Clinicians in outpatient settings write too many unnecessary antibiotic prescriptions

April 18, 2019

An AJIC (American Journal of Infection Control) study published in April revealed that 40 percent of patients who received care at a major Veterans Affairs outpatient center received inappropriate antibiotic prescriptions, which is higher than what previous research on outpatient prescribing has indicated.

Using an electronic antibiotic alert system for when antibiotics were prescribed, researchers within the Veterans Affairs Western New York Healthcare System were able to conduct thorough chart reviews, giving them opportunities to identify four common diagnoses that prompted physicians to prescribe the medications and also what types of antibiotics were most commonly overused. A drug’s use as first-line therapy, dosing, and duration were all used as benchmarks for appropriate prescription – and the results weren’t too good.

According to the study, patients with urinary tract infections (UTIs), bronchitis, skin structure infections, and sinusitis receive the most antibiotics and the most commonly overused drugs are azithromycin, ciprofloxacin, amoxicillin/clavulanate, and cephalexin. Together, these four drugs accounted for nearly 80 percent of unnecessary drug use in the outpatient setting. Outpatient antibiotic prescriptions comprise 60 percent of overall antibiotic use, according to the literature, making them a critical target for antimicrobial stewardship efforts.

Researchers in the AJIC study also learned that unlike patients in the outpatient clinics, those who went to the emergency department for treatment were twice as likely to receive an antibiotic only if they needed it, suggesting their need for the drug was truly legitimate. Healthcare providers concerned about patient satisfaction scores may also feel pressured to prescribe antibiotics to patients who demand them, the study showed.

Additional key findings from the study included:

·   Patients with a diagnosis of sinusitis did not require an antibiotic in 32 percent of cases, as their symptoms were consistent with the common cold. Furthermore, with a sinusitis diagnosis, the incorrect drug was chosen in 53 percent of cases.

·   Prescribing patterns associated with UTIs indicate that the correct drug was chosen in 54.9 percent of cases. Antibiotics were most commonly prescribed for asymptomatic urine bacteria, a condition that does not require antibiotics. In fact, another study published in Infection Control and Hospital Epidemiology shows little evidence that testing patients automatically for UTI is beneficial and actually tends to lead to unnecessary prescribing of antibiotics.

·   Fifty five percent of the 288 prescriptions for azithromycin were deemed unnecessary – it was most commonly misused for bronchitis, sinusitis, upper respiratory tract infections, chronic obstructive pulmonary disease, and community acquired pneumonia.

With fewer and fewer pharmaceutical companies investing in antibiotic research and development, and current drugs losing their power to cure, better prescribing practices are critical. Implementing systems that deliver alerts whenever antibiotics are prescribed, along with greater patient education, is one way to curb unnecessary prescriptions.

“We found that real-time alerts when an antibiotic is prescribed, allowing for immediate intervention, may be an effective way to begin a stewardship program, supplemented by patient education on when an antibiotic is not needed and the harmful effects of misuse,” said Alexis White, PharmD, lead study author.