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Gonzales  R, Steiner  JF, Sande  MA.  Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians.  JAMA. 1997;278:901-904. PubMedGoogle ScholarCrossref
Linder  JA, Stafford  RS.  Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989-1999.  JAMA. 2001;286:1181-1186. PubMedGoogle ScholarCrossref
Piccirillo  JF, Mager  DE, Frisse  ME, Brophy  RH, Goggin  A.  Impact of first-line vs second-line antibiotics for the treatment of acute uncomplicated sinusitis.  JAMA. 2001;286:1849-1856. PubMedGoogle ScholarCrossref
McCaig  LF, Besser  RE, Hughes  JM.  Trends in antimicrobial prescribing rates for children and adolescents.  JAMA. 2002;287:3096-3102. PubMedGoogle ScholarCrossref
Snow  V, Mottur-Pilson  C, Gonzales  R.  Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults.  Ann Intern Med. 2001;134:487-489. PubMedGoogle ScholarCrossref
Snow  V, Mottur-Pilson  C, Gonzales  R.  Principles of appropriate antibiotic use for treatment of acute bronchitis in adults.  Ann Intern Med. 2001;134:518-520. PubMedGoogle ScholarCrossref
Takata  GS, Chan  LS, Shekelle  P, Morton  SC, Mason  W, Marcy  SM.  Evidence assessment of management of acute otitis media, I: the role of antibiotics in treatment of uncomplicated acute otitis media.  Pediatrics. 2001;108:239-247. PubMedGoogle ScholarCrossref
Austin  DJ, Kristinsson  KG, Anderson  RM.  The relationship between the volume of antimicrobial consumption in human communities and the frequency of resistance.  Proc Natl Acad Sci U S A. 1999;96:1152-1156. PubMedGoogle ScholarCrossref
Not Available.  Resistance of Streptococcus pneumoniae to fluoroquinolones—United States, 1995-1999  MMWR Morb Mortal Wkly Rep. 2001;50:800-804. PubMedGoogle Scholar
Hyde  TB, Gay  K, Stephens  DS,  et al.  Macrolide resistance among invasive Streptococcus pneumoniae isolates.  JAMA. 2001;286:1857-1862. PubMedGoogle ScholarCrossref
Gonzales  R, Barrett Jr  PH, Crane  LA, Steiner  JF.  Factors associated with antibiotic use for acute bronchitis.  J Gen Intern Med. 1998;13:541-548. PubMedGoogle ScholarCrossref
Gonzales  R, Barrett Jr  PH, Steiner  JF.  The relation between purulent manifestations and antibiotic treatment of upper respiratory tract infections.  J Gen Intern Med. 1999;14:151-156. PubMedGoogle ScholarCrossref
Hemminki  E.  Review of literature on the factors affecting drug prescribing.  Soc Sci Med. 1975;9:111-116. PubMedGoogle ScholarCrossref
Soumerai  SB, Ross-Degnan  D, Avorn  J, McLaughlin  T, Choodnovskiy  I.  Effects of Medicaid drug-payment limits on admission to hospitals and nursing homes.  N Engl J Med. 1991;325:1072-1077. PubMedGoogle ScholarCrossref
Wazana  A.  Physicians and the pharmaceutical industry: is a gift ever just a gift?  JAMA. 2000;283:373-380. PubMedGoogle ScholarCrossref
Avorn  J, Soumerai  SB.  Improving drug-therapy decisions through educational outreach: a randomized controlled trial of academically based "detailing."  N Engl J Med. 1983;308:1457-1463. PubMedGoogle ScholarCrossref
Avorn  J, Solomon  DH.  Cultural and economic factors that (mis)shape antibiotic use: the nonpharmacologic basis of therapeutics.  Ann Intern Med. 2000;133:128-135. PubMedGoogle ScholarCrossref
National Center for Health Statistics.  Public Use Microdata File Documentation, National Ambulatory Medical Care Survey, 1997 Hyattsville, Md: National Technical Information Service; 1999.
National Center for Health Statistics.  Public Use Microdata File Documentation, National Ambulatory Medical Care Survey, 1998 Hyattsville, Md: National Technical Information Service; 2000.
National Center for Health Statistics.  Public Use Microdata File Documentation, National Ambulatory Medical Care Survey, 1999 Hyattsville, Md: National Technical Information Service; 2001.
