Trends In Antibiotic Prescribing Research Articles

Evidence of a care home effect on antibiotic prescribing for those that transition into a care home: a national data linkage study

AbstractWe compared antibiotic prescribing to older people in different settings to inform antibiotic stewardship interventions. We used data linkage to stratify individuals aged 65 years and over in Northern Ireland, 1st January 2012–31st December 2013, by residence: community dwelling, care home dwelling or ‘transitioned’ if admitted to a care home. The odds of being prescribed an antibiotic by residence were analysed using logistic regression, adjusting for patient demographics and selected medication use (proxy for co-morbidities). Trends in monthly antibiotic prescribing were examined in the 6 months pre- and post-admission to the care home. The odds of being prescribed at least one antibiotic were twofold higher in care homes compared with community dwellers (adjusted odds ratio 2.05, 95% CI 1.93–2.17). There was a proportionate increase of 51.5% in the percentage prescribed an antibiotic on admission, with a monthly average of 23% receiving an antibiotic in the 6 months post admission. While clinical need likely accounts for some of the observed antibiotic prescribing in care homes we cannot rule out more liberal prescribing, given the twofold difference between care home residents and their community dwelling peers having accounted for co-morbidities. The appropriateness of antibiotic prescribing in the care home setting should be examined.

208. Trends in Antibiotic Prescribing for Acute Respiratory Tract Infections and Implementation of a Provider-Directed Intervention Within the Veterans Affairs Healthcare System (VA)

BackgroundWe report VA-wide trends over time in acute respiratory infection (ARI) antibiotic prescribing, and early assessment of an intervention to improve ARI management.MethodsWe created a retrospective cohort of ARI (sinusitis, pharyngitis, bronchitis, and URI-NOS) visits between 2009 and April 2018. Patients with complicating conditions were excluded. Antibiotic prescribing rates were calculated. A provider-directed VA-wide ARI campaign was initiated in October 2017. The Campaign was implemented locally by antibiotic stewards or regional personnel trained in academic detailing (AD). Campaign components: dashboards for tracking provider and facility prescribing metrics, printable feedback reports, and AD educational materials. Metrics include: ARI antibiotic prescribing rates, bronchitis/URI-NOS antibiotic prescribing rates, guideline-concordant antibiotic selection for sinusitis or pharyngitis, and proportion of ARI visits with a sinusitis diagnosis. A Logistic generalized estimating equation model assessed metrics over time pre-/postintervention and χ2 tests compared guideline concordant antibiotic proportions pre-/postintervention.ResultsThere were 1,580,612 and 137,421 ARI visits pre-/postintervention, respectively. Antibiotic prescribing decreased from 2009, annual odds ratio (OR) 0.94 [95% CI 0.93, 0.96; P < 0.001]. An additional effect was observed postintervention [OR 0.88, (0.84, 0.88), P < 0.001]. Bronchitis/URI-NOS prescribing rates decreased from 2009 [annual OR 0.94 (CI 0.93, 0.95), P < 0.001]. Additional effect was observed postintervention [OR 0.86, (0.81, 0.91), P < 0.001]. Overall, the proportion of ARI visits diagnosed with sinusitis increased [annual OR 1.09 (1.08, 1.10), P < 0.01], but the proportion of sinusitis diagnoses decreased [OR 0.72 (0.69, 0.75), P < 0.001] postintervention. Guideline-concordant antibiotic selection was 61.5% vs. 71.2% for sinusitis and 63.3% vs. 67.8% for pharyngitis pre-/postintervention, respectively (both P < 0.001).ConclusionAntibiotic prescribing rates for ARIs within the VA have steadily declined since 2010. Additional decline in antibiotic prescribing was associated with the launch of a national campaign to improve ARI management. Disclosures All authors: No reported disclosures.

