antibiotic prescribing practices; antibiotic overuse; outpatient parenteral antibiotics

Introduction

also see antimicrobial stewardship

Epidemiology

• antibiotic overuse is common
• almost 50% of viral upper respiratory infections treated with antibiotics in urgent care
• 80% of Americans take an antibiotic every year
• antibiotics are prescribed in > 2/3 of adult patient visits for viral upper respiratory tract infections
• based on ICD-10-CM diagnosis codes
  • 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
• 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
• in nursing homes prevention & treatment of urinary tract infections most common use of antibiotics

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)

Management

• outpatients on parenteral antibiotics should be monitored weekly for adverse drug effects

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
  • hispanics more likely other patients to expect antibiotics (41% vs 26%)
  • ~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
• only 1/2 of outpatient antibiotic prescriptions are associated with both an in person visit & a documented infection
• providers more likely to prescribe unnecessary antibiotics later in their clinic sessions
• 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%
• consider the cost to benefit:
  • 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
  • childhood anti-anaerobic antibiotic exposure is associated with inflammatory bowel disease
• 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%
  • accountable justification & peer comparison are two such behavioral interventions
  • prescribing practices revert to former ways when feedback is discontinued
  • inappropriate antibiotic prescribing rates may rebound when behavioral interventions are discontinued
• education is minimally effective in reducing antibiotic overuse
• outpatient parenteral antibiotics may be appropriate for selected patients
• 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
• most patients hospitalized with pneumonia receive antibiotics prescribed at discharge for too long
  • no clinical benefit
  • adverse effect, including diarrhea, common

More general terms

• prescribing practices

Additional terms

• antibiotic (antimicrobial agent)
• antibiotic resistance
• antibiotic therapy
• antimicrobial stewardship