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.     

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.     

Antibiotic prescribing for adult bacteriuria and pyuria in community hospital emergency departments

ObjectiveTo describe emergency department (ED) antibiotic prescribing for urinary tract infections (UTIs) and asymptomatic bacteriuria (ASB) and to identify improvement opportunities.MethodsPatients treated for UTI in 16 community hospital EDs were reviewed to identify prescribing that was unnecessary (any treatment for ASB, duration >7 days for cystitis or >14 days for pyelonephritis) or suboptimal [ineffective antibiotics (nitrofurantoin/fosfomycin) or duration <7 days for pyelonephritis]. Duration criteria were based on recommendations for complicated UTI since criteria for uncomplicated UTI were not reviewed. 14-day repeat ED visits were evaluated.ResultsOf 250,788 ED visits, UTI was diagnosed in 13,466 patients (5%), and 1427 of these (11%) were manually reviewed. 286/1427 [20%, 95% CI: 18–22%] met criteria for ASB and received 2068 unnecessary antibiotic days [mean (±SD) 7 (2) days]. Mean treatment duration was 7 (2) days for cystitis and 9 (2) days for pyelonephritis. Of 446 patients with cystitis, 128 (29%) were prescribed >7 days (total 396 unnecessary). Of 422 pyelonephritis patients, 0 (0%) were prescribed >14 days, 20 (5%) were prescribed <7 days, and 9 (2%) were given ineffective antibiotics. Overall, prescribing was unnecessary or suboptimal in 443/1427 [31%, 95% CI: 29–33%] resulting in 2464/11,192 (22%) unnecessary antibiotic days and 8 (0.5%) preventable ED visits.ConclusionsAmong reviewed patients, poor UTI prescribing in 16 EDs resulted in unnecessary antibiotic days and preventable readmissions. Key areas for improvement include non-treatment of ASB and shorter durations for cystitis.     

Factors Associated with Antibiotic Misuse in Outpatient Treatment for Upper Respiratory Tract Infections

The Centers for Disease Control and Prevention has promoted the appropriate use of antibiotics since 1995 when it initiated the National Campaign for Appropriate Antibiotic Use in the Community. This study examined upper respiratory tract infections included in the campaign to determine the degree to which antibiotics were appropriately prescribed and subsequent admission rates in a veteran population. This study was a retrospective chart review conducted among outpatients with a diagnosis of a respiratory tract infection, including bronchitis, pharyngitis, sinusitis, or nonspecific upper respiratory tract infection, between January 2009 and December 2011. The study found that 595 (35.8%) patients were treated appropriately, and 1,067 (64.2%) patients received therapy considered inappropriate based on the Get Smart Campaign criteria. Overall the subsequent readmission rate was 1.5%. The majority (77.5%) of patients were prescribed an antibiotic. The most common antibiotics prescribed were azithromycin (39.0%), amoxicillin-clavulanate (13.2%), and moxifloxacin (7.5%). A multivariate regression analysis demonstrated significant predictors of appropriate treatment, including the presence of tonsillar exudates (odds ratio [OR], 0.6; confidence interval [CI], 0.3 to 0.9), fever (OR, 0.6; CI, 0.4 to 0.9), and lymphadenopathy (OR, 0.4; CI, 0.3 to 0.6), while penicillin allergy (OR, 2.9; CI, 1.7 to 4.7) and cough (OR, 1.6; CI, 1.1 to 2.2) were significant predictors for inappropriate treatment. Poor compliance with the Get Smart Campaign was found in outpatients for respiratory infections. Results from this study demonstrate the overprescribing of antibiotics, while providing a focused view of improper prescribing. This article provides evidence that current efforts are insufficient for curtailing inappropriate antibiotic use.     

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.     

Primary prevention of acute respiratory tract infections in children using a bacterial immunostimulant: a double-masked, placebo-controlled clinical trial

BACKGROUND: Acute respiratory tract infections (ARTIs) are among the main causes of morbidity and mortality in children. The bacterial extract OM-85 BV has shown some protective effect for ARTIs in preschool children and a reduction in exacerbations of chronic bronchitis in adults. OBJECTIVES: This trial reports results of a double-masked, placebo-controlled, parallel-group clinical study that assessed the efficacy and tolerability of OM-85 BV in the prevention of ARTIs in school girls living in an orphanage. METHODS: Two hundred girls (age range, 6 to 13 years) living in an orphanage entered the trial. Participants were randomly allocated to receive either OM-85 BV or placebo for 10 consecutive days a month for 3 consecutive months. Patients were followed up for 6 months, including the administration period. The trial began in September 1996 and finished in March 1997. Primary end points were the type and number of infections. Secondary end points included when an infection occurred, time to clinical cure, severity of infection, absenteeism from school due to an ARTI, number of antibiotics or other drugs prescribed, and duration of concomitant drug treatment. RESULTS: During the trial, patients in the OM-85 BV group experienced 143 ARTIs (135 upper ARTIs and 8 otitis episodes) and patients in the placebo group experienced 299 ARTIs (273 upper ARTIs, 1 lower ARTI, and 25 otitis episodes). The median number of ARTIs was 1.0 (0.0, 3.0; 5th percentile, 95th percentile) in the OM-85 BV group compared with 3.0 (2.0, 4.0; 5th percentile, 95th percentile) in the placebo group. This difference was statistically significant (P < 0.001). Participants who received OM-85 BV also showed significantly better results (P < 0.001) than participants who received placebo in terms of median duration of illness, median number of missed school days due to an ARTI, median number of antibiotic and drug courses, and median duration of concomitant treatment. There were significant differences (P < 0.05) in severity of ARTIs during month 4 of the trial, with patients receiving OM-85 BV showing less severe ARTIs than patients receiving placebo and shorter mean time to clinical cure from the second month to the fourth month. No adverse events related to the trial medications were reported. Conclusions: OM-85 BV had a preventive effect on ARTIs in the school girls, with a reduction in the antibiotic requirements and the duration of ARTIs. Future studies are needed to further explore the role of OM-85 BV in the prevention of ARTIs.     

Characteristics and temporal trends of "left before being seen" visits in US emergency departments, 1995-2002

The purpose of this study was to describe nationally representative characteristics and temporal trends in "left before being seen" (LBBS) visits in US emergency departments (EDs). The ED portion of the federal National Hospital Ambulatory Medical Care Survey, 1995-2002, was analyzed. Of the 810.6 million ED visits during the 8-year study period, an estimated 11.4 million (1.41%, 95% confidence interval [CI] 1.30-1.52) had an LBBS disposition. The number and proportion of LBBS visits have increased over time, from 1.1 million visits in 1995 (1.15%, 95% CI 0.95-1.35) to 2.1 million visits in 2002 (1.92%, 95% CI 1.67-2.17). LBBS patients were more likely to be younger, non-White, Hispanic, urban, and uninsured compared to non-LBBS patients. The number and proportion of LBBS visits have increased over time. LBBS visits disproportionately affect vulnerable populations. These findings suggest that recent strains on the US ED system are adversely affecting healthcare quality and access.