Not Available.  International Classification of Diseases, Ninth Revision, Clinical Modification. Washington, DC: Public Health Service, US Dept of Health and Human Services; 1988.
Gonzales  R, Malone  DC, Maselli  JH, Sande  MA.  Excessive antibiotic use for acute respiratory infections in the United States.  Clin Infect Dis. 2001;33:757-762. PubMedGoogle ScholarCrossref
Ioannidis  JP, Contopoulos-Ioannidis  DG, Chew  P, Lau  J.  Meta-analysis of randomized controlled trials on the comparative efficacy and safety of azithromycin against other antibiotics for upper respiratory tract infections.  J Antimicrob Chemother. 2001;48:677-689. PubMedGoogle ScholarCrossref
Cabana  MD, Rand  CS, Powe  NR,  et al.  Why don't physicians follow clinical practice guidelines? a framework for improvement.  JAMA. 1999;282:1458-1465. PubMedGoogle ScholarCrossref
Schwartz  RK, Soumerai  SB, Avorn  J.  Physician motivations for nonscientific drug prescribing.  Soc Sci Med. 1989;28:577-582. PubMedGoogle ScholarCrossref
Metlay  JP, Shea  JA, Crossette  LB, Asch  DA.  Tensions in antibiotic prescribing: pitting social concerns against the interests of individual patients.  J Gen Intern Med. 2002;17:87-94. PubMedGoogle ScholarCrossref
Epstein  AM, Read  JL, Winickoff  R.  Physician beliefs, attitudes, and prescribing behavior for anti-inflammatory drugs.  Am J Med. 1984;77:313-318. PubMedGoogle ScholarCrossref
Carrin  G.  Drug prescribing: a discussion of its variability and (ir)rationality.  Health Policy. 1987;7:73-94. PubMedGoogle ScholarCrossref
Cockburn  J, Pit  S.  Prescribing behaviour in clinical practice: patients' expectations and doctors' perceptions of patients' expectations—a questionnaire study.  BMJ. 1997;315:520-523. PubMedGoogle ScholarCrossref
Macfarlane  J, Holmes  W, Macfarlane  R, Britten  N.  Influence of patients' expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study.  BMJ. 1997;315:1211-1214. PubMedGoogle ScholarCrossref
Wilkes  MS, Bell  RA, Kravitz  RL.  Direct-to-consumer prescription drug advertising: trends, impact, and implications.  Health Aff (Millwood). 2000;19:110-128. PubMedGoogle ScholarCrossref
Hamm  RM, Hicks  RJ, Bemben  DA.  Antibiotics and respiratory infections: are patients more satisfied when expectations are met?  J Fam Pract. 1996;43:56-62. PubMedGoogle Scholar
Butler  CC, Rollnick  S, Pill  R, Maggs-Rapport  F, Stott  N.  Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats.  BMJ. 1998;317:637-642. PubMedGoogle ScholarCrossref
Chew  LD, O'Young  TS, Hazlet  TK, Bradley  KA, Maynard  C, Lessler  DS.  A physician survey of the effect of drug sample availability on physicians' behavior.  J Gen Intern Med. 2000;15:478-483. PubMedGoogle ScholarCrossref
Bell  RA, Wilkes  MS, Kravitz  RL.  Advertisement-induced prescription drug requests: patients' anticipated reactions to a physician who refuses.  J Fam Pract. 1999;48:446-452. PubMedGoogle Scholar
Rosenthal  MB, Berndt  ER, Donohue  JM, Frank  RG, Epstein  AM.  Promotion of prescription drugs to consumers.  N Engl J Med. 2002;346:498-505. PubMedGoogle ScholarCrossref
Chren  MM, Landefeld  CS, Murray  TH.  Doctors, drug companies, and gifts.  JAMA. 1989;262:3448-3451. PubMedGoogle ScholarCrossref
Chren  MM, Landefeld  CS.  Physicians' behavior and their interactions with drug companies: a controlled study of physicians who requested additions to a hospital drug formulary.  JAMA. 1994;271:684-689. PubMedGoogle ScholarCrossref
Lurie  N, Rich  EC, Simpson  DE,  et al.  Pharmaceutical representatives in academic medical centers: interaction with faculty and housestaff.  J Gen Intern Med. 1990;5:240-243. PubMedGoogle ScholarCrossref
