUT AND BEYOND

The human intestinal microbiome is composed of a diverse array of bacteria, viruses, and parasites.²¹ The main functions of the gut microbiome include interacting with the immune system and participating in biochemical reactions in the gut, such as absorption of fat-soluble vitamins and the production of vitamin K.

As we know, antibiotics decrease the diversity of gut bacteria, which, in turn, can cause less efficient nutrient extraction, as well as vulnerability to enteric infections.²¹ It is well known, for example, that the bacterial gut microbiome can either inhibit or promote diarrheal illnesses such as those caused by CDI. CDI is now the most common health care-related infection, accounting for about a half-million health care facility infections per year.²² It extends hospital stays an average of almost 10 days and is estimated to cost the health care system $6.3 billion annually.²³

Antibiotics can also eliminate antibiotic-susceptible organisms, allowing resistant organisms to proliferate.⁴ They also promote the transmission of genes for antibiotic resistance between gut bacteria.⁴

Beyond the gut

Less well known is that gut bacteria can promote or inhibit extraintestinal infections.

Gut bacteria and HIV. In early HIV infections, for example, gut populations of Lactobacillus and Bifidobacteria are reduced, and the gut barrier becomes compromised.²⁴ Increasing translocation of bacterial products is associated with HIV disease progression. Preservation of Lactobacillus populations in the gut is associated with markers predictive of better HIV outcomes, including a higher CD4 count, a lower viral load, and less evidence of gut microbial translocation.²⁴ This underscores the importance of maintaining healthy gut flora in patients with HIV, using such steps as avoiding unnecessary antibiotics.

Gut bacteria and stress, depression. Antibiotics directly induce the expression of key genes that affect the stress response.²⁵ While causative studies are lacking, there is a growing body of evidence suggesting that the gut microbiome is involved in two-way communication with the brain and can affect, and be affected by, stress and depression.^21,26-30 Diseases and conditions that seem to have a putative connection to a disordered microbiome (dysbiosis) include depression, anxiety, Crohn disease, type 2 diabetes, and obesity. (For a discussion of the relationship between the gut microbiome and diabetes, see Endocrine Consult: The Gut Microbiome in Type 2 Diabetes.)

Gut bacteria and childhood obesity. Repeated use of broader-spectrum antibiotics in children younger than 24 months of age increases the risk for childhood obesity.^1,6 One theory for the association is that the effects of broad-spectrum antibiotics on the intestinal flora of young children may alter long-term energy homeostasis, resulting in a higher risk for obesity.¹

Gut bacteria and asthma. Studies demonstrate differences in the gut microbiomes of asthmatic and nonasthmatic patients. These differences affect the activities of helper T-cell subsets (Th1 and Th2), which in turn affect the development of immune tolerance.³¹

Although additional studies are needed to confirm these findings, the evidence collected thus far should make us all pause before prescribing drugs that can alter our microbiome in complex and only partially understood ways.

WHAT CAN WE DO RIGHT NOW?

The issues created by the inappropriate prescribing of antibiotics have been known for decades, and multiple attempts have been made to find solutions and implement change. Although some small successes have occurred, little overall progress has been made in reducing antibiotic prescribing in the general population. A historical review of why clinicians prescribe antibiotics inappropriately and the interventions that have successfully reduced this prescribing may prove valuable as we continue to look for new, effective answers.

Why do we overprescribe antibiotics? A 2015 systematic literature review found that patient demand, pharmaceutical company marketing activities, limited up-to-date information sources, and fear of losing patients are major reasons providers cite for prescribing antibiotics.³²

In a separate study that explored antibiotic prescribing habits for acute bronchitis, clinicians cited “patient demand” as the major reason for prescribing antibiotics. Respondents also reported that “other physicians were responsible for inappropriate antibiotic prescribing.”³³

Strategies that work

Some early intervention programs directed at reducing antibiotic prescribing demonstrated success (see Table 2).^34-36

One example comes from a 1996-1998 study of four primary care practices.³⁴ Researchers evaluated the impact of a multidimensional intervention effort targeted at clinicians and patients and aimed at lowering the use of antimicrobial agents for acute uncomplicated bronchitis in adults. It incorporated multiple elements, including office-based and household patient educational materials and a clinician intervention involving education, practice profiling, and academic detailing. Clinicians in this program reduced their rates of antibiotic prescribing for uncomplicated bronchitis from 74% to 48%.³⁴

