January 02, 2020
2 min read

Documentation critical for appropriate antibiotic prescribing

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Ebbing Lautenbach, MD, MPH, MSCE
Ebbing Lautenbach

In 2015, approximately 24 million antibiotic prescriptions in the United States lacked a documented indication and 32 million prescriptions were identified as inappropriate, according to data from the National Ambulatory Medical Care Survey — indicating that nearly half of all prescriptions could be inappropriate.

“We are not saying that 43% of prescriptions are definitely inappropriate,” Michael J. Ray, PhD, MPH, a researcher at Oregon State University’s College of Pharmacy, told Healio. “Rather, we are saying that this is a possibility based on the information we have.”

The researchers conducted a cross-sectional study to determine how often antibiotics are prescribed without a documented indication in the ambulatory care setting and to identify characteristics of the patient, provider and visit associated with inappropriate antibiotic

prescribing. The final study dataset included 28,332 sample visits, which represented 990.9 million ambulatory care visits across the country.

During those visits in 2015, 13.2% resulted in an antibiotic prescription (95% CI, 11.6%-13.7%). Among these prescriptions, 57% were for appropriate indications (95% CI, 52%-62%), 25% were inappropriately prescribed (95% CI, 21%-29%) and 18% had no antibiotic indication (95% CI, 15%-22%).

“This third finding is important because without a diagnostic code that could be considered an indication for antibiotics, it is impossible to judge whether the antibiotic prescribed was appropriate,” Ebbing Lautenbach, MD, MPH, MSCE, Robert Austrian Professor of medicine, professor of epidemiology and chief of the division of infectious diseases, and senior scholar for the Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania Perelman School of Medicine, told Healio. “This makes it very difficult to report accurate rates of appropriate antibiotic prescribing.”

Lautenbach, who was not involved in the study, suggested that the focus on “encounters” made with no documented indication was novel.

“This represents an important target for further research because of the impact of these types of encounters on accurately assessing prevalence of inappropriate prescribing, as well as how these encounters present challenges to developing targets for antimicrobial stewardship,” he said. “Using the results of this study, further work should be done attempting to identify more clearly the why some encounters during which antibiotics were prescribed included no indication for antibiotic prescribing.”

According to Ray and colleagues, antibiotic prescribing without an indication was significantly positively associated with being an adult male, spending more time with the provider and seeing a nonprimary care specialist.

Lautenbach noted that antibiotic prescriptions more often occurred after longer consultations compared with shorter consultations, “perhaps reflecting more complex patients, “coding fatigue,” or “insufficient consultation time.”


Moreover, they discovered that sulfonamides and urinary anti-infective agents were most likely to be prescribed without documentation.

“The large proportion of prescriptions without a documented indication is important in itself,” Ray said. “We are also, to our knowledge, the first to look at the patient and provider characteristics associated with prescribing without documentation.”

In a related editorial, Alastair D. Hay, MD, professor of primary care at the University of Bristol in England, explained that it is imperative that a diagnostic code is used for every antibiotic prescription and every infection is coded correctly. He also recommended the implementation of individualized feedback to improve antibiotic prescribing. However, he noted that when it comes to antimicrobial stewardship, strategies do not “work in isolation.”

“Others include better infection control, vaccination, and improved diagnostic precision, but the incentive for improving diagnostic coding is to provide information that can be used by clinicians to help them reflect and refine their prescribing behavior,” he said. – by Marley Ghizzone


Hay AD, et al. BMJ. 2019;doi:10.1136/bmj.l6816.

Ray MJ, et al. BMJ. 2019;doi:10.1136/bmj.l6461.

Disclosures: Hay, Lautenbach and Ray report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.