Antimicrobial stewardship by family physicians

We commend Smith et al¹ on their efforts to measure knowledge about antimicrobial use and antimicrobial resistance (AMR) in Canada with a national survey. It is certainly a research gap worthy of attention. However, we have some concerns regarding the interpretation of the survey results.

The authors conclude that, based on survey results, “Canadian physicians are demonstrating behaviour patterns of AMR stewardship (eg, patient counseling, refusal to give inappropriate antibiotics).”¹ Although we agree that, in recent years, there has been increasing awareness about AMR and antimicrobial stewardship, we question whether these responses truly reflect the behaviour of Canadian physicians. There is evidence that clinician perception does not necessarily align with actual practice when it comes to antibiotic prescribing, suggesting that self-reported responses from a survey do not accurately reflect appropriateness of prescribing.² A study from Ontario with a cohort of more than 180 000 older patients with acute upper respiratory tract infections found that almost half were prescribed unnecessary antibiotics.³ This is consistent with data from the United States showing similar rates of inappropriate antibiotic use in the community.⁴ We believe the results of this national survey by Smith et al highlight the discordance between observed overprescribing of antibiotics in the community and physicians’ perceptions of appropriate use.

The authors also indicate that most physicians correctly identified that not taking a full course of antibiotics increases the risk of AMR. While we concur that adherence to medication regimens is important, a large proportion of antibiotic prescriptions are prescribed for longer than necessary. A multitude of studies have noted that shorter courses (7 days or fewer) are as effective as long courses for common infections managed in the community (eg, urinary tract infections,⁵ pneumonia,⁶ chronic obstructive pulmonary disease exacerbation⁷). Despite this, approximately 35% of all Ontario prescriptions are longer than 8 days’ duration. Not completing the course of antibiotics has in fact not been linked to increasing levels of AMR. Furthermore, there is evidence that longer courses of antibiotics lead to more AMR.^8,9 As a result, this “finish the course” counseling point has been addressed in a number of recent commentaries calling on clinicians to reconsider this dogma.^10–12

We encourage future efforts to identify characteristics of physician antibiotic prescribing, understand the barriers to appropriate antibiotic use, and incorporate behavioural science theory to optimize antibiotic stewardship interventions. It is vital that family physicians take an active role in antimicrobial stewardship to prescribe antibiotics only when needed, to select the most appropriate agent, and to select the shortest duration necessary to effectively treat the infection. Adopting these principles will ensure that we have effective, and lifesaving, antibiotics for future generations.

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