PerspectiveIn the Journals

CDC estimates 30% of antibiotic prescriptions in US unnecessary

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May 4, 2016

Approximately one in three antibiotics prescribed in outpatient settings in the United States are unnecessary, according to recent data published in JAMA.

The CDC reported that the majority of these misused antibiotics are prescribed for viral respiratory conditions such as common colds, bronchitis, sinus and ear infections.

Thomas Frieden, MD, MPH

Thomas R. Frieden

“Antibiotics are lifesaving drugs, and if we continue down the road of inappropriate use, we’ll lose the most powerful tool we have to fight life-threatening infections,” CDC Director Thomas R. Frieden, MD, MPH, said in a press release. “Losing these antibiotics would undermine our ability to treat patients with deadly infections, cancer, provide organ transplants, and save victims of burns and trauma.”

The CDC estimates that 2 million antibiotic-resistance infections, primarily driven by antibiotic use, occur each year and result in 23,000 deaths. Although antibiotic prescribing declined in the U.S. during the 1990s and early 2000s, prescription rates have remained unchanged since 2010, according to CDC researcher Katherine E. Fleming-Dutra, MD, and colleagues.

To estimate the current rate of antibiotic prescriptions in the U.S., Fleming-Dutra and colleagues assessed data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS). The surveys are administered annually by the CDC’s National Center for Health Statistics to nonfederally employed physicians and nonfederal EDs and outpatient facilities. A group of experts were convened under the Pew Charitable Trusts to determine whether the antibiotic prescriptions were appropriate based on national guidelines and regional variability.

The analysis included data from 184,032 sampled ambulatory care visits in 2010 and 2011, 12.6% of which were associated with antibiotic prescriptions. The researchers estimated there were 506 antibiotic prescriptions (95% CI, 458-554) per 1,000 population annually; however, only 353 prescriptions were deemed appropriate.

“Collectively, across all conditions, an estimated 30% of outpatient, oral antibiotic prescriptions may have been inappropriate,” Fleming-Dutra and colleagues wrote.

Acute respiratory conditions accounted for 221 antibiotic prescriptions (95% CI, 198-245) per 1,000 population, but just half of these, representing 34 million antibiotic prescriptions, were necessary. Sinusitis was the most common diagnosis associated with antibiotic prescribing (56 prescriptions; 95% CI, 48-64), followed by suppurative otitis media (47 prescriptions; 95% CI, 41-54) and pharyngitis (43 prescriptions; 95% CI, 38-49).

Prescribing rates were highest in children aged 2 years and younger (1,287 antibiotic prescriptions per 1,000 population) and varied by region, ranging from 423 prescriptions per 1,000 population in the West to 553 prescriptions per 1,000 population in the South. Fleming-Dutra and colleagues noted that if national prescription rates were similar to those in the lowest-prescribing region, antibiotic use would be reduced by approximately 19%.

“To our knowledge, no data suggest worse outcomes for these conditions in low-prescribing regions due to undertreatment; in fact, there is evidence of antibiotic overuse even in low-prescribing regions,” they wrote.

Based on their data, the researchers determined that a 15% reduction in antibiotic use is needed in order to meet the White House National Action Plan for Combating Antibiotic-Resistant Bacteria goal of reducing at least half of inappropriate outpatient antibiotic prescribing by 2020.

Lauri Hicks

“Setting a national target to reduce unnecessary antibiotic use in outpatient settings is a critical first step to improve antibiotic use and protect patients,” Lauri Hicks, DO, director of the CDC’s Office of Antibiotic Stewardship and commander in the U.S. Public Health Service, said in the release. “We must continue to work together across the entire health care continuum to make sure that antibiotics are prescribed only when needed, and when an antibiotic is needed that the right antibiotic, dose and duration are selected.”

