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Original Investigation |

Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011

Katherine E. Fleming-Dutra, MD1; Adam L. Hersh, MD, PhD2; Daniel J. Shapiro3; Monina Bartoces, PhD1; Eva A. Enns, PhD4; Thomas M. File Jr, MD5; Jonathan A. Finkelstein, MD, MPH6; Jeffrey S. Gerber, MD, PhD7,8; David Y. Hyun, MD9; Jeffrey A. Linder, MD, MPH10; Ruth Lynfield, MD11; David J. Margolis, MD, PhD8; Larissa S. May, MD, MSPH12; Daniel Merenstein, MD13; Joshua P. Metlay, MD, PhD14; Jason G. Newland, MD, MEd15; Jay F. Piccirillo, MD16; Rebecca M. Roberts, MS1; Guillermo V. Sanchez, MPH, PA-C1; Katie J. Suda, PharmD, MS17; Ann Thomas, MD, MPH18; Teri Moser Woo, PhD19; Rachel M. Zetts9; Lauri A. Hicks, DO1
[+] Author Affiliations
1Centers for Disease Control and Prevention, Atlanta, Georgia
2Pediatric Infectious Diseases, University of Utah, Salt Lake City
3School of Medicine, University of California, San Francisco, San Francisco
4Division of Health Policy and Management, University of Minnesota, Minneapolis
5Summa Health System and Northeast Ohio Medical University, Akron
6Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
7Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
8University of Pennsylvania Perelman School of Medicine, Philadelphia
9Pew Charitable Trusts, Washington, DC
10Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
11Minnesota Department of Health, St Paul
12Department of Emergency Medicine, University of California-Davis, Sacramento
13Department of Family Medicine, Georgetown University Medical Center, Washington, DC
14Division of General Internal Medicine, Massachusetts General Hospital, Boston
15Division of Pediatric Infectious Diseases, Washington University School of Medicine, St Louis, Missouri
16Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
17Department of Veterans Affairs, University of Illinois at Chicago, Chicago
18Oregon Public Health Division, Portland
19Pacific Lutheran University, Tacoma, Washington
JAMA. 2016;315(17):1864-1873. doi:10.1001/jama.2016.4151.
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Importance  The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotic use by 50% by 2020, but the extent of inappropriate outpatient antibiotic use is unknown.

Objective  To estimate the rates of outpatient oral antibiotic prescribing by age and diagnosis, and the estimated portions of antibiotic use that may be inappropriate in adults and children in the United States.

Design, Setting, and Participants  Using the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, annual numbers and population-adjusted rates with 95% confidence intervals of ambulatory visits with oral antibiotic prescriptions by age, region, and diagnosis in the United States were estimated.

Exposures  Ambulatory care visits.

Main Outcomes and Measures  Based on national guidelines and regional variation in prescribing, diagnosis-specific prevalence and rates of total and appropriate antibiotic prescriptions were determined. These rates were combined to calculate an estimate of the appropriate annual rate of antibiotic prescriptions per 1000 population.

Results  Of the 184 032 sampled visits, 12.6% of visits (95% CI, 12.0%-13.3%) resulted in antibiotic prescriptions. Sinusitis was the single diagnosis associated with the most antibiotic prescriptions per 1000 population (56 antibiotic prescriptions [95% CI, 48-64]), followed by suppurative otitis media (47 antibiotic prescriptions [95% CI, 41-54]), and pharyngitis (43 antibiotic prescriptions [95% CI, 38-49]). Collectively, acute respiratory conditions per 1000 population led to 221 antibiotic prescriptions (95% CI, 198-245) annually, but only 111 antibiotic prescriptions were estimated to be appropriate for these conditions. Per 1000 population, among all conditions and ages combined in 2010-2011, an estimated 506 antibiotic prescriptions (95% CI, 458-554) were written annually, and, of these, 353 antibiotic prescriptions were estimated to be appropriate antibiotic prescriptions.

Conclusions and Relevance  In the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate, supporting the need for establishing a goal for outpatient antibiotic stewardship.

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