1863. Antibiotic Prescribing Before and After an FDA Boxed Warning on Fluoroquinolones in 2016

BackgroundIn July 2016, the FDA updated its boxed warning for fluoroquinolones (FQ) in light of ongoing safety concerns. Our objective was to examine trends in FQ and other antibiotic prescribing before and after the warning.MethodsWe analyzed electronic health records for inpatient, outpatient, and emergency department encounters during April 2014–August 2017 in the University of North Carolina Health Care System (N = 14,524,758 encounters). Patients under age 2 years were excluded. We estimated FQ prescribing rates per 1,000 encounters (henceforth, “/1,000”). Using an interrupted time series approach, we fit segmented linear regression models to assess trends before and after the FDA warning, accounting for seasonality and autocorrelated errors. We evaluated trends by gender, age, and point of care, and explored potential replacement of FQs by other antibiotics after the warning.ResultsThe average FQ prescribing rate was 9.2/1,000 (95% CI 3.8, 14.7). Before the warning (April 2014–July 2016), the FQ prescribing rate decreased by 0.6/1,000/year (95% CI 0.3, 0.9) (figure). At the time of the warning, the slope for the FQ prescribing rate steepened by 0.8/1,000/year (95% CI −0.1, 1.7); as a result, after the warning (July 2016–August 2017), the rate decreased by 1.4/1,000/year (95% CI 0.7, 2.1). FQ prescribing was most common among adults age ≥65 (mean rate 12.2/1,000), but relative trends were similar across age and gender. Average FQ prescribing rates were highest in the inpatient setting (40.5/1,000) compared with emergency (18.3/1,000) and outpatient (6.2/1,000) encounters; relative trends were similar across settings. Rates for other common antibiotics did not increase after the warning, either overall (figure) or in any subgroup. Results were robust to sensitivity analysis for lagged effects. Additionally, the interpretation of results is anchored by trends for inhaled corticosteroids, which we analyzed as a negative control (figure). ConclusionThe July 2016 FDA warning on FQs was associated with a small deceleration in FQ prescribing. There was no evidence of replacement by antibiotics with similar indications. We observed no evidence of heterogeneity across subgroups defined by gender, age, and point of care. Future research should assess the potential impact of the warning in clinically defined subgroups in various settings.Disclosures All authors: No reported disclosures.

A 20-year observational cohort of a 5 million patient population-Tonsillectomy rates in the context of two national policy changes.

(a) To report national trends for tonsillectomy, tonsillitis, peritonsillar abscess and deep neck space infection in secondary care. (b) To report national trends in sore throat consultations in primary care. (c) To report national trends in antibiotic prescribing in both primary and secondary care between 2011 and 2015. Retrospective nationwide cohort study. Data requested from Information Statistics Department (ISD) Scotland for tonsillectomy, tonsillitis admissions, peritonsillar abscess admissions and deep neck space infection (DNSI) admissions in Scotland, between 1993/94 and 2015/16. Data for antibiotic prescriptions in general practice and hospital admissions between 2011 and 2015. Scottish ENT departments and GP practices. Scottish patients who underwent tonsillectomy or were admitted to hospital with tonsillitis, peritonsillar abscess or deep neck space infection. Scottish patients that attended their GP with tonsillitis. Tonsillectomy rates between 1993/94 and 2015/16 decreased by 48% (P<0.001). Over the same time period, there has been a corresponding 136% increase in tonsillitis admission (P<0.001) and a 167% increase in peritonsillar abscess admissions, (P<0.001). Between 1996/97 and 2015/16, there was a 500% increase in deep neck space abscesses (P<0.001). There has been a significant decrease in tonsillectomy rates over the past two decades. Over the same time period, there has been a significant increase in admissions to secondary care with tonsillitis, peritonsillar abscess and deep neck space infection. These changes have happened in the context of two separate national policies being introduced-Scottish Intercollegiate Guideline Network (SIGN) guidelines for management of sore throat and the Scottish Reduction in Antibiotic Prescribing.

Point prevalence survey of antibiotic use in 26 Saudi hospitals in 2016.

