Outcomes of outpatient visits for acute respiratory illness in veterans with spinal cord injuries and disorders

OBJECTIVE: Respiratory complications are a leading cause of death in persons with spinal cord injuries and disorders (SCI&D). We examined same-day and 60-day hospitalizations and 60-day mortality after acute respiratory illness (ARI) outpatient visits. DESIGN: A longitudinal study was conducted of 8775 ARI visits in the Veterans Health Administration (VA) (October. 1997-September 2002) by persons with SCI&D. ARIs included upper respiratory infections (URI), acute bronchitis, pneumonia, and influenza (P&I). RESULTS: URIs accounted for almost half of all (49%) visits. A total of 14.9% of patients with ARIs were hospitalized the same day; 30.8% were hospitalized within 60 days. Predictors of hospitalization included diagnosis of either P&I or acute bronchitis, comorbid illness, level of injury, age, and VA SCI center visit. Overall 60-day mortality was 2.9% but was 7.9% for pneumonia. Mortality was related to diagnosis (P&I: odds ratio [OR] = 9.80, 95% confidence interval [CI]: 6.27-13.33; acute bronchitis: OR = 2.00, 95% CI: 1.08-2.93), age (65+: OR = 3.96, 95% CI: 2.23-5.70), and comorbid conditions (OR = 1.94, 95% CI: 1.43-2.46). CONCLUSIONS: P&I and acute bronchitis were associated with increased VA hospitalization and mortality rates. The case fatality rate for pneumonia is higher for SCI&D than the general population. Level of injury predicted hospitalization but not death. Efforts to improve prevention and treatment of ARIs in persons with SCI&D are needed.     

Facility-level variation in antibiotic prescriptions for veterans with upper respiratory infections

BACKGROUND: Programs have targeted individual patient and physician behaviors to reduce the use of antibiotics for upper respiratory infections (URIs), but such efforts have had limited success to date. OBJECTIVE: The aim of this study was to measure the extent of variation in antibiotic prescribing patterns at the hospital-facility level to determine whether organizational factors may be associated with patterns of antibiotic prescribing. METHODS: This was a cross-sectional study using linked pharmacy and encounter data to measure hospital-level variation in patterns of antibiotic prescribing at US Department of Veterans Affairs (VA) medical centers between October 1, 2000, and September 30, 2001. The main outcome measure was the proportion of visits for URIs or acute bronchitis with an antibiotic dispensed within 1 day before to 3 days after the encounter, restricted to primary-care and emergency/urgent care clinics at VA medical centers with > or =100 annual visits for URIs. RESULTS: A median of 523 visits for URIs occurred across 108 medical centers. The median proportion of visits with an antibiotic dispensed was 52% (range, 14%-88%). Hospitals in the South had increased odds of prescribing antibiotics for veterans with URIs compared with hospitals in the Northeast (odds ratio, 1.8 [95% CI, 1.2-2.5]). Among facilities with <200,000 visits per year, an increase in the percentage of unscheduled outpatient visits increased the odds of prescribing antibiotics for veterans with URIs (odds ratio per 10% increase, 1.3 [95% CI, 1.1-1.5]). CONCLUSIONS: Our results suggest variation in antibiotic prescribing for URIs at the hospital-facility level within the VA health care system. Organizational factors, such as time pressure, may be important targets for future interventions designed to reduce inappropriate antibiotic use in ambulatory care settings.     

Acute Respiratory Infection-Related Patient Behaviors and Expectations in Wyoming

Nurse practitioners (NPs) and other clinicians often overprescribe antibiotics for patients with viral acute respiratory infections (ARIs). Little is known about how patients approach ARI management or what they expect when they present with ARIs. This study of 655 households in Wyoming explored patient approaches and expectations regarding ARI management. Results indicate that although many patients expect antibiotics for ARIs, they also desire to be listened to regarding their concerns and receive advice regarding symptoms. NPs may be able to decrease antibiotic prescribing by directly addressing patient concerns, outlining options for symptom management, and providing convenient options for follow-up.     

Antibiotic prescribing in ambulatory care settings for adults with colds, upper respiratory tract infections, and bronchitis

BACKGROUND: Imprudent prescribing of antibiotics for patients with colds, upper respiratory tract infections (URIs), and bronchitis may contribute to antibiotic resistance and waste economic resources. OBJECTIVE: The purpose of this study was to determine the antibiotic prescribing rate for adults diagnosed with colds, URIs, and bronchitis in 1996 and to compare these rates with those reported for 1992. METHODS: This was a retrospective, cross-sectional analysis of a US government data base of ambulatory physician practices. The number of adults ( > or = 18 years of age) with a diagnosis of cold, URI, or bronchitis and the percentage receiving antibiotics were determined from the 1996 National Ambulatory Medical Care Survey (NAMCS). The antibiotic prescribing rate was the main outcome measure. RESULTS: In 1996, approximately 13.9 million office visits resulted in a primary diagnosis of cold, URI, or acute bronchitis; of these visits, 46%, 47%, and 60%, respectively, resulted in the prescribing of an antibiotic. The respective rates in 1992 were 51%, 52%, and 66%. The rates of antibiotic prescribing were 12% to 16% higher when all drugs, not just the first drug listed in the NAMCS database, were analyzed. In 1996, antibiotic prescribing rates for persons 45 to 64 years of age and persons > 64 years of age were significantly lower than for those aged 18 to 44 years. CONCLUSIONS: The rates of potentially inappropriate antibiotic prescribing decreased modestly from 1992 to 1996; however, previous rates may have been underestimated. The antibiotic prescribing rates for colds, URIs, and acute bronchitis may be as high as 61%, 63%, and 72%, respectively, when all drug information is analyzed. Antibiotics are over-prescribed, which may increase antibiotic resistance and waste health care resources.     