Ziegler  MG, Lew  P, Singer  BC.  The accuracy of drug information from pharmaceutical sales representatives.  JAMA. 1995;273:1296-1298. PubMedGoogle ScholarCrossref
Lambert  BL, Salmon  JW, Stubbings  J, Gilomen-Study  G, Valuck  RJ, Kezlarian  K.  Factors associated with antibiotic prescribing in a managed care setting: an exploratory investigation.  Soc Sci Med. 1997;45:1767-1779. PubMedGoogle ScholarCrossref
Avery  AJ, Walker  B, Heron  T, Teasdale  SJ.  Do prescribing formularies help GPs prescribe from a narrower range of drugs? a controlled trial of the introduction of prescribing formularies for NSAIDs.  Br J Gen Pract. 1997;47:810-814. PubMedGoogle Scholar
Mather  JL, Bayliff  CD, Reider  MJ, Hussain  Z, Colby  WD.  The impact of formulary reservations on drug utilization: a controlled trial.  Can J Hosp Pharm. 1994;47:111-116. PubMedGoogle Scholar
Harrold  LR, Field  TS, Gurwitz  JH.  Knowledge, patterns of care, and outcomes of care for generalists and specialists.  J Gen Intern Med. 1999;14:499-511. PubMedGoogle ScholarCrossref
Walker  S, McGeer  A, Simor  AE, Armstrong-Evans  M, Loeb  M.  Why are antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly people? a qualitative study of physicians' and nurses' perceptions.  CMAJ. 2000;163:273-277. PubMedGoogle Scholar
Safavi  KT, Hayward  RA.  Choosing between apples and apples: physicians' choices of prescription drugs that have similar side effects and efficacies.  J Gen Intern Med. 1992;7:32-37. PubMedGoogle ScholarCrossref
Hasty  M, Schrager  J, Wrenn  K.  Physicians' perceptions about managed care restrictions on antibiotic prescribing.  J Gen Intern Med. 1999;14:756-758. PubMedGoogle ScholarCrossref
Hadley  J, Mitchell  JM, Sulmasy  DP, Bloche  MG.  Perceived financial incentives, HMO market penetration, and physicians' practice styles and satisfaction.  Health Serv Res. 1999;34:307-321. PubMedGoogle Scholar
Reschovsky  J, Reed  M, Blumenthal  D, Landon  B.  Physicians' assessments of their ability to provide high-quality care in a changing health care system.  Med Care. 2001;39:254-269. PubMedGoogle ScholarCrossref
Mainous 3rd  AG, Hueston  WJ, Eberlein  C.  Colour of respiratory discharge and antibiotic use.  Lancet. 1997;350:1077. PubMedGoogle ScholarCrossref
Metlay  JP, Stafford  RS, Singer  DE.  National trends in the use of antibiotics by primary care physicians for adult patients with cough.  Arch Intern Med. 1998;158:1813-1818. PubMedGoogle ScholarCrossref
Mainous III  AG, Hueston  WJ, Love  MM.  Antibiotics for colds in children: who are the high prescribers?  Arch Pediatr Adolesc Med. 1998;152:349-352. PubMedGoogle ScholarCrossref
Hutchinson  JM, Foley  RN.  Method of physician remuneration and rates of antibiotic prescription.  CMAJ. 1999;160:1013-1017. PubMedGoogle Scholar
Oxman  AD, Thomson  MA, Davis  DA, Haynes  RB.  No magic bullets: a systematic review of 102 trials of interventions to improve professional practice.  CMAJ. 1995;153:1423-1431. PubMedGoogle Scholar
Bero  LA, Grilli  R, Grimshaw  JM, Harvey  E, Oxman  AD, Thomson  MA, for the Cochrane Effective Practice and Organization of Care Review Group.  Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings.  BMJ. 1998;317:465-468. PubMedGoogle ScholarCrossref
Soumerai  SB, Majdumar  S, Lipton  HL.  Evaluating and improving physician prescribing.  In: Strom  BL. ed.  Pharmacoepidemiology. New York, NY: John Wiley & Sons Inc; 2000:483-503.Google Scholar
Soumerai  SB, Avorn  J.  Principles of educational outreach ("academic detailing") to improve clinical decision making.  JAMA. 1990;263:549-556. PubMedGoogle ScholarCrossref
Gonzales  R, Steiner  JF, Lum  A, Barrett Jr  PH.  Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults.  JAMA. 1999;281:1512-1519. PubMedGoogle ScholarCrossref
Original Contribution
February 12, 2003