Employing EMRs. A more recent study focused on use of electronic medical rec­ords (EMRs) and communications to modify clinician antibiotic prescribing.³⁵ By sending clinicians monthly emails comparing their prescribing patterns to those of peers and “typical top performers,” inappropriate antibiotic prescriptions for ARTIs went from 19.9% to 3.7%.³⁵

In another effort, the same researchers modified providers’ EMRs to detect when potentially inappropriate antibiotics were prescribed. The system then prompted the clinician to provide an “antibiotic justification note,” which remained visible in the patient’s chart. This approach, which encouraged providers to follow prescribing guidelines by capitalizing on their concerns about their reputations, produced a 77% reduction in antibiotic prescribing.³⁵

Focusing on the public. Studies have also examined the effectiveness of educating the public about when antibiotics are not likely to be helpful and of the harms of unnecessary antibiotics.

Studies conducted in Tennessee and Wisconsin that combined prescriber and community education about unnecessary antibiotics for children found that the intervention reduced antibiotic prescribing in both locations by about 19%, compared with about a 9% reduction in the control groups.^36,37

DOES PRESCRIBING ANTIBIOTICS AFFECT PATIENT SATISFACTION?

The results are mixed as to whether prescribing antibiotics affects patient satisfaction. Two studies in the early 2000s found that both patients and parents reported higher satisfaction with clinicians who explained why antibiotics were not indicated versus those who simply prescribed them—and that such explanations do not need to take a lot of time (see Table 3 for patient care tips).^37,38

A more recent study found that higher antibiotic prescribing practices in Britain were associated with modestly higher patient satisfaction ratings.³⁹ The authors of this study noted, however, that reduced antibiotic prescribing may be a proxy for other practice patterns that affected satisfaction ratings.

REDUCING ANTIBIOTIC PRESCRIBING REDUCES RESISTANCE

There is also strong evidence that when clinicians decrease antibiotic prescribing, antimicrobial resistance follows suit. One of the earlier landmark studies to demonstrate this was a Finnish study published in 1997.⁴⁰ The authors found that a reduction of macrolide antibiotic consumption in Finland led to a reduction in streptococci macrolide resistance from 16.5% to 8.6%.⁴⁰

Multiple studies have since demonstrated similar results for both respiratory and urinary tract infections.^41,42 A 2017 meta-analysis of 32 studies found that antibiotic stewardship programs reduced the incidence of infections and colonization with multidrug-resistant Gram-negative bacteria (by 51%), extended-spectrum beta-lactamase–producing Gram-negative bacteria (48%), and methicillin-resistant Staphylococcus aureus (37%). There was also a reduction in the incidence of CDI (32%).⁴³

Clinical questions: What are the trends in patient outcome for Staphylococcus aureus bacteremia (SAB)? Does the use of evidence-based care processes decrease mortality in SAB?

Background: SAB is associated with poor clinical outcomes. Prior research has demonstrated that several evidence-based interventions, namely appropriate antibiotics, echocardiography, and infectious disease consults, have been associated with improved outcomes. The use of these interventions in clinical practice and their large-scale impact on SAB mortality is not known.

Clinical questions: What are the trends in patient outcome for Staphylococcus aureus bacteremia (SAB)? Does the use of evidence-based care processes decrease mortality in SAB?

Background: SAB is associated with poor clinical outcomes. Prior research has demonstrated that several evidence-based interventions, namely appropriate antibiotics, echocardiography, and infectious disease consults, have been associated with improved outcomes. The use of these interventions in clinical practice and their large-scale impact on SAB mortality is not known.

Clinical questions: What are the trends in patient outcome for Staphylococcus aureus bacteremia (SAB)? Does the use of evidence-based care processes decrease mortality in SAB?

Background: SAB is associated with poor clinical outcomes. Prior research has demonstrated that several evidence-based interventions, namely appropriate antibiotics, echocardiography, and infectious disease consults, have been associated with improved outcomes. The use of these interventions in clinical practice and their large-scale impact on SAB mortality is not known.