Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011 | Infectious Diseases | JAMA | JAMA Network
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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.
Linder  JA.  Editorial commentary: antibiotics for treatment of acute respiratory tract infections: decreasing benefit, increasing risk, and the irrelevance of antimicrobial resistance.  Clin Infect Dis. 2008;47(6):744-746.PubMedGoogle ScholarCrossref
3.
Swedres-Svarm Reports.  Swedres-Svarm 2014. http://www.sva.se/en/antibiotics/svarm-reports. Accessed May 26, 2015.
4.
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(9):1308-1316.PubMedGoogle Scholar
5.
Vaz  LE, Kleinman  KP, Raebel  MA,  et al.  Recent trends in outpatient antibiotic use in children.  Pediatrics. 2014;133(3):375-385.PubMedGoogle ScholarCrossref
6.
Suda  KJ, Hicks  LA, Roberts  RM, Hunkler  RJ, Taylor  TH.  Trends and seasonal variation in outpatient antibiotic prescription rates in the United States, 2006 to 2010.  Antimicrob Agents Chemother. 2014;58(5):2763-2766.PubMedGoogle ScholarCrossref
7.
Shulman  ST, Bisno  AL, Clegg  HW,  et al.  Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2014;58(10):1496].  Clin Infect Dis. 2012;55(10):1279-1282.PubMedGoogle ScholarCrossref
8.
Lieberthal  AS, Carroll  AE, Chonmaitree  T,  et al.  The diagnosis and management of acute otitis media [published correction appears in Pediatrics. 2014;133(2):346].  Pediatrics. 2013;131(3):e964-e999.PubMedGoogle ScholarCrossref
9.
Chow  AW, Benninger  MS, Brook  I,  et al; Infectious Diseases Society of America.  IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults.  Clin Infect Dis. 2012;54(8):e72-e112.PubMedGoogle ScholarCrossref
10.
Rosenfeld  RM, Piccirillo  JF, Chandrasekhar  SS,  et al.  Clinical practice guideline (update): adult sinusitis.  Otolaryngol Head Neck Surg. 2015;152(2)(suppl):S1-S39.PubMedGoogle Scholar
11.
Centers for Disease Control and Prevention.  Get smart: know when antibiotics work.http://www.cdc.gov/getsmart. Accessed April 12, 2016.
12.
The White House.  National action plan for combating antibiotic-resistant bacteria.https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf. Accessed April 12, 2016.
13.
Metlay  JP.  Editorial commentary: setting national targets for antibiotic use.  Clin Infect Dis. 2015;60(9):1317-1318.PubMedGoogle Scholar
14.
Healthy People 2020.  Immunization and infectious diseases.https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectives. Accessed October 20, 2015.
16.
Centers for Disease Control and Prevention.  Ambulatory health care data.http://www.cdc.gov/nchs/ahcd.htm. Accessed December 14, 2012.
17.
Gonzales  R, Malone  DC, Maselli  JH, Sande  MA.  Excessive antibiotic use for acute respiratory infections in the United States.  Clin Infect Dis. 2001;33(6):757-762.PubMedGoogle ScholarCrossref
18.
Kronman  MP, Zhou  C, Mangione-Smith  R.  Bacterial prevalence and antimicrobial prescribing trends for acute respiratory tract infections.  Pediatrics. 2014;134(4):e956-e965.PubMedGoogle ScholarCrossref
19.
Shapiro  DJ, Hicks  LA, Pavia  AT, Hersh  AL.  Antibiotic prescribing for adults in ambulatory care in the United States of America, 2007-09.  J Antimicrob Chemother. 2014;69(1):234-240.PubMedGoogle ScholarCrossref
20.
Levri  K, Thomas  A. Evaluation of Antibiotics Administered for Acute Upper Respiratory Tract Infections—Oregon, 2011. Paper presented at: EIS Conference; April 28, 2014; Atlanta, GA.
21.
US Census Bureau, Population Division, Vintage 2010 Special Tabulation and Vintage 2011 Special Tabulation.
22.
Shaikh  N, Leonard  E, Martin  JM.  Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis.  Pediatrics. 2010;126(3):e557-e564.PubMedGoogle ScholarCrossref
23.
Fine  AM, Nizet  V, Mandl  KD.  Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis.  Arch Intern Med. 2012;172(11):847-852.PubMedGoogle ScholarCrossref
24.
Irwin  RS, Baumann  MH, Bolser  DC,  et al; American College of Chest Physicians (ACCP).  Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines.  Chest. 2006;129(1)(suppl):1S-23S.PubMedGoogle ScholarCrossref
25.
Hersh  AL, Jackson  MA, Hicks  LA; American Academy of Pediatrics Committee on Infectious Diseases.  Principles of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics.  Pediatrics. 2013;132(6):1146-1154.PubMedGoogle ScholarCrossref
26.
Ralston  SL, Lieberthal  AS, Meissner  HC,  et al; American Academy of Pediatrics.  Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis.  Pediatrics. 2014;134(5):e1474-e1502.PubMedGoogle ScholarCrossref
27.
Snow  V, Mottur-Pilson  C, Gonzales  R; American College of Physicians-American Society of Internal Medicine; American Academy of Family Physicians; Centers for Disease Control; Infectious Diseases Society of America.  Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults.  Ann Intern Med. 2001;134(6):487-489.PubMedGoogle ScholarCrossref
28.
National Asthma Education and Prevention Program.  Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: US Dept of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute; 2007.
29.
Fiore  AE, Fry  A, Shay  D, Gubareva  L, Bresee  JS, Uyeki  TM; Centers for Disease Control and Prevention (CDC).  Antiviral agents for the treatment and chemoprophylaxis of influenza—recommendations of the Advisory Committee on Immunization Practices (ACIP).  MMWR Recomm Rep. 2011;60(1):1-24.PubMedGoogle Scholar
30.
Bradley  JS, Byington  CL, Shah  SS,  et al; Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.  The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.  Clin Infect Dis. 2011;53(7):e25-e76.PubMedGoogle ScholarCrossref
31.
American Academy of Family Physicians; American Academy of Otolaryngology-Head and Neck Surgery; American Academy of Pediatrics Subcommittee on Otitis Media With Effusion.  Otitis media with effusion.  Pediatrics. 2004;113(5):1412-1429.PubMedGoogle ScholarCrossref
32.
Gupta  K, Hooton  TM, Naber  KG,  et al; Infectious Diseases Society of America; European Society for Microbiology and Infectious Diseases.  International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases.  Clin Infect Dis. 2011;52(5):e103-e120.PubMedGoogle ScholarCrossref
33.
Wald  ER, Applegate  KE, Bordley  C,  et al; American Academy of Pediatrics.  Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years.  Pediatrics. 2013;132(1):e262-e280.PubMedGoogle ScholarCrossref
34.
Gerber  JS, Prasad  PA, Localio  AR,  et al.  Racial differences in antibiotic prescribing by primary care pediatricians.  Pediatrics. 2013;131(4):677-684.PubMedGoogle ScholarCrossref
35.
Centers for Disease Control and Prevention.  Get smart know when antibiotics work: measuring outpatient antibiotic prescribing.http://www.cdc.gov/getsmart/community/programs-measurement/measuring-antibiotic-prescribing.html. Accessed February 16, 2016.
36.
European Centre for Disease Prevention and Control.  Annual epidemiological report 2014: antimicrobial resistance and health care–associated infections.http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1292. Accessed April 12, 2016.
37.
Groth  A, Enoksson  F, Hermansson  A, Hultcrantz  M, Stalfors  J, Stenfeldt  K.  Acute mastoiditis in children in Sweden 1993-2007—no increase after new guidelines.  Int J Pediatr Otorhinolaryngol. 2011;75(12):1496-1501.PubMedGoogle ScholarCrossref
38.
Centers for Disease Control and Prevention (CDC).  Progress in introduction of pneumococcal conjugate vaccine—worldwide, 2000-2008.  MMWR Morb Mortal Wkly Rep. 2008;57(42):1148-1151.PubMedGoogle Scholar
39.
Drekonja  DM, Filice  GA, Greer  N,  et al.  Antimicrobial stewardship in outpatient settings: a systematic review.  Infect Control Hosp Epidemiol. 2015;36(2):142-152.PubMedGoogle ScholarCrossref
40.
Hing  E, Shimizu  IM, Talwalkar  A.  Nonresponse bias in estimates from the 2012 National Ambulatory Medical Care Survey. http://www.cdc.gov/nchs/data/series/sr_02/sr02_171.pdf. Accessed April 12, 2016.
Original Investigation
May 3, 2016

Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011

Author Affiliations
  • 1Centers for Disease Control and Prevention, Atlanta, Georgia
  • 2Pediatric Infectious Diseases, University of Utah, Salt Lake City
  • 3School of Medicine, University of California, San Francisco, San Francisco
  • 4Division of Health Policy and Management, University of Minnesota, Minneapolis
  • 5Summa Health System and Northeast Ohio Medical University, Akron
  • 6Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
  • 7Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 8University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 9Pew Charitable Trusts, Washington, DC
  • 10Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
  • 11Minnesota Department of Health, St Paul
  • 12Department of Emergency Medicine, University of California-Davis, Sacramento
  • 13Department of Family Medicine, Georgetown University Medical Center, Washington, DC
  • 14Division of General Internal Medicine, Massachusetts General Hospital, Boston
  • 15Division of Pediatric Infectious Diseases, Washington University School of Medicine, St Louis, Missouri
  • 16Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
  • 17Department of Veterans Affairs, University of Illinois at Chicago, Chicago
  • 18Oregon Public Health Division, Portland
  • 19Pacific Lutheran University, Tacoma, Washington
JAMA. 2016;315(17):1864-1873. doi:10.1001/jama.2016.4151
Abstract

Importance  The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotic use by 50% by 2020, but the extent of inappropriate outpatient antibiotic use is unknown.

Objective  To estimate the rates of outpatient oral antibiotic prescribing by age and diagnosis, and the estimated portions of antibiotic use that may be inappropriate in adults and children in the United States.

Design, Setting, and Participants  Using the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, annual numbers and population-adjusted rates with 95% confidence intervals of ambulatory visits with oral antibiotic prescriptions by age, region, and diagnosis in the United States were estimated.

Exposures  Ambulatory care visits.

Main Outcomes and Measures  Based on national guidelines and regional variation in prescribing, diagnosis-specific prevalence and rates of total and appropriate antibiotic prescriptions were determined. These rates were combined to calculate an estimate of the appropriate annual rate of antibiotic prescriptions per 1000 population.

Results  Of the 184 032 sampled visits, 12.6% of visits (95% CI, 12.0%-13.3%) resulted in antibiotic prescriptions. Sinusitis was the single diagnosis associated with the most antibiotic prescriptions per 1000 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]). Collectively, acute respiratory conditions per 1000 population led to 221 antibiotic prescriptions (95% CI, 198-245) annually, but only 111 antibiotic prescriptions were estimated to be appropriate for these conditions. Per 1000 population, among all conditions and ages combined in 2010-2011, an estimated 506 antibiotic prescriptions (95% CI, 458-554) were written annually, and, of these, 353 antibiotic prescriptions were estimated to be appropriate antibiotic prescriptions.

Conclusions and Relevance  In the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate, supporting the need for establishing a goal for outpatient antibiotic stewardship.

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