Predictors of Broad-Spectrum Antibiotic Prescribing for Acute Respiratory Tract Infections in Adult Primary Care

Author Affiliations

Author Affiliations: Division of Geriatrics and VA National Quality Scholars Program, San Francisco VA Medical Center, San Francisco, Calif (Drs Steinman and Landefeld), and Department of Medicine, University of California, San Francisco (Drs Steinman, Landefeld, and Gonzales).

JAMA. 2003;289(6):719-725. doi:10.1001/jama.289.6.719

Context  Broad-spectrum antibiotics are commonly prescribed, but little is known about the physicians who prescribe and the patients who take these agents.

Objective  To identify factors associated with prescribing of broad-spectrum antibiotics by physicians caring for patients with nonpneumonic acute respiratory tract infections (ARTIs).

Design, Setting, and Patients  Cross-sectional study using data from the National Ambulatory Medical Care Survey between 1997 and 1999. Information was collected on a national sample of 1981 adults seen by physicians for the common cold and nonspecific upper respiratory tract infections (URTIs) (24%), acute sinusitis (24%), acute bronchitis (23%), otitis media (5%), pharyngitis, laryngitis, and tracheitis (11%), or more than 1 of the above diagnoses (13%).

Main Outcome Measure  Prescription of broad-spectrum antibiotics, defined for this study as quinolones, amoxicillin/clavulanate, second- and third-generation cephalosporins, and azithromycin and clarithromycin.

Results  Antibiotics were prescribed to 63% of patients with an ARTI, ranging from 46% of patients with the common cold or nonspecific URTIs to 69% of patients with acute sinusitis. Broad-spectrum agents were chosen in 54% of patients prescribed an antibiotic, including 51% of patients with the common cold and nonspecific URTIs, 53% with acute sinusitis, 62% with acute bronchitis, and 65% with otitis media. Multivariable analysis identified several clinical and nonclinical factors associated with choice of a broad-spectrum agent. After adjusting for diagnosis and chronic comorbid illnesses, the strongest independent predictors of broad-spectrum antibiotic prescribing were physician specialty (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.5 for internal medicine physicians compared with general and family physicians) and geographic region (OR, 2.6; 95% CI, 1.4-4.8 for Northeast and OR, 2.4; 95% CI, 1.4-4.2 for South [both compared with West]). Other independent predictors of choosing a broad-spectrum agent included black race, lack of health insurance, and health maintenance organization membership, each of which was associated with lower rates of broad-spectrum prescribing. Patient age, sex, and urban vs rural location were not significantly associated with prescribing choice.

Conclusions  Broad-spectrum antibiotics are commonly prescribed for the treatment of ARTIs, especially by internists and physicians in the Northeast and South. These high rates of prescribing, wide variations in practice patterns, and the strong association of nonclinical factors with antibiotic choice suggest opportunities to improve prescribing patterns.