Overuse of antibiotics in outpatient settings may be worse than we thought

Providers in outpatient settings might be unnecessarily prescribing antibiotics at rates higher than previously estimated—increasing the potential for patients to develop antibiotic-resistant infection or superbugs, according to a study published last week in JAMA Internal Medicine.

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Study details

For the study, researchers analyzed prescription and medical coverage data from the 2014 Truven Health MarketScan Commercial Claims and Encounters Database to examine antibiotic prescriptions for respiratory diagnoses that antibiotics cannot treat, such as allergies, asthma, bronchitis, and influenza.

The researchers reviewed claims data from 2014 on 156 million visits to hospital-based emergency departments (EDs), medical offices, retail clinics, and urgent care centers among U.S. patients under age 65. The sample is not considered nationally representative of the U.S. population because it did not include Medicare, Medicaid, or uninsured patients.

Researchers said the use of claims data is one of the study's limitations, because the data are not designed to accurately depict why patients received a specific treatment.

Findings

Among the visits examined, the researchers found that antibiotics were prescribed in:

  • 39% of the 2.7 million urgent care center visits;
  • 36.4% of the 58,206 retail clinic visits;
  • 13.8% of the 4.8 million ED visits; and
  • 7.1% of the 148.5 million medical office visits.

The researchers determined that antibiotics were prescribed for patients with respiratory diagnoses that such drugs cannot treat in:

  • 17% of total retail clinic visits;
  • 16% of total urgent care visits;
  • 6% of total medical office visits; and
  • 5% of total ED visits.

When the researchers looked only at visits that involved a respiratory diagnosis that could not be treated with antibiotics, they found that antibiotics were prescribed in:

  • 45.7% of urgent care visits;
  • 24.6% of ED visits;
  • 17% of medical office visits; and
  • 14.4% of retail clinic visits.

According to the researchers, "Previous work demonstrated that in the 2010-2011 period at least 30% of antibiotic prescriptions written in physician offices and EDs were unnecessary." The researchers wrote that their new findings suggest "unnecessary antibiotic prescribing nationally in all outpatient settings may be higher than the estimated 30%."

Discussion

Katherine Fleming-Dutra, deputy director of CDC's Office of Antibiotic Stewardship and an author of the study, said, "Taking an antibiotic when it is not needed provides no benefit and could be harmful." For instance, Fleming-Dutra said unnecessarily using antibiotics can increase a patient's risk of acquiring an antibiotic-resistant infection or superbug—which are more difficult to treat than other conditions.

Rita Redberg, chief editor of JAMA Internal Medicine and a professor at the University of California-San Francisco Medical Center, and colleagues in an editorial accompanying the study wrote that the study's findings provide new evidence that the likelihood of a patient receiving an unnecessary antibiotic might depend on where they receive their care.

David Hyun, a senior officer at the Pew Charitable Trust's Antibiotic Resistance Project and an author of the study, said the findings "will help us with an antibiotic stewardship strategy that's not just focused on doctor's offices and emergency departments." Hyun said, "If we are going to be successful in improving antibiotic use to reduce antibiotic resistance, we need to address every health care setting where antibiotics are being used and make sure in each of those settings we maximize the appropriateness of antibiotics that are being used. Urgent care centers and retail health clinics are certainly going to be a major contributor in the effort moving forward to reduce antibiotic resistance by improving antibiotic use."

Laurel Stoimenoff, CEO of the Urgent Care Association (UCA), said urgent care centers over the past two years have focused on improving antibiotic stewardship. She noted that UCA has partnered with George Washington University's Antibiotic Resistance Action Center to improve antibiotic prescribing practices. In addition, she said UCA's College of Urgent Care Medicine in June released an antibiotic stewardship toolkit, which provided a framework for clinics and other facilities frequently prescribing antibiotics.

However, Stoimenoff said challenges persist because urgent care centers provide episodic care, which means providers do not have the long-established relationships with their patients that might be helpful in recommending against the use of antibiotics in some instances (Rapaport, Reuters, 7/16; Ross Johnson, "Transformation Hub," Modern Healthcare, 7/16; Sun, "To Your Health," Washington Post, 7/16).

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