Contents

Search

antibiotic prescribing practices; antibiotic overuse; outpatient parenteral antibiotics

also see antimicrobial stewardship Indications: - outpatient parenteral antibiotic therapy - bone infections - joint infections - endocarditis - cardiac device infections - abdominal infections - skin infections & soft tissue infections - infections with antibiotic resistant organisms for which there is no oral alternative (especially urinary tract infection) [15] Epidemiology: - antibiotic overuse is common - almost 50% of viral upper respiratory infections treated with antibiotics in urgent care [19] - 80% of Americans take an antibiotic every year [11] - antibiotics are prescribed in > 2/3 of adult patient visits for viral upper respiratory tract infections [13] - based on ICD-10-CM diagnosis codes [20] - 23% of prescriptions inappropriate, generally for acute bronchitis or acute upper respiratory tract infection - 36% potentially appropriate, often for acute sinusitis, acute suppurative otitis media, or acute pharyngitis - 13% appropriate, for urinary tract infections, streptococcal pharyngitis or tonsillitis, bacterial pneumonia - 29% of antibiotic prescriptions without an associated diagnosis code [20] - 25% of antibiotic prescriptions inappropriate, 18% lacked a documented indication - providers who prescribe antibiotics for upper respiratory tract infection more likely to encode as sinusitis [21] - in nursing homes prevention & treatment of urinary tract infections most common use of antibiotics [25] Management: - outpatients on parenteral antibiotics should be monitored weekly for adverse drug effects [7,15] Notes: - patient beliefs & expectations are part of the problem - > 1/2 of healthcare providers believe patients expect antibiotics during a visit for a viral infection, whereas only ~1/4 of patients actually expect them [12] - hispanics more likely other patients to expect antibiotics (41% vs 26%) [12] - ~1/2 of hispanic patients & 20% of all patients obtain antibiotics from a source other than their doctor or clinic, most often grocery stores, friends & family, or leftovers from a previous prescription [12] - only 1/2 of outpatient antibiotic prescriptions are associated with both an in person visit & a documented infection [27] - providers more likely to prescribe unnecessary antibiotics later in their clinic sessions [9] - 1st-line antibiotics were prescribed for 37% of adults with sinusitis or pharyngitis & for 67%, 51%, & 60% of children with otitis media, sinusitis, or pharyngitis, respectively - overall, useof 1st-line agents was 52% [16] - consider the cost to benefit: [3] - 1 in 4000 chance that an antibiotic will help most acute upper respiratory infections - 1 in 4 chance antibiotic will cause diarrhea - 1 in 50 chance antibiotic will cause skin reaction - 1 in 1000 chance antibiotic cause an ER visit - antibiotics can lead to more resistant infections that are harder to treat - patients exposed to antibiotics for urinary tract infection or respiratory tract infections subsequently harbor bacteria resistant to those antibiotics; this effect is strongest immediately following antibiotic exposure but persists for as long as 12 months [4] - childhood anti-anaerobic antibiotic exposure is associated with inflammatory bowel disease [6] - prescribing practices may be changed by simple measures - providing pediatricians with regular reports on their prescribing habits relative to national guidelines, can cut inappropriate antibiotic prescribing by 50% [5] - accountable justification & peer comparison are two such behavioral interventions [17] - prescribing practices revert to former ways when feedback is discontinued [10] - inappropriate antibiotic prescribing rates may rebound when behavioral interventions are discontinued [17] - education is minimally effective in reducing antibiotic overuse [26] - outpatient parenteral antibiotics may be appropriate for selected patients [15] - the FDA has created a website that will provide direct & timely access to information about when bacterial or fungal infections are likely to respond to a specific drug - approach is intended to aid health care professionals in making more informed prescribing decisions that will both benefit their patients & prevent the spread of resistant bacteria [18] - most patients hospitalized with pneumonia receive antibiotics prescribed at discharge for too long [22] - no clinical benefit - adverse effect, including diarrhea, common

Related

antibiotic (antimicrobial agent) antibiotic resistance antibiotic therapy antimicrobial stewardship

