Primary care: Fighting AMR on the front line of medicine

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Primary care physicians are the front line of medicine, so they have a huge role in slowing antimicrobial resistance (AMR) that could be problematic in health care.

They are not alone – all clinicians have a part to play, and it does not have to be difficult, just consistent, said Priya Nori, MD, medical director of antimicrobial stewardship at the Montefiore Health System in the Bronx, New York.

And what about patients demanding antibiotics to fight off an illness with cold or flu-like symptoms? Doctors should remember that’s probably caused by a virus, especially during winter in northern parts of the country, and antibiotics won’t work. The patients themselves may be slightly less demanding because many came out of the COVID-19 pandemic with greater understanding about the differences between viruses and bacteria, she said.

Nori spoke with Medical Economics to discuss AMR within the state of medicine as of late 2024 and early 2025. This transcript has been edited for length and clarity.

Medical Economics: What is the role of primary care physicians in creating antimicrobial resistance or resolving AMR?

Priya Nori, MD
_{© Montefiore Health System}

Priya Nori, MD: I would consider those folks our front line. They're the ones who are taking care of our families, our communities, and they're the ones who are ensuring that everybody's as safe as humanly possible and healthy. And so they have a huge role to play. If you look at where antibiotics are being consumed most heavily in human health care, it is really the ambulatory care space. That means primary care providers, internal medicine or family practice, pediatricians, urgent care centers and dentistry – these locations probably cover the vast majority of ambulatory or outpatient antibiotic use. And when you look at inpatient versus outpatient antibiotic use and contribution to AMR, the outpatient space swallows the inpatient space, because they take care of many, many more people there. And so the best way to think about how to target AMR in the outpatient setting is to think about, what are the conditions that our outpatient colleagues see most readily? These are going to be things like acute respiratory infections, especially now, as we are in the full thick of flu season. We have RSV (respiratory syncytial virus), we have typical cold viruses, we have COVID-19 coming and going every couple of months. This is the brunt of what primary care providers are seeing right now, and so it's going to be very important in terms of them being a pillar of prevention of antibiotic resistance.

The most important thing there is really to use their diagnostics to be able to understand what's a viral infection, what's a bacterial infection, understanding that viral infections do not respond to antibiotics, but bacterial infections do. But guess what? I would say nine times out of 10, it's going to be a virus, especially in the colder months. So, diagnosing appropriately, understanding that antibiotics won't help viral infections.

And importantly, and this is probably the hardest part, reiterating that with patients and families, and having a good set of tools to counsel patients and families that this is a virus. Antibiotics are not going to help you, but instead, I'm going to give you supportive care. I'm going to give you decongestants. I'm going to write you a note to stay home from work for a few days, and I'm going to set up a mechanism to call you to see how you're doing, to follow up on your symptoms to make sure they're going in the right direction. And, heaven forbid, you're getting worse, we will quickly treat you with an antibiotic that I will prescribe, because at that point, there's a higher chance that it could be a bacterial infection. So recognizing, counseling and having a plan B at their disposal, I think are the best things that primary care docs, PAs, nurse practitioners can do to be the front line against AMR

Medical Economics: How can clinicians effectively communicate the importance of antimicrobial stewardship to patients who may expect or demand antibiotics unnecessarily?

Priya Nori, MD: So I think we can invoke a couple of things. One is that, building off of all that we learned during COVID, I find that now patients and families are more in tune with the concept of this is a virus, that is a bacteria, antibiotics don't treat viruses. A lot of what causes coughing and fevers and sneezing and all of that is due to a virus, and antibiotics are not the answer. So we can keep on with the momentum of that, the concept of antibiotic resistance. I would say any good citizen cares about that and I think that can be an effective conversation to be had, but that is still kind of out there, that's like a societal burden. But if you really want to reorient the conversation to the patient and their immediate surroundings and family, invoking things like adverse drug reactions, allergic rashes, ending up in the ER, antibiotic associated diarrhea, Clostridioides difficile. Everybody's kind of obsessed with the microbiome these days, whether they know what it means or not. These antibiotics perturb the microbiome, and they do so for months, and it takes months to get things back to normal. And now we know we're learning more about the microbiome every day. It's a very complex organism, but it contributes to lots, including rheumatologic conditions, cancer down the road, and when I speak to my pediatric colleagues in infectious diseases, I'll often be reminded that early childhood exposure to antibiotics can set these children up for chronic health issues like asthma, obesity, inflammatory bowel disease. And then, heaven knows, further down the road, are we changing the immune system? Are we changing the microbiome such that they're at increased risk for things like certain cancers, Alzheimer's disease, other inflammatory conditions like multiple sclerosis? There's a lot that we don't know. So we have to reorient the conversation back to the individual, to really, I think, make a difference in their mindset around overuse of antibiotics.

Medical Economics: What can other clinicians and health care workers, and specifically infection prevention personnel, do to help against AMR?

Priya Nori, MD: I would say the number one thing, the lowest hanging fruit that we can do to prevent infections in our communities, within the four walls of our hospitals, is hand hygiene. Believe it or not, I mean, that sounds very simple, right? But that is forgotten much of the time. That is a step that is often left out of either direct interaction between lay persons, or a physician to another colleague, or physician to patient. We get so busy in our days that we often forget to do that, and I think that we can greatly reduce the burden, especially of viral infections, especially during respiratory season, by just ensuring that whatever we touch, wherever we go, whoever we interact with, we're washing our hands. We have alcohol rub with us handy to quickly take care of that after every specific interaction or whatever we touch. I truly think that goes a very long way. Hand hygiene is the lowest hanging fruit in the community, in the hospital, you name it. The other one is, again, the vaccination issue. I'll keep coming back to that, because not only do we know it prevents antibiotic resistant infections, it prevents illnesses in general. It prevents the burden of illness. It maintains the economy, it keeps people at work, it keeps all the gears turning of society so that we can continue to advance the ship forward. So those are the basic things that I would say. Let's not relent. Let's just keep at it with those. Let's lean in harder.