To evaluate the antibiotic prescribing trends, qualitatively and quantitatively, among Saudi Ministry of Health (MOH) hospitals. In May 2016, information about the hospitals and patients was collected for all inpatients from 26 MOH hospitals in Saudi Arabia. Additional information about antibiotic treatment and infections was gathered. Data collection was done using Global Point Prevalence Survey (PPS) tool designed by University of Antwerp, Belgium. A total of 3240 antibiotic doses were administrated to 2182 patients who represented 46.9% of the total eligible admitted patients. Of those patients on antibiotics, 510 (24%) patients were in the Intensive Care Unit (ICU), 646 (30.4%) patients were medically treated, and 972 (45.7%) patients were in surgical departments. The most commonly prescribed antibiotic group was third-generation cephalosporin (17.2%) and the most frequent indication was respiratory ract infectiont (n=597; 18.2%). Antibiotics for surgical prophylaxis represented 23.4% of the total antibiotic doses. Of those, 78% were administrated for more than 24hs. The rate of adherence to antibiotic guidelines was 48.1%. The indications for antibiotics were not documented in the patients' notes for 51.1% of the prescriptions. This national PPS provided a useful tool to identify targets for quality improvement in order to enhance the prudent use of antibiotics in hospital settings. This survey can provide a background to assess the quality of antibiotic utilisation after any intervention by administering it regularly.

Current prescribing trends of antibiotics by dentists in Australia from 2013 to 2016. Part 1

Current prescribing trends of antibiotics by dentists in Australia from 2013 to 2016. Part 1

Part 1. Current prescribing trends of antibiotics by dentists in Australia from 2013 to 2016.

Literature has shown dentists tend to overprescribe antibiotics and do not always prescribe in accordance with recommended guidelines. Unnecessary prescribing is one major factor that contributes to the development of antibiotic resistance. The aim of the present study was to assess the antibacterial prescribing patterns of dentists in Australia from 2013 to 2016. Data on dental antibacterial prescriptions dispensed under the Pharmaceutical Benefits Scheme(PBS) from 2013 to 2016 was accessed and prescribing trends analysed. The prescribing rates were standardized to the dose and population. There was a slight decrease in the dispensed use of most antibacterials from 2013 to 2016, but there was a significant increase in the dispensed use of amoxicillin/clavulanic acid of 11.2%. Amoxicillin was the most commonly dispensed antibiotic, accounting for approximately 65% of all antibacterials from 2013 to 2016, while phenoxymethylpenicillin accounted for only 1.4% of prescriptions in 2016. There were low but significant quantities of dispensed antibiotic prescriptions that do not fit with current guidelines. The data suggest that dentists in Australia are prescribing some antibiotics inappropriately and there is a preference for moderate- to broad-spectrum agents. The current PBS dental schedule is inconsistent with prescribing guidelines and may contribute to inappropriate prescribing.

Reducing inappropriate third-generation cephalosporin use for community-acquired pneumonia in a small Australian emergency department.

Antimicrobial stewardship is a key component of hospital accreditation in Australia and contributes to the prevention and containment of antimicrobial resistance. The Second Australian Report on Antimicrobial Use and Resistance in Human Health (AURA Report) 2017 calls for greater participation by small hospitals in antimicrobial stewardship activities. Community acquired pneumonia (CAP) and third generation cephalosporin (3GCs) use is a known target for intervention. This paper reports the results of an educational intervention for reducing inappropriate prescribing of 3GCs in the empiric treatment of CAP. The intervention was based on a leadership and education campaign in an Emergency Department (ED) in a 96 bed acute rural hospital in New South Wales, Australia. A two-point retrospective audit within (April-June 2010, April-June 2011) was conducted comparing pre-intervention and post-intervention antibiotic prescribing trends for CAP from ED presentations. Data was collected via audit tool and appropriateness was assessed against endorsed guidelines. The main outcome measures were improved prescribing appropriateness and decreased utilisation. Whilst statistically insignificant, a reduction (6.4%) in inappropriate prescribing and a reduction in 3GC utilisation (16.7%) was demonstrated. Small hospitals have active contributions to make to prevent and contain antimicrobial resistance via antimicrobial stewardship. The challenge is collecting this data for national data sets whilst instituting local benefits in the context of limited resources. Our results suggest change can occur in antibiotic prescribing, studies such as this model a targeted strategy for resource poor facilities to contribute to national AU data whilst instituting local AMS change.

