Antibiotics are also obtainable through means other than prescription. Available over the counter in Mexico and many other countries, antibiotics can make their way to U.S. consumers across the border, through the mail, at swap meets and in local import shops (Calva, Ceron, Bjalil, & Holbrook, 1993; Casner & Guerra, 1992; Sola & Saddler, 2003). Regardless of how antibiotics are obtained, consumer behaviors determine the eventual pattern of antibiotic use. Many of these behaviors may contribute to the development of resistant organisms; examples include not completing the entire course of therapy, sharing the antibiotics between family members, and hoarding leftover medication for future use.

Fortunately, controlled interventions that included components of both clinician and patient education have demonstrated significant decreases in prescribing rates for adult and pediatric upper respiratory infections (Finkelstein, Davis, & Dowell, 2001; Gonzales, Steiner, Lum, & Barrett, 1999; Welschen, Kuyenhoven, Hoes, & Verheij, 2004,). Trials that expanded educational efforts to the community have also shown efficacy in reducing both the inappropriate prescribing of antibiotics and resistant pneumococcal carriage rates in the general public (Belongia, Sullivan, Chyou, Madagame, Reed & Schwartz, 2001; Hennessy, Petersen, Bruden, Parkinson, Hurlburt, Getty, Schwartz & Butler, 2002; Perz, Craig, Coffey, Jorgensen, Mitchel, Hall, Schaffner, & Griffin, 2002).

Public education about judicious use may also provide a degree of moral support for prescribing clinicians. Promotion of realistic expectations among consumers may reduce the likelihood of confrontational patient/clinician encounters regarding the prescription of antibiotics. In one study, pediatricians suggested that parental education would be the most important means of reducing inappropriate antibiotic use (Bauchner, Pelton, & Klein, 1999). In a focus group of physicians, Barden, Dowell, Schwartz and Lackey (1998) noted that unrealistic patient expectations were the single most important cause of inappropriate prescribing.

Thus, the combined goals of the OHSU “Teaching Primary Care Residents Judicious Antibiotic Use” project and the Oregon AWARE program include extensive training for clinicians on how to use patient education materials effectively, how to understand the patient’s true agenda accurately, and how to negotiate with and educate patients about when and how to use antibiotics appropriately.

The Resident Curriculum on Judicious Use
To accomplish this goal, our team is developing a curriculum for primary care residents to improve both understanding of judicious antibiotic use and how to educate patients about this important public health issue. The curriculum is evidence-based, using sources such as the joint American Academy of Pediatrics/American Academy of Family Physicians guidelines on diagnosis and treatment of otitis media (AAFP/AAO-HNS/AAP, 2004) as the basis for the information presented. We encouraged the faculty in each residency program to complete the curriculum by offering continuing medical education (CME) credit as well. This helps improve the likelihood that the residents will get consistent messages from both the curriculum and their faculty preceptors.