Combating Irrational and Inappropriate Antibiotic Prescribing Practices

Antibiotic use is the primary driver of antibiotic resistance.¹ When used appropriately, antibiotics are highly effective for curing infections of bacterial origin, but their use is also associated with a range of adverse events from allergic reactions to Clostridium difficile infections.²

A greater problem is that many prescriptions are dispensed inappropriately for infections that do not respond to antibiotics. The Centers for Disease Control and Prevention (CDC) reported that 262.5 million outpatient antibiotic prescriptions were dispensed in the United States in 2011 — at least 30% of which were unneccessary.^1,3

Data collected since then indicate improvements in some areas but not in others.¹ “In 2011 there were about 75 million prescriptions dispensed for children in the United States, and that went down to 64 million in 2014,” Katherine Fleming-Dutra, MD, Medical Epidemiologist at the CDC’s Office of Antibiotic Stewardship told Infectious Disease Advisor, “but the adult rates have really remained very stable, and the geographic patterns have remained stable as well.”

Inappropriate Antibiotic Prescribing Trends

One of the biggest issues in antibiotic use is a significant trend toward overprescribing. “We noted that overprescribing was common among all age groups — 29% prescribed in outpatient settings to children, 35% to adults age 20 to 64, and 18% in people over age 65,” Dr Fleming-Dutra said. “Many of these unnecessary antibiotics were prescribed for acute respiratory conditions, including common colds, acute bronchitis, viral pharyngitis, and even some sinus and ear infections,” she wrote in a blog post on the CDC website.⁴

A review by Hicks et al³ using data from 2011 reported that more than 60% of antibiotics were prescribed in the outpatient setting, and an estimated 58% of antibiotic prescriptions for children were written for respiratory infections that have viral etiologies.^3,5-7

This pattern, referred to as “irrational prescribing,” is widely reported and is attributable to a variety of causes that are not well understood. What is known is that a substantial portion of antibiotic overprescription was linked to overdiagnosis of conditions such as sinusitis and otitis media without meeting diagnostic criteria and with high variability in diagnosis by race and by clinician.⁸

Regional Differences in Prescribing

Patterns of regional, socioeconomic, gender, and racial biases of antibiotic prescribing practices are common. “We have certainly observed differences,” Dr Fleming-Dutra stated. “It’s very well documented that women receive antibiotics at higher rates than men. We also see clear regional and geographic differences — the South has higher antibiotic prescribing rates than other parts of the country, while the West often has the lowest. [Those in] rural areas receive them at higher rates and are more likely to get broad-spectrum antibiotics. We are actively trying to understand better why that is and what’s driving those differences.”

Racial Differences in Prescribing

A recent retrospective study by Goyal et al⁸ of a cohort of 39,445 pediatric patients given inappropriate antibiotic prescriptions from 7 emergency departments (EDs) in 2013 (for acute respiratory tract infections that were viral in nature) found significant differences in racial and ethnic trends. Minority children in the study were more likely not to receive a prescription for antibiotics than non-Hispanic white children, which was ironically, the appropriate treatment choice.⁸

As lead author, Monika Goyal, MD, MSCE, Director of Research, Division of Emergency Medicine at the Children’s National Health System in Washington, DC, told Infectious Disease Advisor, “I don’t think inappropriate antibiotic prescribing is limited to clinicians who work in EDs. Published literature also describes racial and ethnic differences in unnecessary antibiotic prescribing in the primary care setting.”^9-12 One of these studies, by Gerber et al,¹² found that even when treated by the same clinician, black children were less likely to be diagnosed with acute respiratory tract infections and to receive antibiotic prescriptions, and when they were, they received lower proportions of broad-spectrum antibiotic prescriptions than white children.

Dr Fleming-Dutra concurred. “We have noted racial differences in some of our analyses as well. Our group did an analysis of ear infections among children nationally — and we did note that black children were more likely to receive a guideline-recommended narrow-spectrum antibiotic for the infection — so it was actually the right antibiotic.¹³ It’s not always clear why this is happening, but we are trying to understand better what’s driving it.”