Assessment of inappropriate antibiotic prescribing among a large cohort of general dentists in the United States

BackgroundThe purpose of this study was to assess dental antibiotic prescribing trends over time, to quantify the number and types of antibiotics dentists prescribe inappropriately, and to estimate the excess health care costs of inappropriate antibiotic prescribing with the use of a large cohort of general dentists in the United States. MethodsWe used a quasi-Poisson regression model to analyze antibiotic prescriptions trends by general dentists between January 1, 2013, and December 31, 2015, with the use of data from Express Scripts Holding Company, a large pharmacy benefits manager. We evaluated antibiotic duration and appropriateness for general dentists. Appropriateness was evaluated by reviewing the antibiotic prescribed and the duration of the prescription. ResultsOverall, the number and rate of antibiotic prescriptions prescribed by general dentists remained stable in our cohort. During the 3-year study period, approximately 14% of antibiotic prescriptions were deemed inappropriate, based on the antibiotic prescribed, antibiotic treatment duration, or both indicators. The quasi-Poisson regression model, which adjusted for number of beneficiaries covered, revealed a small but statistically significant decrease in the monthly rate of inappropriate antibiotic prescriptions by 0.32% (95% confidence interval, 0.14% to 0.50%; P = .001). ConclusionsOverall antibiotic prescribing practices among general dentists in this cohort remained stable over time. The rate of inappropriate antibiotic prescriptions by general dentists decreased slightly over time. Practical ImplicationsFrom these authors’ definition of appropriate antibiotic prescription choice and duration, inappropriate antibiotic prescriptions are common (14% of all antibiotic prescriptions) among general dentists. Further analyses with the use of chart review, administrative data sets, or other approaches are needed to better evaluate antibiotic prescribing practices among dentists.

Incidence and antibiotic prescribing for clinically diagnosed urinary tract infection in older adults in UK primary care, 2004-2014.

Urinary tract infections (UTI) are an important cause of morbidity and antibiotic use in older adults but there are little data describing disease burden in primary care. The aim of this study was to estimate the incidence of clinically diagnosed UTI and examine associated empirical antibiotic prescribing. We conducted a retrospective observational study using linked health records from almost one million patients aged ≥65 years old, registered with 393 primary care practices in England. We estimated incidence of clinically diagnosed UTI between March 2004 and April 2014, and used multilevel logistic regression to examine trends in empiric antibiotic prescribing. Of 931,945 older adults, 196,358 (21%) had at least one clinically diagnosed UTI over the study period. In men, the incidence of clinically diagnosed UTI per 100 person-years at risk increased from 2.81 to 3.05 in those aged 65–74, 5.90 to 6.13 in those aged 75–84, and 8.08 to 10.54 in those aged 85+. In women, incidence increased from 9.03 to 10.96 in those aged 65–74, 11.35 to 14.34 in those aged 75–84, and 14.65 to 19.80 in those aged 85+. Prescribing of broad-spectrum antibiotics decreased over the study period. There were increases in the proportion of older men (from 45% to 74%) and women (from 55% to 82%) with UTI, prescribed a UTI specific antibiotic. There were also increases in the proportion of older men (42% to 69%) and women (15% to 26%) prescribed antibiotics for durations recommended by clinical guidelines. This is the first population-based study describing the burden of UTI in UK primary care. Our findings suggest a need to better understand reasons for increasing rates of clinically diagnosed UTI and consider how best to address this important clinical problem.