General

prescribing practices

References

  1. Journal Watch 24(19):153, 2004 Welschen I, Kuyvenhoven MM, Hoes AW, Verheij TJ. Effectiveness of a multiple intervention to reduce antibiotic prescribing for respiratory tract symptoms in primary care: randomised controlled trial. BMJ. 2004 Aug 21;329(7463):431. Epub 2004 Aug 05. PMID: 15297305 http://bmj.bmjjournals.com/cgi/content/full/329/7463/431
  2. Coca A & Mainous AG Relation of time spent in an encounter with the use of antibiotics in pediatric office visits for viral respiratory infections Arch Pedriatr Adolesc Med 2005; 159:1145 PMID: 16330738
  3. Prescriber's Letter 15(10): 2008 COMMENTARY: Antibiotic Overuse POSTER: Cold or Flu. Antibiotics Don't Work for You Handout: Cold or Flu. Antibiotics Don't Work for You Detail-Document#: 241006 (subscription needed) http://www.prescribersletter.com
  4. Costelloe C et al. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: Systematic review and meta-analysis. BMJ 2010 May 18; 340:c2096 PMID: 20483949
  5. Physician's First Watch, Oct 10, 2012 Massachusetts Medical Society http://www.jwatch.org - Study Succeeds in Cutting Inappropriate Antibiotic Prescribing by Pediatricians: Findings Among the Research Featured at First IDWeek Conference http://www.idweek.org/pr-stewardship - Hersh AL et al. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics 2011 Dec; 128:1053. PMID: 22065263
  6. Kronman MP et al. Antibiotic exposure and IBD development among children: A population-based cohort study. Pediatrics 2012 Oct; 130:e794 PMID: 23008454
  7. Tice AD, Rehm SJ, Dalovisio JR, Bradley JS et al Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004 Jun 15;38(12):1651-72 PMID: 15227610
  8. Barnett ML and Linder JA. Antibiotic prescribing to adults with sore throat in the United States, 1997-2010. JAMA Intern Med 2013 Oct 3 PMID: 24091806 JAMA Intern Med. Published online October 03, 2013
  9. Orciari Herman A, Fairchild DG, Hefner JE Tired Clinicians = More Antibiotic Prescribing? Physician's First Watch, Oct 7, 2014 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org - Linder JA et al Time of Day and the Decision to Prescribe Antibiotics. JAMA Intern Med. Published online October 06, 2014 PMID: 25286067 http://archinte.jamanetwork.com/article.aspx?articleid=1910546
  10. Gerber JS et al Durability of Benefits of an Outpatient Antimicrobial Stewardship Intervention After Discontinuation of Audit and Feedback. JAMA. Published online October 10, 2014 PMID: 25317759 http://jama.jamanetwork.com/article.aspx?articleid=1916352
  11. Hicks LA et al. US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis 2015 May 1; 60:1308 PMID: 25747410
  12. Francois Watkins LK, Sanchez GV, Albert AP et al Knowledge and Attitudes Regarding Antibiotic Use Among Adult Consumers, Adult Hispanic Consumers, and Health Care Providers - United States, 2012-2013. MMWR. Weekly. July 24, 2015 / 64(28);767-770 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6428a5.htm
  13. Jones BE et al. Variation in outpatient antibiotic prescribing for acute respiratory infections in the veteran population: A cross- sectional study. Ann Intern Med 2015 Jul 21; 163:73 PMID: 26192562
  14. Hallsworth M et al. Provision of social norm feedback to high prescribers of antibiotics in general practice: A pragmatic national randomised controlled trial. Lancet 2016 Feb 18 PMID: 26898856
  15. Medical Knowledge Self Assessment Program (MKSAP) 17, 19 American College of Physicians, Philadelphia 2015, 2021
  16. Hersh AL et al. Frequency of first-line antibiotic selection among US ambulatory care visits for otitis media, sinusitis, and pharyngitis. JAMA Intern Med 2016 Oct 24 PMID: 27775770
