In addition to public health based community education programs, CDC recognized the need for improved clinician education on antibiotic use, since in the United States antibiotics are primarily prescribed by a physician or other licensed clinician. To address this need, CDC granted money to the University of California – San Diego (UCSD) in 1999 to develop a judicious antibiotic use curriculum for medical students. This curriculum includes formal didactic sessions on principles of antibiotic resistance, drug choice, infection control and other pertinent topics, as well as small group exercises that allow learners to practice patient education skills such as negotiating with patients about the need for antibiotics and educating them about how to use antibiotics properly when they are indicated.

While the medical student curriculum was broad-based, the CDC also recognized that 80% of antibiotics are prescribed in the outpatient setting, many of these for common respiratory infections. Thus, in follow-up to the UCSD project, the CDC called for proposals to adapt this curriculum for use by primary care residents (physicians doing graduate medical education in family medicine, internal medicine, and pediatrics). The CDC awarded this grant to our team at Oregon Health & Science University, recognizing our ability to integrate the residency curriculum with the medical student curriculum (OHSU was a beta-test site for the UCSD curriculum and now hosts the Web-based components of that curriculum) and Oregon AWARE’s established program of educational activities.

Oregon AWARE’s public health awareness strategies aim to reduce inappropriate antibiotic use behaviors among consumers by providing the general population of well adults with information about the growing threat of antibiotic resistance and the importance of appropriate use of antibiotics. The coalition’s four main consumer messages are: 1) don’t take antibiotics to treat viral illnesses like colds or the flu, 2) unnecessary use increases the risk of developing resistant infections, 3) when antibiotics are prescribed, take every dose even if symptoms improve, and 4) never share antibiotics, take leftovers, or take them without a prescription. The Oregon AWARE coalition has created a number of materials to reinforce these basic messages.

The Case for a Combined Educational Approach
Public education about safe antibiotic use is critical because decreasing inappropriate antibiotic prescribing through clinician education is not the only factor in the appropriate use equation. Unfortunately, surveys have shown that many consumers have misconceptions about the types of illnesses that can be effectively treated with antibiotics (Dowler, Thomas, & Saddler, 2003; Vanden Eng, Marcus, Hadler, Imhoff, Vugia, Cieslak, Zell, Deneen, McCombs, Zansky, Hawkins, & Besser, 2003). The same studies show that many consumers are also unaware of the dangers associated with inappropriate use of antibiotic medications. Although clinicians serve as gatekeepers for consumers who obtain their antibiotics by legal means in the U.S., patients play an important role in the interactions that lead to prescription. The advent of medical consumerism and the expansion of direct-to-consumer marketing of pharmaceuticals in the U.S., among other factors, have placed patients in a role of unprecedented power in the realm of health-related decision making (Roter & Hall, 1992).