While restricting antibiotic use in hospitals has been heavily emphasized to stave off the rise of drug-resistant infections, a new study shows such efforts are conspicuously absent in outpatient settings — where 80% of these life-saving drugs are prescribed.

“We have been seeking to solve a problem we don’t really understand,” Jeffrey A. Linder, MD, MPH, lead author of the study, said recently in San Francisco at an IDWeek 2018 press conference.

Linder, chief of internal medicine and Geriatrics at Northwestern University School of Medicine in Chicago, said, “The way that we have been looking at outpatient antibiotic prescribing — only focusing on in-person visits and a restricted number of diagnoses — has been missing a lot of the prescribing.”

In reviewing records, Linder and colleagues found that 46% of outpatient antibiotics were prescribed without an infection-related diagnosis of the patient. They also found 20% of antibiotics overall were prescribed in the absence of an in-person encounter, he said.

Linder and his colleagues “measured the prevalence of non-visit-based and non-infection-related oral, antibacterial antibiotic prescribing between November 2015 and October 2017 using the EHR of an integrated health delivery system.” They noted that “there were 509,534 antibiotic prescriptions made to 279,169 unique patients by 2,413 clinicians in 514 clinics.”¹

Of the 20% of drugs prescribed without a patient visit, half were done over the phone. Somewhat disturbingly, 4% of the overall antibiotics prescribed were done by automatic refill.

“It is a little concerning that we see a refill for an antibiotic prescription,” Linder said. “This is a workflow where someone calls in for a chronic condition — high blood pressure or a cholesterol medication — [and we] enable easy refills like that.”

Though the findings suggest antibiotic use is somewhat indiscriminate in outpatients, clinicians can prescribe drugs without a patient visit and do not necessarily have to enter the diagnosis code.

“Everybody realizes doctors can prescribe antibiotics in the absence of a visit,” he says. “There is nothing saying we have to put down an infectious diagnosis when prescribing antibiotics.”

Examples where these practices may be common include people with chronic UTIs or teenagers taking multiple courses of antibiotics for acne. However, in looking at such exceptions to the general rule, these were not thought to be a reasonable explanation for the larger pattern.

“The type of antibiotics that we are seeing and the frequency with which antibiotics are being prescribed does not really fit with those two examples,” Linder said.

More likely, some busy outpatient clinicians are prescribing antibiotics as a kind of stopgap measure because they do not have time to thoroughly examine the patient and review the medical record.

Under this same duress, infection codes may be entered improperly or not entered at all.

“Some of this is bad coding,” Linder said. “We don’t have incentives to get the diagnosis coding exactly right at the time. But even if it is just bad recordkeeping, it is still a significant problem. Outpatient prescribing in the U.S. accounts for about 80% of antibiotics prescribed,” he said.

According to Linder and his colleagues, clinicians prescribing the antibiotics “were 63% attending physicians, 18% residents/fellows, 10% nurse practitioners, and 7% physician assistants.” Also, “The most common antibiotic classes were penicillins (30%), macrolides (23%), cephalosporins (14%), fluoroquinolones (11%), tetracyclines (10%), and sulfonamides (6%).”

REFERENCE

1. Linder JA, Brown T, Lee, JY, et al. Abstract 632. Non-Visit-Based and Non-Infection-Related Ambulatory Antibiotic Prescribing. IDWeek 2108. San Francisco, Oct. 3-7.