Effect of general practice characteristics and antibiotic prescribing on Escherichia coli antibiotic non-susceptibility in the West Midlands region of England: a 4 year ecological study.

To assess the effect of general practice characteristics and antibiotic prescribing on the number of non-susceptible Escherichia coli isolated from urine specimens submitted from community settings, we undertook an ecological study of the general practice population in the West Midlands. Descriptive analysis and multilevel modelling of temporal trends in antibiotic prescribing and non-susceptibility of E. coli urine isolates to a range of antibiotics prescribed in the community over a 4 year period. Nine of the 16 antibiotic prescribing/non-susceptibility combinations demonstrated a significant statistical linear correlation with non-susceptibility either for prescribing in a quarter or for prescribing within the previous 12 months. The magnitude of the effect varied, from a 0.3% increase in the odds of non-susceptibility to ampicillin/amoxicillin (when prescribing ampicillin/amoxicillin) to a 6.3% increase in the odds of non-susceptibility to nitrofurantoin (when prescribing nitrofurantoin) for an increase of 50 DDDs per 1000 practice population within a quarter (equivalent to ∼10 courses of antibiotics). In all 16 models, single-handed general practices were shown to have a significant association with increased numbers of non-susceptible E. coli urine isolates (adjusted ORs 1.083-1.657). Increased prescribing of ampicillin/amoxicillin in winter periods was associated with increased non-susceptibility of E. coli isolated from urine specimens. Small increases in antibiotic prescribing in individual general practices reduce the number of susceptible bacteria in the practice population. To maintain the effectiveness of available treatment, antibiotic stewardship should be encouraged and supported within each practice.

Susceptibility Trends of Urinary Tract Infections Over a 15 Year Period on a University Campus

BackgroundAcute uncomplicated cystitis (AUC) is one of the most common infections for which antimicrobials are prescribed. Despite IDSA AUC guideline recommendations, prescribing practices are varied throughout the US. Per IDSA recommendations, nitrofurantoin (NTF), fosfomycin, and trimethoprim/sulfamethoxazole (TMP/SMX) are all considered first line therapy for AUC, however there is concern of resistance to some of these agents. Quality improvement activity at the University of California, Davis Student Health Center (UCDSHC) has made prescribing NTF preferred for acute cystitis since 2001 as TMP/SMX has community resistance rates of ~20%. Ciprofloxacin is the second line agent at UCDSHC.MethodsUCDSHC reviewed all urine cultures and susceptibilities for clinical and epidemiologic purposes. Susceptibility results were gathered from the UCDSHC microbiology laboratory from 2001–2016. Prescribing data was obtained from UCDSHC under diagnosis codes consistent with cystitis or UTI to demonstrate antibiotic prescribing trends. Susceptibilities were evaluated over the 15-year time period (2001–2016). TMP/SMX, FQ’s, and NTF were the primary agents evaluated in this study.ResultsFrom 2001–2016, 3,831 E. coli and 296 S. saprophyticus isolates were evaluated, accounting for 88% of the total number of organisms. E. coli susceptibilities to NTF remained >98% from 2001–2016. E. coli susceptibilities to FQ’s trended down from 99% in 2001 to 88% in 2016. E. coli susceptibilities to TMP/SMX remained stable around 80% from 2001–2016. S. saprophyticusremained highly susceptible to NTF, FQ’s, and TMP/SMX (95%, 97%, and 100% respectively at the end of the study period). In total, 12,298 prescriptions were written from 2008–20016. Eighty percent (9,875) were NTF and 17% (2,016) were FQ’s. The remaining 1% and 2% were TMP/SMX and ‘Other’, respectively.ConclusionAfter changes in prescribing practice in 2001, NTF was used in 80% of cystitis cases over 15 years and retained excellent activity against common urinary pathogens. FQ’s retained acceptable activity for empiric use for urinary tract infections, but susceptibilities trended down notably despite limited FQ use. TMP/SMX did not regain increased activity over the time period.Disclosures All authors: No reported disclosures.

