A Multicultural Approach to Decreasing Unnecessary Antibiotic Prescribing for Pharyngitis

Antimicrobial resistance is a global crisis. In the United States alone, two million people are infected every year with untreatable microbes, resulting in 23,000 deaths (CDC, 2014). Over- prescribing of antibiotics has been cited as major contributor to the crisis. (WHO, 2015). According to the CDC Morbidity and Mortality Weekly Report (2011), 50% of antibiotic prescriptions in the United States are unnecessary. Non-prescription antibiotics account for 19-100% of antibiotic use outside northern Europe and North America, with increased antimicrobial resistance in countries with greater use (Morgan, Okeke, Laxminarayan, Perencevich & Weisenberg, 2011).

 International guidelines for pharyngitis approach diagnostic scoring and the use of rapid antigen testing differently, but they largely concur on the need to decrease unnecessary antibiotic prescribing (Shullman, 2014; Ebell, 2014; Cohen, et al, 2015; and Hoare & Ward & Arroll, 2016). Differences in the perceived benefit of rapid antigen tests to aid in the detection and treatment of streptococcal pharyngitis have also been addressed (Lean, Arnup, Danchin & Steer, 2014; Steward, et al, 2014; and Cohen, et al, 2016). A 2103 Cochrane review (Spinks) examined the actual rate of rheumatic fever in various populations, identified complications due to untreated Streptococcal pharyngitis, and the described the natural course of the disease.

Using the 2012 Infectious Disease Society of America Guidelines, Ellis & Camacho (2015) devised a management algorithm for prescribing antibiotics based on clinical presentation, rapid antigen test results, and likelihood of complications according to age and comorbidities. The algorithm provides clinicians with a succinct evidence-based pathway for clinical management of pharyngitis and opens dialogue with multicultural patients concerning their ideas, concerns and expectations.

Despite the vast amount of clinical evidence, many clinicians continue to overprescribe antibiotics. Barriers to clinician antibiotic stewardship are lack of knowledge of clinical practice guidelines and their application, and lack of understanding of patient expectations in different cultural settings. Perceived pressure to prescribe antibiotics, and failure to ascertain the actual expectations of patients can lead to unnecessary antibiotic prescribing (Mathys, 2009, and Mustafa, Wood & Elwyn, 2014). Cultural differences may account for increased use and expectations of antibiotic prescribing, but it is significantly less than that perceived by clinicians (Watkins, Lousisek, Sanchez, Albert, Roberts & Kicks, 2015).

Combating the spread of global antimicrobial resistance requires cooperation of clinicians around the world. The purpose of this presentation is to reduce unnecessary antibiotic prescribing across different cultures. This presentation demonstrates application of key clinical guideline recommendations, and addresses patient cultural considerations andexpectations. A seven-minute trilingual video (English, Spanish and Arabic with English subtitles) uses a multicultural setting to depict sample clinical scenarios. The video demonstrates brief and friendly discussions with patients on the risk of infection and potential complications, versus the risk of developing resistance to antibiotics. Alternative treatment modalities for pharyngitis are also presented.