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Large study finds rampant antibiotic misuse for respiratory infections

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June 14, 2018

A review of national outpatient data collected during two recent influenza seasons in the United States found widespread overuse of antibiotics for acute respiratory infections, researchers reported.

Among nearly 15,000 outpatients enrolled in a study by CDC epidemiologist Fiona P. Havers, MD, and colleagues, nearly half of patients who received antibiotics did not need them, including almost one-third of influenza patients without pneumonia.

“Acute respiratory infections (ARIs) remain the clinical category for which antibiotics are most commonly prescribed. However, most ARIs are caused by viruses for which antibiotics have no role in treatment,” Havers and colleagues wrote in JAMA Network Open.

“Inappropriate antibiotic use contributes to the development of antibiotic-resistant organisms, which cause an estimated 2 million illnesses and 23,000 deaths annually in the United States. Understanding antibiotic prescribing practices for ARIs in outpatient settings is critical to designing strategies for reducing inappropriate antibiotic use.”

Image of man having a respiratory exam.
In a large study, almost half of patients prescribed antibiotics for acute respiratory infections did not need them.
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In the cohort study, Havers and colleagues assessed data from 14,987 patients aged 6 months and older who were evaluated for ARIs at clinics associated with five U.S. Influenza Vaccine Effectiveness Network sites during the 2013-2014 and 2014-2015 influenza seasons. All patients were tested for influenza, and the researchers extracted antibiotic prescriptions, medical history, and ICD-9 diagnosis codes from medical and pharmacy records. A subset of patients was assessed for group A streptococcal (GAS) test results.

According to Havers and colleagues, 6,136 (41%) patients received a prescription for antibiotics, including 3,423 (56%) who were treated with broad-spectrum antibiotics. Of the patients who received an antibiotic prescription, 2,522 (41%) had diagnoses for which an antibiotic was not indicated, including 2,106 (84%) who were diagnosed with a viral upper respiratory infection or bronchitis. Of 3,306 patients (22%) who were found not to have pneumonia but were diagnosed with laboratory-confirmed influenza, antibiotics were prescribed to 945 (29%), comprising 17% of all antibiotic prescriptions among patients with nonpneumonia ARI, Havers and colleagues reported.

Among the patients without pneumonia, 656 (20%) were prescribed an influenza antiviral medication, including 89 who received both an antibiotic and an antiviral medication.

Of 1,248 patients with pharyngitis, a subset of 1,137 (91%) underwent GAS testing. A total of 440 of these 1,248 patients (35%) received antibiotic prescriptions, including 168 (38%) whose GAS testing results were negative.

Among 1,200 patients with sinusitis and no additional indication for an antibiotic regimen but who received antibiotics, 454 (38%) displayed symptoms for 3 days or less before the outpatient visit, indicating acute sinusitis for which antibiotics were not necessary.


Havers and colleagues said their findings revealed potential courses of action for achieving the National Action Plan for Combating Antibiotic-Resistant Bacteria of cutting inappropriate antibiotic prescribing in half by 2020.

“We must strengthen outpatient antibiotic stewardship efforts to eliminate antibiotic treatment for viral [upper respiratory tract infections] and acute bronchitis, which our study indicates would make the largest contribution to decreasing unnecessary antibiotic prescriptions,” they wrote. “Increased efforts are needed to support improved adherence to guidelines for antibiotic prescribing for common diagnoses, including more stringent adherence to GAS pharyngitis testing guidelines and clinical criteria for antibiotic treatment of sinusitis as well as interventions focused on appropriate selection of first-line antibiotics for these conditions if treatment is indicated.

“In addition, our findings indicate that improved point-of-care influenza diagnostics and increased recognition and appropriate treatment of influenza virus infection may also aid in decreasing unnecessary antibiotic use for ARIs. ” – by Jennifer Byrne

Disclosures: Havers reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

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