Trends and patterns in antibiotic prescribing among out-of-hours primary care providers in England, 2010-14.

Antimicrobial resistance is a global threat, increasing morbidity and mortality. In England, publicly funded clinical commissioning groups (CCGs) commission out-of-hours (OOH) primary care services outside daytime hours. OOH consultations represent 1% of in-hours general practice (GP) consultations. Antibiotic prescriptions increased 32% in non-GP community services between 2010 and 2013. We describe OOH antibiotic prescribing patterns and trends between 2010 and 2014. We: estimated the proportion of CCGs with OOH data available; described and compared antibiotic prescribing by volume of prescribed items, seasonality and trends in GP and OOH, using linear regression; and compared the proportion of broad-spectrum to total antibiotic prescriptions in OOHs with their respective CCGs in terms of seasonality and trends, using binomial regression. Data were available for 143 of 211 (68%) CCGs. OOH antibiotic prescription volume represented 4.5%-5.4% of GP prescription volume and was stable over time (P = 0.37). The proportion of broad-spectrum antibiotic prescriptions increased in OOH when it increased in the CCG they operated in (regression coefficient 0.98; 95% CI 0.96-0.99). Compared with GP, the proportion of broad-spectrum antibiotic prescriptions in OOH was higher but decreased both in GP and OOH (-0.57%, 95% CI - 0.54% to - 0.6% and -0.76%, 95% CI - 0.59% to - 0.93% per year, respectively). OOH proportionally prescribed more antibiotics than GPs although we could not comment on prescribing appropriateness. OOH prescribing volume was stable over time, and followed GP seasonal patterns. OOH antibiotic prescribing reflected the CCGs they operated in but with relatively more broad-spectrum antibiotics than in-hours GP. Understanding factors influencing prescribing in OOH will enable the development of tailored interventions promoting optimal prescribing in this setting.

Trends in antibiotic prescribing by dental practitioners in Germany

PurposeTo analyze the structure of antibiotic prescriptions by dentists in Germany during a time-period of four years in relation to medical antibiotic prescriptions. Materials and methodsWe collected nationwide data from all statutory health insurances on dental prescriptions of systemic antibiotics from 2012 to 2015. The annual reports of the “Research Institute for Local Health Care Systems” (WIdO, Berlin) provided the basis for this longitudinal data base analysis. The types of antibiotics, the number of prescriptions and the prescribed 'defined daily doses' (DDD) were analyzed. The results were compared to antibiotic prescriptions of German physicians. ResultsAn average of 8.8% per year of all antibiotic prescriptions is issued by dentists. The mostly prescribed antibiotic is amoxicillin. The share of amoxicillin on all dental prescriptions increased from 35.6% in 2012 to 45.8% in 2015 (p < 0.01). About three-quarters of all dentally prescribed DDD can be attributed to amoxicillin and clindamycin. On the part of the physicians the proportion of clindamycin is 18 fold lower than in the dental field. ConclusionsDental and medical antibiotic prescriptions in Germany show statistically significant differences regarding the shares of the prescribed antibiotics. In an international comparison the high proportion of Clindamycin in Germany is noticeable.

News You Can Use : New DEA registration requirements as of January 1; JAPhA study on antibiotic prescribing trends; updated guidelines for physical activity for diabetes patients; FDA adds new warnings to testosterone labeling; FDA approves multidose dry eye treatment; new CDC tools for opioid prescribing for chronic pain; better-tasting TB meds

News You Can Use : New DEA registration requirements as of January 1; JAPhA study on antibiotic prescribing trends; updated guidelines for physical activity for diabetes patients; FDA adds new warnings to testosterone labeling; FDA approves multidose dry eye treatment; new CDC tools for opioid prescribing for chronic pain; better-tasting TB meds

The extinction of topical erythromycin therapy for acne vulgaris and concern for the future of topical clindamycin

