Prescription Antibiotic Use Among the US population 1999-2018: National Health and Nutrition Examination Surveys

Situations predisposing primary care patients to use antibiotics without a prescription in the United States

Background

Patients' situations can impact their intentions to use antibiotics without medical guidance (non-prescription use) in the future. This survey determines the prevalence of intended (future) use of non-prescription antibiotics for 13 predefined situations and identifies the sociodemographic characteristics associated with intended use for these types of situations.

Methods

Patient surveys (N = 564) were conducted from January 2020 to June 2021 in the waiting rooms of 6 safety-net primary care clinics and 2 emergency departments in a private healthcare system. We used principal component analysis to identify 3 situational summary factors: barriers to a doctor visit, accessibility of non-prescription antibiotics, and previous symptom relief with antibiotics. Multivariate linear regression identified the sociodemographic predictors associated with each summary factor.

Results

The most common situations triggering patients to use non-prescription antibiotics were a perceived high cost of doctor visits (29.8%), having leftover prescription antibiotics (50.4%), and experiencing symptom relief with prior use of antibiotics (47.5%). Multivariate regression results revealed that younger patients (P < 0.04) and patients attending the safety-net health system (P < 0.001) had more intended use of non-prescription antibiotics for all 3 summary factors.

Conclusions

Future stewardship interventions should consider the types of situations that drive patients' decisions to use antibiotics without a prescription. Interventions aimed at reducing barriers to health care (eg, high costs and long waits associated with doctor appointments) and educating individuals on medically appropriate, nonantibiotic treatment options may reduce antibiotic use and antimicrobial resistance.

National Level Cross-Sectional Study on Antibiotic Use in Children during the Pre- and Early COVID-19 Eras

This study aimed to investigate national data for a quantitative evaluation of antibiotic usage in Korean children during the pre- and early COVID-19 period. This was a cross-sectional study from 2016 to 2021 of children <18 years, grouped by age (0, 1, 2-4, 5-11, and 12-17 years) and city/province. Systemic antibiotic prescriptions, days of administration, and population by age and region were collected. Days of therapy (DOT)/1000 pediatric inhabitant per day (PID) was used for antibiotic quantitative monitoring. A total of 257,088,265 antibiotic doses were prescribed to 170,309,944 children during the 6-year period. The highest DOT during the entire study period was observed in the 1-year age group, followed by the 2-4- and 0-year age groups. The highest DOT was observed in 2019, with 72.8 DOT/1000 PID in the 1-year age group, which fell to 34.7 DOT/1000 PID in 2020, however, DOT soon increased at similar rates to that in the pre-COVID-19 period. A higher DOT/1000 PID was observed for third-generation cephalosporins in 58.8% of the regions compared to beta-lactam/beta-lactamase inhibitors. To conclude, reductions in antibiotic use during the early COVID-19 pandemic period were not maintained. Further interventions are needed to decrease antibiotic overuse and misuse.

Dynamics of Pediatric Antibiotic Use Differ between High- and Low-Prescribing Clinics after Pneumococcal Conjugate Vaccines

OBJECTIVE

To compare dispensed oral antibiotic prescription rates (DAPRs) after implementation of pneumococcal conjugate vaccine (PCV) in high antibiotic-prescribing clinics (HPC) with low antibiotic-prescribing clinics (LPC) in 2 distinct ethnic groups of children (Jewish and Bedouin children) <5 years of age.

METHODS

Clinics with ≥50 insured children, active both pre-PCV (2005-2009) and post-PCV (2010-2018) implementation, were included. HPC and LPC were defined by DAPRs above or below the median in each age and ethnic group. Monthly dispensed antibiotic prescription rate (DAPR) trends (adjusted for age and ethnicity) were calculated using interrupted time series. Mean yearly incidence rate-ratios (late PCV13 vs pre-PCV) were calculated.

RESULTS

Bedouin HPC had the highest pre-PCV overall-DAPR per 1000 child-years ± SD (2520.4 ± 121.2), followed by Jewish HPC (1885.5 ± 47.6), Bedouin LPC (1314.8 ± 81.6), and Jewish LPC (996.0 ± 19.6). Shortly after PCV implementation, all DAPRs and amoxicillin/amoxicillin-clavulanate DAPRs declined in all groups except Jewish LPC, stabilizing within 4-5 years post-PCV. The rates and magnitudes of declines were directly proportional to the pre-PCV DAPR magnitudes, achieving near-complete closure of the pre-PCV DAPR gaps between the 4 groups (rates during late-PCV13 ranging from 1649.4 ± 23.5 [Bedouin HPC] to 1200.3 ± 72.4 [Jewish LPC]).

CONCLUSIONS

PCVs are a powerful tool in reducing outpatient antibiotic consumption among young children, especially in HPC, resulting in partial closure of DAPR gap between HPC and LPC. The higher impact on HPC suggests that PCV-associated declines of respiratory disease may strongly contribute to a judicious antibiotic approach in clinics with high antibiotic consumption.

Assessment of Changes in Visits and Antibiotic Prescribing During the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use and the COVID-19 Pandemic

IMPORTANCE

The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use aimed to improve antibiotic prescribing in ambulatory care practices by engaging clinicians and staff to incorporate antibiotic stewardship into practice culture, communication, and decision-making. Little is known about implementation of antibiotic stewardship in ambulatory care practices.

OBJECTIVE

To examine changes in visits and antibiotic prescribing during the AHRQ Safety Program.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study evaluated a quality improvement intervention in ambulatory care throughout the US in 389 ambulatory care practices from December 1, 2019, to November 30, 2020.

EXPOSURES

The AHRQ Safety Program used webinars, audio presentations, educational tools, and office hours to engage stewardship leaders and clinical staff to address attitudes and cultures that challenge judicious antibiotic prescribing and incorporate best practices for the management of common infections.

MAIN OUTCOMES AND MEASURES

The primary outcome of the Safety Program was antibiotic prescriptions per 100 acute respiratory infection (ARI) visits. Data on total visits and ARI visits were also collected. The number of visits and prescribing rates from baseline (September 1, 2019) to completion of the program (November 30, 2020) were compared.

RESULTS

Of 467 practices enrolled, 389 (83%) completed the Safety Program; of these, 292 (75%) submitted complete data with 6 590 485 visits to 5483 clinicians. Participants included 82 (28%) primary care practices, 103 (35%) urgent care practices, 34 (12%) federally supported practices, 39 (13%) pediatric urgent care practices, 21 (7%) pediatric-only practices, and 14 (5%) other practice types. Visits per practice per month decreased from a mean of 1624 (95% CI, 1317-1931) at baseline to a nadir of 906 (95% CI, 702-1111) early in the COVID-19 pandemic (April 2020), and were 1797 (95% CI, 1510-2084) at the end of the program. Total antibiotic prescribing decreased from 18.2% of visits at baseline to 9.5% at completion of the program (-8.7%; 95% CI, -9.9% to -7.6%). Acute respiratory infection visits per practice per month decreased from baseline (n = 321) to a nadir of 76 early in the pandemic (May 2020) and gradually increased through completion of the program (n = 239). Antibiotic prescribing for ARIs decreased from 39.2% at baseline to 24.7% at completion of the program (-14.5%; 95% CI, -16.8% to -12.2%).

CONCLUSIONS AND RELEVANCE

In this study of US ambulatory practices that participated in the AHRQ Safety Program, significant reductions in the rates of overall and ARI-related antibiotic prescribing were noted, despite normalization of clinic visits by completion of the program. The forthcoming AHRQ Safety Program content may have utility in ambulatory practices across the US.