Original ContributionsAntibiotic prescribing for patients with colds, upper respiratory tract infections, and bronchitis: A national study of hospital-based emergency departments*
Introduction
By and large, infection has become a relatively minor threat to life, as we have civilized ourselves and installed plumbing and even less a threat now that we have antibiotics.1 The spread of antibiotic-resistant bacteria is an important problem in medicine and in public health.2, 3, 4, 5, 6, 7, 8, 9 Before the mid 1980s, virtually all strains of Streptococcus pneumoniae in the United States were sensitive to penicillin. However, over the past 15 years the Centers for Disease Control and Prevention has detected a 60-fold rise in high-level resistance to penicillin.10 Today, in some areas of the United States, more than 30% of invasive isolates of S pneumoniae demonstrate intermediate- or high-level resistance to penicillin.11, 12, 13 Often, penicillin-resistant strains are also resistant to other antibiotics, including macrolides, trimethoprim-sulfamethoxazole, and second- and third-generation cephalosporins.10, 14, 15, 16
Drug-resistant strains of S pneumoniae have attracted considerable attention, because this organism is responsible for common, often lethal infections, such as meningitis, pneumonia, and bacteremia.5, 10 At the same time, antibiotic resistance is growing among other pathogens, including Streptococcus pyogenes, Haemophilus influenzae, enterococci, staphylococci, Neisseria gonorrhoeae, Salmonella, Mycobacterium tuberculosis, and Escherichia coli and other urinary pathogens.7, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24
The spread of antibiotic resistance is multifactorial. Bacteria acquire resistance naturally, through genetic mutations and through the exchange of genetic material among microorganisms.7, 14, 25, 26 However, it is under the selective pressure of frequent antibiotic use that resistant strains are encouraged to multiply and spread rapidly.10 Indeed, one of the most consistent risk factors for the carriage of and infection with drug-resistant S pneumoniae is recent antibiotic use.2, 3, 4, 10, 27, 28, 29, 30, 31 Several studies have demonstrated a direct association between recent antibiotic use in the outpatient setting (at least 1 course of antibiotics within 2 months) and nasopharyngeal colonization with drug-resistant S pneumoniae. Recent antibiotic use is also an independent risk factor for invasive infections caused by drug-resistant S pneumoniae.27, 28, 29, 30
Reducing unnecessary antibiotic use is a critical step in any effort to decrease the prevalence of antibiotic-resistant S pneumoniae.5, 10, 27, 30, 31, 32, 33, 34, 35 Of special concern is the overuse of antibiotics for routine colds, upper respiratory tract infections (URIs), and acute bronchitis. In almost all cases, these are viral, self-limited conditions that do not benefit from antibiotic use.34, 35, 36, 37, 38, 39, 40, 41 Nevertheless, antibiotics are commonly prescribed. According to the National Ambulatory Medical Care Survey (NAMCS), a statistical sample of records from physicians’ offices, 31% of all outpatient antibiotic prescriptions were for colds, URIs, or bronchitis.42 In a subsequent analysis of the NAMCS data, Gonzales et al33 found that antibiotics were prescribed for 51% of adult patients with colds, 52% of patients with URIs, and 66% of patients with acute bronchitis. In a study of Medicaid claims data in Kentucky, Mainous et al43, 44 reported that 60% of patients with common colds and 75% of patients with bronchitis received antibiotics.
Although recent studies have characterized antibiotic use in office-based practice, little is known about antibiotic prescribing rates in emergency departments. It is known, however, that “acute upper respiratory tract infection excluding pharyngitis” is the leading illness-related diagnosis during ED visits.45 In 1997, antibiotics were the second-leading category of drugs prescribed, after analgesics; overall, antibiotics accounted for 16.8% of all ED drug mentions.45
In this study, we used data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to examine antibiotic prescribing patterns in EDs. We conducted this study with the following specific objectives: (1) to identify the most common conditions for which antibiotics were prescribed; (2) to measure antibiotic prescription rates for patients with common colds, URIs, and bronchitis; and (3) to determine whether patient age, sex, race, Hispanic ethnicity, smoking status, practice location, level of provider training or other variables were associated with higher rates of antibiotic use.
Section snippets
Methods
Data for this study were obtained from the 1996 NHAMC, a national probability sample survey conducted by the National Center for Health Statistics.46 The survey was conducted between December 25, 1995, and December 22, 1996. NHAMCS targets patient visits to nonfederal, short-stay hospital EDs; chronic care, military, and Veterans Administration hospitals are excluded. Hospitals whose average length of stay for all patients is less than 30 days and whose specialty is “general” or “children’s
Results
According to the 1996 NHAMCS, there were an estimated 90.3 million ED visits in 1996. The leading diagnoses resulting in antibiotic prescriptions are listed in Table 1.Condition (ICD -9 Code) No. of Visits With Antibiotics Percentage of Total Antibiotics Otitis media (381.0, 381.3, 381.4, 382.0, 382.9) 2,655,628 1,466,425 12.2 Urinary tract infections (590, 595, 599) 1,744,156 1,036,037 8.7 Acute bronchitis (466, 490) 2,056,478 861,910 7.2
Discussion
This study provides new data about the overuse of antibiotics in EDs in the United States. Using a representative national database, we found that antibiotics are prescribed commonly for viral URIs. One fourth of patients with colds and URIs and more than 40% of patients with acute bronchitis received antibiotic prescriptions. Overprescribing was a widespread and nearly uniform practice; prescribing rates did not vary significantly with patient race, sex, ethnicity, or practice locale.
The
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Address for reprints: Susan Stone, MD, MPH, LAC+USC Emergency Medicine, 1200 North State Street, Room 1011, Los Angeles, CA 90033; 323-226-6667; E-mail [email protected].