• Only prescribe antibiotic therapy when likely to be beneficial to the patient
• Use an agent targeting the likely pathogens
• Use the antibiotic for the appropriate dose and duration

Medical School Curriculum

In 1999, Division of Bacterial & Mycotic Diseases (DBMD) and Division of Healthcare Quality Promotion (DHQP) contracted with WESTAT and the University of California, San Diego for the development of a curriculum to teach medical students about the appropriate use of antibiotics in hospital and outpatient settings. The curriculum is part of a larger curriculum for fourth year medical students that teaches concepts from basic science in the context of clinical care. The antibiotic use curriculum is built around activities promoting prudent decision-making about antibiotic use.

The curriculum is delivered in three formats to maximize learning: large group lectures, small group discussions, and a web-based computerized module. Lectures will cover topics such as: the extent of the problem of antibiotic resistance, mechanisms of resistance, principles of judicious use, diagnostic techniques, and appropriate antibiotic treatment and prophylaxis.

Small group discussions use case-based learning and give students the opportunity to learn from their peers and model appropriate behaviors (e.g. talking with a patient about why antibiotics may not be necessary). Discussions focus on control measures for nosocomial infections, high-risk environments, patient education scenarios, cases involving complex decision-making and questions of ethics, and strategies to prevent recurring infections.

The web-based computerized module provides self-directed learning opportunities to complement the material provided in the lecture and small group settings. The computer module is case-based with on-line resources and a pre- and post-test. In each of the thirteen cases, the user selects a working-diagnosis, orders diagnostic tests, and makes a decision about antibiotic use. If an antibiotic is prescribed, the user determines the dose and duration of treatment. For all the choices made, feedback is given including to what extent the specific choices would contribute to emerging resistance to antibiotics.

The evaluation of the curriculum included components designed to evaluate the acceptability of the curriculum to students as well as the acquisition of knowledge of the topics presented.

Results: The curriculum was pilot tested at six medical schools identified by the Association of American Medical Colleges (AAMC). Thirty students per school, composed of third-year and fourth-year students, participated in the pilot tests. The faculty were infectious disease faculty or fellows. The methods consisted of a pre-test, lectures, small groups, Web cases, and post-test. The assessment focused on acceptability of the materials, ability of the materials to communicate the primary educational messages, and feasibility of the implementation. Data used for the curriculum assessment consisted of student pre- and post-test scores, student evaluation of lectures, small groups, and Web cases, faculty assessment of the curriculum content, and administrator assessment of the process. Overall, results were positive for all areas of the curriculum and had significant impact on student knowledge. Students gave close to perfect ratings for the objectives, lecture organization, small group activities, and web cases. Faculty and administrators also gave the curriculum high marks.

During 2004, the curriculum will be promoted to medical schools by the AAMC.

National Media Campaign

The Respiratory Diseases Branch and the Division of Bacterial and Mycotic Disease's Health Communication Department launched a national media education campaign promoting appropriate antibiotic use in the community for upper respiratory infections. The target audiences of the education campaign are parents of young children.

While there are many public and private organizations promoting and subsidizing interventions for appropriate antibiotic use, a strategic national approach to intervene in patient behavior has not been attempted. Evaluation of past interventions has shown that multifaceted campaigns geared towards increasing the public's knowledge of antibiotic resistance, when combined with interventions to improve provider prescribing behavior, have been effective in reducing the misuse and overuse of antibiotics. Since public demand plays an important role in the misuse and overuse of antibiotics, mass media strategies are an appropriate means of reaching the target audience and should help to increase knowledge and change attitudes and behavior about taking antibiotics for viral upper respiratory tract infections.

The media campaign was developed by Ogilvy Public Relations Worldwide and consists of three phases. Phase I of the campaign consisted of the development, production, and distribution of print, radio, and television PSAs. These media were designed and tested using formative research and focus groups. In June, as part of the national conference on appropriate antibiotic use, media kits were distributed to state partners and workshops were conducted on the implementation of the kits for their respective campaigns.

Phase II consisted of a national launch and media event on September 17, 2003 at the Interscience Conference on Antimicrobial Agents and Chemotherapy in Chicago, IL. Phase III is currently underway and will focus on establishing evaluation projects, expanding our partners and methods of dissemination, and assessing the impact of Phase II.

HEDIS Measures

Although awareness of the consequences of inappropriate antibiotic prescribing is increasing both among physicians and patients, the practice remains widespread. One mechanism for highlighting the importance of specific medical practices, such as appropriate antibiotic use, is the public reporting of performance on selected quality of care measures by managed care plans. The most widely used system of performance measures, the Health Plan Employer Data and Information Set (HEDIS), offers an excellent vehicle for raising public awareness and improving medical practice.

In 1999, 410 health plans representing 52 million members reported HEDIS results to the National Committee for Quality Assurance. Because HEDIS did not contain any measures related to the management of acute conditions, adding measures in the area of appropriate use of antibiotics in children would improve the measurement set. Previous attempts to develop such measures suffered from insufficient testing of new measures prior to HEDIS inclusion and have ultimately resulted in withdrawal of the measures.

For this project, experts in appropriate antibiotic use collaborated with a multidisciplinary team of researchers with expertise in the development and testing of HEDIS measures to develop and test two measures of appropriate antibiotic use in children. The objectives were to (1) Develop and test a performance measure that examines antibiotic prescribing rates for URI in children and adolescents and (2) Develop and test a performance measure that examines Group A Strep (GAS) testing rates in children and adolescents diagnosed with pharyngitis and prescribed an antibiotic. As a result of the study, two measures were developed. They are Appropriate Treatment for Children with URI and Appropriate Testing for Children with Pharyngitis. Both measures have been approved for HEDIS 2004.