By Seema Gupta, MD, MSPH

Clinical Assistant Professor, Department of Family and Community Health, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV

Dr. Gupta reports no financial relationships relevant to this field of study.

SYNOPSIS: In the United States in 2010 and 2011, an estimated 30% of outpatient oral antibiotic prescriptions may have been inappropriate, a finding that supports the need for establishing a goal for outpatient antibiotic stewardship.

SOURCE: Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among U.S. ambulatory care visits, 2010-2011. JAMA 2016;315:1864-1873.

Antimicrobials are perhaps one of the most successful forms of chemotherapy in the history of medicine. Since their discovery in the early 1900s, antibiotics have contributed significantly to the control of communicable diseases that have been the leading causes of human morbidity and mortality throughout human history. However, as their popularity and utilization expanded, antibiotic resistance has become a significant public health issue, both in the United States and across the world, potentially creating infectious diseases that may become unresponsive to antibiotic treatments.

In the United States, at least 2 million people become infected with antibiotic-resistant bacteria, and at least 23,000 people die each year as a direct result of these infections.1 According to the CDC, antibiotic resistance in the United States costs an estimated $20 billion a year in excess healthcare costs, $35 billion in other societal costs, and results in more than 8 million additional days in the hospital. The primary driver of antibiotic resistance is the overuse and misuse of antibiotics. In 2011, healthcare providers prescribed 262 million courses of antibiotics, equating to more than five prescriptions written for every six residents.2 It is also estimated that approximately 50% of antibiotic prescriptions written in the outpatient setting and 30-50% of antibiotics prescribed in hospitals may be unnecessary or inappropriate.3 Therefore, decreasing inappropriate use is essential to reducing both antibiotic resistance and adverse events.

Despite the release of a national action plan for combating antibiotic-resistant bacteria that sets a target of reducing inappropriate antibiotic use in the outpatient setting by 50% by 2020, the precise degree to which antibiotic use is inappropriate and amenable to reduction is unknown.4 Additionally, previous goals and measures for the appropriate use of antibiotics have focused on targeted, specific age groups and conditions.

Fleming-Dutra et al established a baseline of the current rate of outpatient, oral antibiotic prescriptions by age and diagnosis and estimated the overall rate of appropriate, outpatient antibiotic prescriptions in the United States.

Using the 2010-2011 data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, researchers estimated the baseline annual numbers and population-adjusted rates with 95% confidence intervals (CI) of ambulatory visits with oral antibiotic prescriptions in the United States by age, region, and diagnosis. Researchers found that in 2010 and 2011, of the 184,032 sampled ambulatory care visits, 12.6% of visits (95% CI, 12%-13.3%) resulted in antibiotic prescriptions, with an estimated 506 antibiotic prescriptions (95% CI, 458-554) per 1,000 population annually. The number of antibiotic prescriptions varied geographically across the United States, ranging from 423 antibiotic prescriptions (95% CI, 343-504) in the West to 553 antibiotic prescriptions (95% CI, 459-648) in the South, per 1,000 population. The annual antibiotic prescription rate was found to be highest among children younger than two years of age at 1,287 antibiotic prescriptions (95% CI, 1,085-1,489) per 1,000 population.

Sinusitis was the diagnosis associated with the most antibiotic prescriptions per 1,000 population (56 antibiotic prescriptions [95% CI, 48-64]), followed by suppurative otitis media (47 antibiotic prescriptions [95% CI, 41-54]), and pharyngitis (43 antibiotic prescriptions [95% CI, 38-49]). Overall, acute respiratory conditions per 1,000 population led to 221 antibiotic prescriptions (95% CI, 198-245) annually, but only 111 antibiotic prescriptions were estimated to be appropriate for these conditions. Researchers also found that among all conditions and ages combined in 2010 and 2011, an estimated 506 antibiotic prescriptions (95% CI, 458-554) per 1,000 population were written annually, and, of these, only 353 antibiotic prescriptions were estimated to be appropriate.

COMMENTARY

In the United States, an estimated 154 million prescriptions for antibiotics were written in ambulatory care settings annually from 2010-2011. In this study, researchers found that almost half of antibiotic prescriptions for acute respiratory conditions may have been unnecessary, representing 34 million antibiotic prescriptions annually. It is even more astounding to consider that collectively, across all conditions, an estimated 30% of outpatient, oral antibiotic prescriptions may have been inappropriate, although this is likely a conservative estimate. Although these findings offer a critical starting point to understand prescribing practices in the ambulatory care setting, it is equally vital that clinicians consider national, regional, and local approaches to address this challenge in view of geographic variances. However, there will be some elements common to all strategies, which include altering clinician behavior and practice culture as well as educating patients and families regarding the role of antibiotics in medical care.

The Fleming-Dutra et al study also establishes baseline estimates about outpatient antibiotic prescribing. Targeting interventions at both clinician and patient/community levels would enable reaching the national goal of reducing outpatient antibiotic use by 50% by 2020. As there are a number of antibiotic stewardship activities ongoing in outpatient settings across the nation, it is critical clinicians do their part to ensure appropriate antibiotic prescribing. This includes a consideration of displaying informational posters in patient waiting rooms to encourage active conversations around the need for antibiotics. Studies demonstrate most patients will be satisfied without antibiotics if physicians communicate why an antibiotic is unnecessary, what patients can do to feel better, what to expect with their illnesses, and when they should return if they are not improving or are getting worse.5 After all, antibiotic resistance is one of the most urgent public health threats of our time, and by rethinking each time we consider prescribing an antibiotic, we can treat patients appropriately while sustaining the efficacy of existing agents.

REFERENCES

  1. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. Available at: http://1.usa.gov/1s07BAF.
  2. Hicks LA, Bartoces MG, Roberts RM, et al. U.S. outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis 2015;60:1308-1316.
  3. Shapiro DJ, Hicks LA, Pavia AT, et al. Antibiotic prescribing for adults in ambulatory care in the USA, 2007–09. J Antimicrob Chemother 2014;69:234-240.
  4. National Action Plan for Combating Antibiotic-Resistant Bacteria. Available at: http://1.usa.gov/1yiurjQ.
  5. Drekonja DM, Filice GA, Greer N, et al. Antimicrobial stewardship in outpatient settings: A systematic review. Infect Control Hosp Epidemiol 2015;36:142-152.