  17. Meeker D, Linder JA, Fox CR et al Effects of Behavioral Interventions on Inappropriate Antibiotic Prescribing in Primary Care 12 Months After Stopping Interventions. JAMA. 2017;318(14):1391-1392 PMID: 26864410 https://jamanetwork.com/journals/jama/article-abstract/2656800 - Linder JA, Meeker D, Fox CR et al Effects of Behavioral Interventions on Inappropriate Antibiotic Prescribing in Primary Care 12 Months After Stopping Interventions. JAMA. 2017 Oct 10;318(14):1391-1392. PMID: 29049577
  18. FDA News Release. Dec 13, 2017 FDA launches new tool for sharing information that allows doctors to better manage antibiotic use; improve patient care. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm588836.htm
  19. Palms DL, Hicks LA, Bartoces M et al. Comparison of antibiotic prescribing in retail clinics, urgent care centers, emergency departments, and traditional ambulatory care settings in the United States. JAMA Intern Med 2018 Jul 16. PMID: 30014128 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2687524 - Incze MA, Redberg RF, Katz MH. Overprescription in urgent care clinics - The fast and the spurious. JAMA Intern Med 2018 Jul 16 PMID: 30014130 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2687523
  20. Chua KP, Fischer MA, Linder JA. Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross sectional study. BMJ 2019;364:k5092 PMID: 30651273 Free full text https://www.bmj.com/content/364/bmj.k5092
  21. Martinez KA et al. Coding bias in respiratory tract infections may obscure inappropriate antibiotic use. J Gen Intern Med 2019 Jun; 34:806. PMID: 30652274 https://link.springer.com/article/10.1007%2Fs11606-018-4823-x
  22. Vaughn VM, Flanders SA, Snyder A. Excess Antibiotic Treatment Duration and Adverse Events in Patients Hospitalized With Pneumonia: A Multihospital Cohort Study. Ann Intern Med. 2019. July 9 PMID: 31284301 https://annals.org/aim/article-abstract/2737823/excess-antibiotic-treatment-duration-adverse-events-patients-hospitalized-pneumonia-multihospital - Spellberg B, Rice LB. Duration of Antibiotic Therapy: Shorter Is Better. Ann Intern Med. 2019. July 9 PMID: 31284302 https://annals.org/aim/article-abstract/2737827/duration-antibiotic-therapy-shorter-better
  23. Shively NR, Buehrle DJ, Clancy CJ, Decker BK. Prevalence of Inappropriate Antibiotic Prescribing in Primary Care Clinics within a Veterans Affairs Health Care System. Antimicrob Agents Chemother. 2018 Jul 27;62(8). PMID: 29967028 Free PMC Article
  24. Ray MJ et al Antibiotic prescribing without documented indication in ambulatory care clinics: national cross sectional study. BMJ 2019;367:l6461 PMID: 31826860 https://www.bmj.com/content/367/bmj.l6461 - Hay AD Coding infections in primary care. BMJ 2019;367:l6816 PMID: 31826859 https://www.bmj.com/content/367/bmj.l6816
  25. Thompson ND, Stone ND, Brown CJ et al. Antimicrobial use in a cohort of US nursing homes, 2017. JAMA. 2021;325(13):1286-1295. April 6. PMID: 33821897 https://jamanetwork.com/journals/jama/article-abstract/2778111
  26. Schwartz KL, Ivers N, Langford BJ et al. Effect of antibiotic-prescribing feedback to high-volume primary care physicians on number of antibiotic prescriptions: A randomized clinical trial. JAMA Intern Med 2021 Jul 6; [e-pub]. PMID: 34228086 PMCID: PMC8261687 (available on 2022-07-06) https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2781806 - Mitchell SL, D'Agata EMC, Hanson LC et al. The trial to reduce antimicrobial use in nursing home residents with Alzheimer disease and other dementias (TRAIN-AD): A cluster randomized clinical trial. JAMA Intern Med 2021 Jul 12; [e-pub]. PMID: 34251396 PMCID: PMC8276127 (available on 2022-07-12) https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2782003
  27. Fischer MA, Mahesri M, Lii J, Linder JA Non-visit-based and non-infection-related antibiotic use in the US: A cohort study of privately insured patients during 2016-2018. Open Forum Infect Dis 2021 Sep; 8:ofab412 PMID: 34580643 PMCID: PMC8436380 Free PMC articl https://academic.oup.com/ofid/article/8/9/ofab412/6333650