A randomized, double-blind, parallel-group, multicenter, placebo-controlled study of the safety and efficacy of extended-release guaifenesin/pseudoephedrine hydrochloride for symptom relief as an adjunctive therapy to antibiotic treatment of acute respiratory infections

Purpose: This study assessed the effi cacy and safety of guaifenesin 600 mg and pseudoephedrine hydrochloride 60 mg extended-release bilayer tablets in providing relief of acute respiratory symptoms when used as an adjunct to antibiotics in patients with an acute respiratory infection (ARI). Methods: Adult patients experiencing symptoms of ARI and meeting the physician's usual diagnostic criteria for oral antibiotic treatment were prescribed an antibiotic and randomized to adjunctive guaifenesin/pseudoephedrine hydrochloride or matching placebo twice daily for 7 days. Patients completed symptom diaries and treatment assessments twice daily and attended offi ce visits on Days 4 and 8. Results: The safety/intent-to-treat (ITT) population analysis included 601 patients (guaifenesin/ pseudoephedrine, n = 303; placebo, n = 298). Mean symptom scores were lower with guaifenesin/ pseudoephedrine from Day 3 for every symptom assessed, with statistically significant improvements in total symptom score from Day 3 (P = 0.026). The greatest effects of treatment with guaifenesin/pseudoephedrine were observed for nasal congestion and sinus headache. Time to overall relief was shorter with guaifenesin/pseudoephedrine (P = 0.038). Signifi cantly more patients reported "the medication was helping during the day" on Day 2 with guaifenesin/ pseudoephedrine (P = 0.002). Patient assessments of symptom relief showed a signifi cant preference for guaifenesin/pseudoephedrine versus placebo (P = 0.021). Treatment with guaifenesin/ pseudoephedrine was well tolerated. Insomnia (2.6%), nausea (2.3%), and headache (1.3%) were the most common treatment-related adverse effects. Conclusions: As adjunctive therapy for symptom relief for patients taking antibiotics for ARIs, guaifenesin/pseudoephedrine shortened time to relief and improved bothersome respiratory symptoms better than placebo, with greatest effects seen for nasal congestion and sinus headache.     

Antibiotic Utilization for Acute Respiratory Tract Infections in U.S. Emergency Departments

Inappropriate use of antibiotics for acute respiratory tract infections (ARTIs) has decreased in many outpatient settings. For patients presenting to U.S. emergency departments (EDs) with ARTIs, antibiotic utilization patterns are unclear. We conducted a retrospective cohort study of ED patients from 2001 to 2010 using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). We identified patients presenting to U.S. EDs with ARTIs and calculated rates of antibiotic utilization. Diagnoses were classified as antibiotic appropriate (otitis media, sinusitis, pharyngitis, tonsillitis, and nonviral pneumonia) or antibiotic inappropriate (nasopharyngitis, unspecified upper respiratory tract infection, bronchitis or bronchiolitis, viral pneumonia, and influenza).There were 126 million ED visits with a diagnosis of ARTI, and antibiotics were prescribed in 61%. Between 2001 and 2010, antibiotic utilization decreased for patients aged <5 presenting with antibiotic-inappropriate ARTI (rate ratio [RR], 0.94; confidence interval [CI], 0.88 to 1.00). Utilization also decreased significantly for antibiotic-inappropriate ARTI patients aged 5 to 19 years (RR, 0.89; CI, 0.85 to 0.94). Utilization remained stable for antibiotic-inappropriate ARTI among adult patients aged 20 to 64 years (RR, 0.99; CI, 0.97 to 1.01). Among adults, rates of quinolone use for ARTI increased significantly from 83 per 1,000 visits in 2001 to 2002 to 105 per 1,000 in 2009 to 2010 (RR, 1.08; CI, 1.03 to 1.14). Although significant progress has been made toward reduction of antibiotic utilization for pediatric patients with ARTI, the proportion of adult ARTI patients receiving antibiotics in U.S. EDs is inappropriately high. Institution of measures to reduce inappropriate antibiotic use in the ED setting is warranted.     

Prescribing practices that promote antibiotic resistance: strategies for change

Approximately 90% of all upper respiratory infections are caused by viruses, yet antibiotics are prescribed for 50% to 70% of patients who seek medical care for these conditions (Neiderman, Skerrett, & Yamauchi, 1998). Prescribing antibiotics for conditions for which there is no proven benefit is not a harmless practice; it contributes to the development of antibiotic resistance (Ware, 2000). This article will discuss the magnitude of the problem of antibiotic resistance as it relates to pediatric outpatient upper respiratory tract infection and otitis media, analyze practitioner prescribing practices that contribute to widespread antibiotic use, and suggest provider and patient intervention to improve the rational use of antibiotics.