The bad news: Up to 43% of antibiotics prescribed in the ambulatory care setting are prescribed inappropriately or in the absence of a documented indication.
The good news: Family physicians and other primary care clinicians are much more likely to prescribe antibiotics appropriately than their peers in other specialties.
Those are the main findings from an analysis(www.bmj.com) of patient visits to office-based health care professionals published online Dec. 11 in The BMJ.
The findings come amid concerns(www.who.int) from the World Health Organization that development of new antibiotics, particularly to fight infections that have become resistant to current treatment options, is lagging. And they follow on the heels of a 2019 CDC report that showed mixed results in the ongoing fight against antibiotic resistance in the United States.
The researchers based their analysis on a sample of 28,332 patient visits sampled during the 2015 National Ambulatory Medical Care Survey. Only patients who received at least one antibiotic prescription were included in the analysis.
- An analysis of more than 28,000 patient visits during which at least one antibiotic was prescribed found that more than 40% of prescriptions were inappropriate or had no documented indication.
- Primary care physicians were significantly more likely to prescribe antibiotics appropriately compared with physicians in other specialties.
- PCPs also were much less likely to prescribe antibiotics without a documented indication.
The prescribing physicians were divided into three broad categories. Family physicians, general practitioners, pediatricians and internists were grouped under the umbrella of primary care. Gynecologists, urologists, dermatologists and otolaryngologists were categorized as members of specialties in which antibiotics are commonly prescribed, and a third category consisted of physicians in all other specialties.
The researchers then reviewed the ICD-9-CM codes for each visit during which an antibiotic was prescribed and classified the prescriptions as "appropriate," "inappropriate" or "no documented indication" based on diagnostic criteria used in previously published research.(jamanetwork.com)
The research team estimated that 990.8 million ambulatory care visits to office-based health care professionals occurred in 2015. Of those, 13.2% -- roughly 130 million visits -- involved a patient receiving an antibiotic prescription.
In these visits, the researchers determined that 57% of antibiotic prescriptions were appropriate, 25% were inappropriate and 18% had no documented indication.
Based on their calculations, the researchers estimated that in 2015, more than 56 million prescriptions for antibiotics were potentially inappropriate.
One important finding was a significantly higher percentage (69%) of family physicians and other primary care physicians wrote appropriate prescriptions when compared with those other specialties.
In addition, primary care physicians were far less likely to prescribe an antibiotic without a documented indication (12%) compared with other specialists who commonly prescribe antibiotics (24%) or those in all other specialties (29%).
Time also appeared to affect prescribing patterns, because patients who had shorter visits with a physician were less likely to receive an antibiotic without an indication than those who had longer visits.
Even aside from the high rates of known inappropriate prescribing observed in the study, the researchers wrote that "the magnitude of antibiotic prescriptions without a documented indication poses a barrier to antimicrobial stewardship and public health efforts intended to evaluate and improve antibiotic prescribing in ambulatory care settings."
"By identifying factors associated with prescribing without a documented indication, we can better inform antimicrobial stewardship and public health interventions," they added.
In an accompanying editorial,(www.bmj.com) Alastair Hay, M.B.Ch.B., M.D., a professor of primary care at the Bristol Medical School's Centre for Academic Primary Care in Bristol, U.K., called for the creation of a peer-referenced, individualized prescribing feedback system that would support changes in physician prescribing behaviors.
According to Hay, such a system would function best if it met three criteria:
- a diagnostic code is recorded every time an antibiotic is prescribed;
- all infections are coded, not just those for which an antibiotic is being prescribed; and
- a global scale is used to measure illness severity with each diagnostic code.
In addition to providing physicians with targeted data on their use of diagnostic codes and antibiotics compared with peers, Hay wrote, such a system would also allow them to monitor their use of diagnostic codes for more severe infections and the proportion of patients with each condition who are prescribed antibiotics.
Resources for Family Physicians
It's important to note that the AAFP has official policy encouraging members to be judicious in prescribing antibiotics and to use them only for appropriate indications.
In addition, the Academy offers numerous resources intended to guide members in making appropriate antibiotic prescribing decisions across various clinical scenarios.
Related AAFP News Coverage
Study: FM Residents Tops in Correctly Prescribing Antimicrobials
Extra Training in Judicious Stewardship Proves Beneficial
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American Family Physician: Editorial: Curbing Inappropriate Antibiotic Prescribing: What Works?