In a related editorial, Pranita D. Tamma, MD, MHS, and Sara E. Cosgrove, MD, MS, of Johns Hopkins University, discussed several strategies that could improve antibiotic prescribing practices. The authors wrote that clinicians’ concerns related to diagnostics, patient satisfaction and peer practices will need to be eased, and that patients should be educated on the role of antibiotics. Another approach, they wrote, is the development of point-of-care rapid diagnostic tests that can distinguish between viral and bacterial infections.

Pranita Tamma

Pranita D. Tamma

“Now that baseline estimates about outpatient antibiotic prescribing have been determined, future work needs to focus on interventions targeting both clinicians and patients to help reach the national goal,” Tamma and Cosgrove wrote. “It will be critical to continue to evaluate progress in improving antibiotic use in conjunction with widespread adoption of antibiotic stewardship activities in the outpatient setting.” – by Stephanie Viguers

Disclosures: Cosgrove reports serving as a consultant for Novartis and her institution receiving Pfizer Grants for Learning and Change/The Joint Commission. Tamma reports her institution receiving Pfizer Grants for Learning and Change/The Joint Commission and grants from Merck. Fleming-Dutra, Frieden and Hicks report no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.

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Priya Nori

Priya Nori

In the stewardship world, we are all extremely enthusiastic about this article. It was extremely well-done, and it was led by a group at the CDC that has been looking at outpatient antibiotic use for a number of years, not just recently, but going back since the early 2000s. This is different in the sense that this is the first study to really quantify the amount of antibiotics that is truly unnecessary. What they have grossly come up with is that about one in three, or 30%, of these prescriptions are probably not needed.

This study is definitely a wake-up call. The overall proportion of unnecessary antibiotic use is weighted much more toward the outpatient setting. Most patients in America are seeing some type of health care provider throughout the year. For some, it is more than once. If a patient has a certain set of medical conditions such as diet control, diabetes, hypertension, or high cholesterol and has to be seen on a routine basis for medical care, at each one of those points, if they happen to present with something that resembles an infection, it is more likely that they are going to receive an antibiotic prescription. There is a lot of pressure on the provider to make that patient better or to give the impression that something has been done for that patient for that particular problem. Often, sending the patient out with just a pat on the back, saying “all you need is some TLC,” is not quite satisfying to the patient or to the doctor, because there is this feeling that you have let them down or you did not do what they were expecting.

However, putting that aside, there are guidelines for treating these conditions and high-quality CDC resources to educate providers on what to treat, and more importantly, what not to treat. Those resources are all available to providers at their fingertips and can be accessed online. It takes a lot of guesswork out of how to know whether to treat a condition or not. There are also very good patient resources from the CDC, which help to reach the patient on a level that is most comfortable for them and provides them with statistics about what happens to people when they receive unnecessary antibiotics.

Providers should draw from the educational materials to say, “Take your antibiotics as prescribed. Don’t stop it too early. Don’t stop it just because you feel well,” because it is the same issue of breeding resistant bacteria. While inappropriate use could be giving a patient an antibiotic prescription when they have a viral infection, inappropriate use could also be the patient not taking a long enough course of the antibiotic for that bacterial infection.

Some very nice studies recently have shown that checking back with health care providers and letting them know whether they are performing well according to guidelines or if they are overprescribing antibiotics has been shown to be a very powerful method of changing their behavior. What is very interesting to me is that these studies have borrowed from other areas outside of medicine. They have borrowed from behavioral psychology and behavioral modification to influence the behavior of health care providers to get them to prescribe more judiciously and more in accordance with guidelines. A lot of these techniques are cheap to implement. They used tools and devices that were already available to these doctors, such as receiving reports on prescribing through e-mail and building alerts in the electronic medical record to say, “Do you really need this antibiotic?” or, “Please justify why you need this antibiotic.” At our health care system, we are hoping to really tackle this issue in our immense outpatient ambulatory network by using some behaviorally based modifications that have been shown to be successful in these recent really rigorous studies.

Priya Nori, MD
Assistant professor, department of medicine (Infectious Diseases)
Medical director, antibiotic stewardship program
Department of medicine, Albert Einstein College of Medicine

Disclosure: Nori reports no relevant financial disclosures.