Understanding Inappropriate Prescribing of Antibiotics

A study published in JAMA explored the appropriateness of outpatient antibiotic prescriptions in the United States. During 2010-2011, there were 506 annual antibiotic prescriptions per every 1000 population, but only 353 were likely appropriate. An accompanying editorial establish the need to set a goal for outpatient antibiotic stewardship. Antibiotic use needs to be improved and with focused interventions targeting both clinicians and patients, it would be possible to reach nationally appropriate goals.

The study titled “Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011” led by Katherine Fleming-Dutra, MD, estimated portions of antibiotic use that may be inappropriate in adults and children in the United States.

Findings

The researchers used 2 annual surveys in 2010 and 2011 to collect data about patients’ demographic characteristics and symptoms, physicians' diagnoses, and medications ordered, including antibiotics. They found that out of the 184,032 visits, 12.6% of encounters were associated with antibiotic prescriptions. Furthermore, 30% of outpatient prescriptions were in fact unnecessary and inappropriate.

The authors recommend development of diagnostic tests that can distinguish viral infections from bacterial infections in order to improve outpatient antibiotic use.

They used the 2010-2011 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) to collect data on patient demographics. Per 1000 population, the diagnosis that was associated with the most antibiotic prescriptions was sinusitis (56 antibiotic prescriptions), followed by suppurative otitis media (47), and pharyngitis (43). Collectively, acute respiratory conditions per 1000 population led to 221 antibiotic prescriptions each year but only 111 of these were actually appropriate for these conditions.

In general, across all ages and conditions, per 1000 population, an estimated 506 antibiotic prescriptions were written annually. And out of these, only 353 antibiotic prescriptions were estimated to be appropriate.

Spillage of Unnecessary Antibiotic Prescriptions

National guidelines state that patients with bronchitis, bronchiolitis, viral upper respiratory tract infections, asthma and allergy, influenza, and viral pneumonia should not receive antibiotics. Antibiotics prescribed for these conditions are considered inappropriate. And yet the study highlighted staggering numbers of inappropriate antibiotic prescriptions.

In an accompanying editorial, Pranita D. Tamma, MD, MHS, and Sara E. Cosgrove, MD, MS, wrote that the estimates in the Fleming-Dutra’s study were likely conservative, but they serve as a good starting point to understanding prescribing practices in the ambulatory care setting.

“Now that baseline estimates about outpatient antibiotic prescribing have been determined, future work needs to focus on interventions targeting both clinicians and patients to help reach the national goal,” wrote Pranita D. Tamma, MD, MHS, and Sara E. Cosgrove, MD, MS, and an accompanying editorial. “It will be critical to continue to evaluate progress in improving antibiotic use in conjunction with widespread adoption of antibiotic stewardship activities in the outpatient setting.”