Objective: This study aims to evaluate changes in topical antibiotic prescribing trends for acne.Methods: We retrospectively reviewed the National Ambulatory Medical Care Survey data from 1993 to 2012 for all visits in which acne vulgaris was the primary diagnosis.Results: Acne vulgaris represented an estimated 94.5 million (92.3, 96.8) visits during the 20-year study period. Bivariate analysis showed that over time erythromycin use declined (p < 0.001) and clindamycin use rose (p = 0.10). Multivariate analysis showed that the likelihood of erythromycin use declined to near zero (p < 0.001), whereas clindamycin utilization increased (p < 0.05). PubMed searches of “erythromycin AND resistance” and “clindamycin AND resistance” demonstrated increasing publication frequency by year, fit with sigmoidal functions (erythromycin: R2 = 0.93 and clindamycin: R2 = 0.94). Yearly publications consistently exceeded 100 papers for erythromycin and clindamycin resistance in 1983 and 2003, respectively, roughly corresponding to the interval between reports of their utility in acne.Conclusions: Our findings suggest topical erythromycin use for acne has essentially ceased. By contrast, clindamycin use is increasing. Current recommendations discourage topical antibiotic monotherapy in favor of combination therapy with benzoyl peroxide and topical retinoids. Our group’s previous work demonstrated that this trend is indeed occurring.

Outpatient Antibiotic Prescribing Practices for Uncomplicated Urinary Tract Infection in Women in the United States, 2002-2011.

Background. Urinary tract infection (UTI) is one of the most common diagnoses leading to an antibiotic prescription for women seeking ambulatory care. Understanding current national outpatient antibiotic prescribing practices will help ongoing stewardship efforts to optimize antibiotic use; however, information on recent national outpatient antibiotic prescribing trends for UTI is limited. Methods. We analyzed the National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Survey datasets from 2002 to 2011. Outpatient visits of women aged ≥18 years with a diagnosis of uncomplicated UTI were included for analysis. We conducted weighted descriptive analyses, examined time trends in antibiotic prescribing, and used multivariable logistic regression to identify patient and provider factors associated with fluoroquinolone prescribing. Results. A total of 7111 visits were identified. Eighty percent of visits resulted in an antibiotic prescription; fluoroquinolones were the most frequently prescribed antibiotics throughout the study period (49% overall). Older patients (adjusted odds ratio [AOR] for adults aged ≥70 years = 2.5; 95% confidence interval [CI], 1.6-3.8) and patients treated by internists (AOR = 2.0; 95% CI, 1.1-3.3) were more likely than younger patients and those treated by family practitioners to receive fluoroquinolones. Outpatient visits in the West US Census region were less likely to be associated with fluoroquinolone prescribing (AOR = 0.6; 95% CI, .4-1.0) compared with visits in the Northeast. Conclusions. Fluoroquinolones were the most frequently selected antibiotic treatment for uncomplicated UTI in women during the study period. Outpatient antibiotic stewardship initiatives should include efforts to reduce overuse of fluoroquinolones for uncomplicated UTI.

Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Infections in the Veteran Population: A Cross-sectional Study.

Despite efforts to reduce antibiotic prescribing for acute respiratory infections (ARIs), information on factors that drive prescribing is limited. To examine trends in antibiotic prescribing in the Veterans Affairs population over an 8-year period and to identify patient, provider, and setting sources of variation. Retrospective, cross-sectional study. All emergency departments and primary and urgent care clinics in the Veterans Affairs health system. All patient visits between 2005 and 2012 with primary diagnoses of ARIs that typically had low proportions of bacterial infection. Patients with infections or comorbid conditions that indicated antibiotic use were excluded. Overall antibiotic prescription; macrolide prescription; and patient, provider, and setting characteristics extracted from the electronic health record. The proportion of 1 million visits with ARI diagnoses that resulted in antibiotic prescriptions increased from 67.5% in 2005 to 69.2% in 2012 (P < 0.001). The proportion of macrolide antibiotics prescribed increased from 36.8% to 47.0% (P < 0.001). Antibiotic prescribing was highest for sinusitis (adjusted proportion, 86%) and bronchitis (85%) and varied little according to fever, age, setting, or comorbid conditions. Substantial variation was identified in prescribing at the provider level: The 10% of providers who prescribed the most antibiotics did so during at least 95% of their ARI visits, and the 10% who prescribed the least did so during 40% or fewer of their ARI visits. Some clinical data that may have influenced the prescribing decision were missing. Veterans with ARIs commonly receive antibiotics, regardless of patient, provider, or setting characteristics. Macrolide use has increased, and substantial variation was identified in antibiotic prescribing at the provider level. U.S. Department of Veterans Affairs, Centers for Disease Control and Prevention.

