Antibiotics for Everyone?

Everyone Gets an Antibiotic Prescription

American adults aged 65 or older were prescribed enough outpatient antibiotic courses, on average, for every older adult to receive at least one prescription annually, according to a recent study.^[1] In a separate study,^[2] either an antibiotic or nonantibiotic prescription was associated with improved patient satisfaction scores in direct-to-consumer telemedicine visits for respiratory tract infections.

A group of Centers for Disease Control and Prevention researches evaluated outpatient antibiotic prescriptions from 2011 to 2014 in adults aged 65 or older.^[1] Approximately 50 million antibiotic courses were prescribed annually, correlating to 1110 prescriptions per 1000 person-years. Prescribing rates were stable during this timeframe. The prescribing rate for women was higher than for men, and the prescribing rate rose with increasing age. The five most common antibiotic classes prescribed, in descending order, were quinolones, penicillins, macrolides, cephalosporins, and trimethoprim-sulfamethoxazole.

Ciprofloxacin was the single most prescribed antibiotic in patients aged 75 or older. The unadjusted proportion of all antibiotics prescribed by specialty was: family practice (23%), internal medicine (20%), nurse practitioners and physician assistants (14%), dentistry (11%), and urology (6%). A similar prescribing specialty distribution was reported with fluoroquinolone prescribing.

Prescriptions and Patient Satisfaction

In a separate study^[2] related to outpatient antibiotic use, researchers from the Cleveland Clinic evaluated the association between antibiotic prescriptions in direct-to-consumer telemedicine visits for respiratory tract infections. Of the 8437 telemedicine visits with 85 physicians between 2013 and 2016, an antibiotic was prescribed 66% of the time. A nonantibiotic medication was prescribed in 16% of visits, and no prescription of any kind was provided in 18% of visits. Patients rated visits as 5 stars in 91% of visits with an antibiotic prescription, 86% of visits with a nonantibiotic prescription, and 73% with no prescription. Receipt of an antibiotic (adjusted odds ratio [aOR], 3.23; 95% confidence interval [CI], 2.67-3.91) or nonantibiotic prescription (aOR, 2.21; 95% CI, 1.80-2.71) was associated with a 5-star patient satisfaction rating compared with no prescription. Provider antibiotic prescribing rates were also significantly correlated with patient satisfaction.

Viewpoint

The stable, high rate of outpatient prescriptions for respiratory tract infections and high rate of quinolone prescribing found by Kabbani and colleagues^[1] are alarming, especially in light of the US Food and Drug Administration's (FDA's) safety warning discouraging fluoroquinolone use to treat uncomplicated infections and the White House's 2014 National Strategy for Combating Antibiotic-Resistant Bacteria, calling for a 50% reduction in inappropriate antibiotic use for serious bacterial infections. Of note, the evaluation periods in these studies predate or overlap with the FDA's safety warnings and the National Strategy. It remains to be seen whether warnings and increased antimicrobial stewardship efforts will impact the common yet often unnecessary outpatient antibiotic use in the United States.

Although the findings by Martinez and colleagues^[2] seem to incentivize inappropriate antibiotic use for respiratory tract infections, similar research has not consistently reported a negative impact of denying patient requests.^[3] Whether perceived or real, providers and antibiotic stewards must recognize the need for nonantibiotic strategies in the management of respiratory tract infections. Such strategies include clear communication of a nonbacterial diagnosis, lack of benefit of antibiotics, potential harms of antibiotics, and providing nonantibiotic prescriptions for symptom management. Furthermore, the study authors called for counterincentives for prescribing an unnecessary antibiotic for respiratory tract infections.

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