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 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.
“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 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.