Impact of clinical decision support on receipt of antibiotic prescriptions for acute bronchitis and upper respiratory tract infection.

Antibiotics are commonly recognized as non-indicated for acute bronchitis and upper respiratory tract infection (URI), yet their widespread use persists. Clinical decision support in the form of electronic warnings is hypothesized to prevent non-indicated prescriptions. The purpose of this study was to identify the effect of clinical decision support on a common type of non-indicated prescription. Using National Ambulatory Medical Care Survey data from 2006 to 2010, ambulatory visits with a primary diagnosis of acute bronchitis or URI and orders for antibiotic prescriptions were identified. Visits were classified on the basis of clinician report of decision-support use. Generalized estimating equations were used to assess the effect of decision support on likelihood of antibiotic prescription receipt, controlling for patient, provider, and practice characteristics. Clinician use of decision support increased sharply between 2006 (16% of visits) and 2010 (55%). Antibiotic prescribing for acute bronchitis and URI increased from ∼35% of visits in 2006 to ∼45% by 2010. Use of decision support was associated with a 19% lower likelihood of receiving an antibiotic prescription, controlling for patient, provider, and practice characteristics. In spite of the increased use of decision-support systems and the relatively fewer non-indicated antibiotic prescriptions resulting from the use of decision support, a secular upward trend in non-indicated antibiotic prescribing offset these improvements. The overall effect of decision support suggests an important role for technology in reducing non-indicated prescriptions. Decision support alone may not be sufficient to eliminate non-indicated prescriptions given secular trends.

Trends in antibiotic prescribing in primary care for clinical syndromes subject to national recommendations to reduce antibiotic resistance, UK 1995-2011: analysis of a large database of primary care consultations.

To measure trends in antibiotic prescribing in UK primary care in relation to nationally recommended best practice. A descriptive study linking individual patient data on diagnosis and prescription in a large primary care database, covering 537 UK general practices during 1995-2011. The proportion of cough/cold episodes for which antibiotics were prescribed decreased from 47% in 1995 to 36% in 1999, before increasing to 51% in 2011. There was marked variation by primary care practice in 2011 [10th-90th percentile range (TNPR) 32%-65%]. Antibiotic prescribing for sore throats fell from 77% in 1995 to 62% in 1999 and then stayed broadly stable (TNPR 45%-78%). Where antibiotics were prescribed for sore throat, recommended antibiotics were used in 69% of cases in 2011 (64% in 1995). The use of recommended short-course trimethoprim for urinary tract infection (UTI) in women aged 16-74 years increased from 8% in 1995 to 50% in 2011; however, a quarter of practices prescribed short courses in ≤16% of episodes in 2011. For otitis media, 85% of prescriptions were for recommended antibiotics in 2011, increasing from 77% in 1995. All these changes in annual prescribing were highly statistically significant (P < 0.001). The implementation of national guidelines in UK primary care has had mixed success, with prescribing for coughs/colds, both in total and as a proportion of consultations, now being greater than before recommendations were made to reduce it. Extensive variation by practice suggests that there is significant scope to improve prescribing, particularly for coughs/colds and for UTIs.