Patient and provider characteristics and outcomes associated with outpatient antibiotic overuse in acute adult bronchitis

Antibiotic Prescribing Practices for Upper Respiratory Tract Infections Among Primary Care Providers: A Descriptive Study

Background

Most antibiotics are prescribed in the ambulatory setting with estimates that up to 50% of use is inappropriate. Understanding factors associated with antibiotic misuse is essential to advancing better stewardship in this setting. We sought to assess the frequency of unnecessary antibiotic use for upper respiratory infections (URIs) among primary care providers and identify patient and provider characteristics associated with misuse.

Methods

Unnecessary antibiotic prescribing was assessed in a descriptive study by using adults ≥18 years seen for common URIs in a large, Upper Midwest, integrated health system, electronic medical records from June 2017 through May 2018. Individual provider rates of unnecessary prescribing were compared for primary care providers practicing in the departments of internal medicine, family medicine, or urgent care. Patient and provider characteristics associated with unnecessary prescribing were identified with a logistic regression model.

Results

A total of 49 463 patient encounters were included. Overall, antibiotics were prescribed unnecessarily for 42.2% (95% confidence interval [CI], 41.7–42.6) of the encounters. Patients with acute bronchitis received unnecessary antibiotics most frequently (74.2%; 95% CI, 73.4–75.0). Males and older patients were more likely to have an unnecessary antibiotic prescription. Provider characteristics associated with higher rates of unnecessary prescribing included being in a rural practice, having more years in practice, and being in higher volume practices such as an urgent care setting. Fifteen percent of providers accounted for half of all unnecessary antibiotic prescriptions.

Conclusions

Although higher-volume practices, a rural setting, or longer time in practice were predictors, unnecessary prescribing was common among all providers.

Development and validation of antibiotic stewardship metrics for outpatient respiratory tract diagnoses and association of provider characteristics with inappropriate prescribing

OBJECTIVE

To determine metrics and provider characteristics associated with inappropriate antibiotic prescribing for respiratory tract diagnoses (RTDs).

DESIGN

Retrospective cohort study.

SETTING

Primary care practices in a university health system.

PARTICIPANTS

Patients seen by an attending physician or advanced practice provider (APP) at their primary care office visit with International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM)-coded RTDs.

METHODS

Medical records were reviewed for 1,200 randomly selected office visits in which an antibiotic was prescribed to determine appropriateness. Based on this gold standard, metrics and provider characteristics associated with inappropriate antibiotic prescribing were determined.

RESULTS

Overall, 69% of antibiotics were inappropriate. Metrics utilizing prespecified RTDs most strongly associated with inappropriate prescribing were (1) proportion prescribing for RTDs for which antibiotics are almost never required (eg, bronchitis) and (2) proportion prescribing for any RTD. Provider characteristics associated with inappropriate antibiotic prescribing were APP versus physician (72% vs 58%; P = .02), family medicine versus internal medicine (76% vs 63%; P = .01), board certification 1997 or later versus board certification before 1997 (75% vs 63%; P = .02), nonteaching versus teaching practice (73% vs 51%; P < .01), and nonurban vs urban practice (77% vs 57%; P < .01).

CONCLUSIONS

Metrics utilizing proportion prescribing for RTDs for which antibiotics are almost never required and proportion prescribing for any RTD were most strongly associated with inappropriate prescribing. APPs and clinicians with family medicine training, with board certification 1997 or later, and who worked in nonteaching or nonurban practices had higher proportions of inappropriate prescribing. These findings could inform design of interventions to improve prescribing and could represent an efficient way to track inappropriate prescribing.

Antibiotic Prescriptions for Respiratory Tract Viral Infections in the Colombian Population

Antimicrobials are frequently inappropriately prescribed for the management of upper respiratory tract infections (URTIs); therefore, the frequency of antibiotic prescriptions for patients with viral URTIs was assessed in this study. A cross-sectional study, including ambulatory patients diagnosed with viral URTI, was conducted, and records of antimicrobial prescriptions were obtained. Sociodemographic, clinical (diagnostic), and pharmacological (antimicrobial) variables were assessed. Through multivariate analysis, variables associated with the use of antibiotics for viral infections were identified. A total of 341,182 patients with viral URTIs were identified. The patients, who were from 26 different departments of Colombia, had a mean age of 29.7 ± 23.5 years and a female predominance of 58.7% (n = 200,195). The most frequent viral infections were as follows: acute rhinopharyngitis (common cold) (n = 206,211; 60.4%); unspecified acute tonsillitis (n = 27,432; 8.0%); and acute pharyngitis (n = 26,411; 7.7%). A total of 24.8% of the patients (n = 84,453) received a prescription for antibiotics, predominantly penicillins (n = 61,871; 18.1%) and cephalosporins (n = 10,926; 3.2%). Patients treated in Atlántico, Valle, and Risaralda departments, along with those older than 5 years, were more likely to receive antibiotics for the treatment of viral infections. Antibiotics are frequently prescribed for the management of URTIs, which is considered an inappropriate practice due to a lack of clinical benefits, increased generation of antimicrobial resistance, and a risk of adverse reactions due to the use of medications that patients do not require. Drug utilization studies are a great tool for monitoring how antibiotics are being used and planning interventions to improve their use.