“This is a question that we hope to help answer with future research that will focus on understanding which discrete factors contribute to racial and ethnic differences in provision of clinical care,” Dr Goyal said.

Strategies for Improving Antibiotic Prescribing Patterns

The experts agreed that effective and appropriate use of antibiotics begins with antibiotic stewardship. Dr Goyal observed that, “quality improvement initiatives that extend antibiotic stewardship to the ED may help to curtail inappropriate antibiotic prescribing in that setting. These initiatives could improve the quality of care for all patients and need not be specific to any particular patient demographic.”

Dr Fleming-Dutra pointed to a current move toward using the minimum effective duration of therapy, which has yet to be determined for all bacterial conditions. “That is a key factor of antibiotic stewardship strategy in all settings of health care, where the goal is to maximize the benefits to the patient — to cure the infection while minimizing the risk of adverse events from antibiotics and antibiotic resistance.”

The CDC has been involved in public education efforts since the 1990s, Dr Fleming-Dutra said. In 2003, the program was officially named the Get Smart: Know When Antibiotics Work in Doctor’s Offices, providing information aimed at improving clinician’s understanding of appropriate prescribing practices.¹⁴ The program is currently undergoing revision and a new version is to be released in accordance with US Antibiotics Awareness Week, November 13-18, 2017.

References

1. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2013. http://www.cdc.gov/drugresistance/threat-report-2013/. Accessed April 11, 2016.
2. Fleming-Dutra KE, Hersh Al, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315:1864-1873.
3. Hicks LA, Bartoces MG, Roberts RM, et al. US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis. 2015;60:1308-1316.
4. Fleming-Dutra K. Why Do We Prescribe Antibiotics When They Aren’t Needed? https://blogs.cdc.gov/safehealthcare/why-do-we-prescribe-antibiotics-when-they-arent-needed/. Updated November 18, 2016. Accessed September 28, 2017.
5. Suda KJ, Hicks LA, Roberts RM, Hunkler RJ, Danziger LH. A national evaluation of antibiotic expenditures by healthcare setting in the United States, 2009. J Antimicrob Chemother. 2013;68:715-718.
6. Centers for Disease Control and Prevention (CDC). Office-related antibiotic prescribing for persons aged ≤14 years—United States, 1993–1994 to 2007–2008. MMWR Morb Mortal Wkly Rep. 2011;60:1153-1156.
7. Grijalva CG, Nuorti JP, Griffin MR. Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings.  JAMA. 2009;302:758-766.
8. Goyal MK, Johnson TJ, Chamberlain JM, et al; Pediatric Care Applied Research Network (PECARN). Racial and ethnic differences in antibiotic use for viral illness in emergency departments. Pediatrics. 2017;140(4).
9. Natale JE, Joseph JG, Rogers AJ, et al; PECARN (Pediatric Emergency Care Applied Research Network). Cranial computed tomography use among children with minor blunt head trauma: association with race/ethnicity.  Arch Pediatr Adolesc Med. 2012;166:732-737.
10. Yaeger JP, Temte JL, Hanrahan LP, Martinez-Donate P. Roles of clinician, patient, and community characteristics in the management of pediatric upper respiratory tract infections.  Ann Fam Med. 2015;13:529-536.
11. Goyal MK, Hayes KL, Mollen CJ. Racial disparities in testing for sexually transmitted infections in the emergency department.  Acad Emerg Med. 2012;19:604-607.
12. Gerber JS, Prasad PA, Localio AR, et al. Racial differences in antibiotic prescribing by primary care pediatricians.  Pediatrics. 2013;131:677-684.
13. Fleming-Dutra KE, Shapiro DJ, Hicks LA, Gerber JS, Hersh AL. Race, otitis media, and antibiotic selection.  Pediatrics. 2014;134:1059-1066.
14. Centers for Disease Control and Prevention. Antibiotic Prescribing and Use. https://www.cdc.gov/antibiotic-use/index.html Accessed September 28, 2017.