Infection
Inappropriate antibiotics for upper respiratory infections increase adverse events
Sep
September 02, 2023
4 min read
Source/Disclosures
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Disclosures:
Percival reports no relevant financial disclosures.
More than 211 million outpatient oral antibiotic prescriptions were written in 2021, according to the CDC. Data show that around 30% of outpatient prescriptions are inappropriate.
Most inappropriate or unnecessary antibiotic prescribing is for upper respiratory infections (URIs). Inappropriate use of antibiotics is often associated with the societal harm of increased antimicrobial resistance, but the individual harm of adverse drug events (ADEs) is often underappreciated.
Increase in ADEs
A recent study estimated the risk for ADEs and attributable health care expenditures associated with inappropriate antibiotics for common respiratory infections, including bacterial (pharyngitis, sinusitis) and viral (influenza, URI or nonsuppurative otitis media [OM]) infections. The study included previously healthy adults aged 18 to 64 years with no antibiotic exposure in the last 90 days and no other infection-related diagnosis at the time of antibiotic dispensing. The researchers obtained data from a commercial insurance database using ICD-10 codes for inpatient and outpatient claims, along with outpatient pharmacy-dispensed medications from April 2016 to September 2018. They identified ADEs using ICD-10 codes on medical claims during follow-up and deemed antibiotics appropriate for bacterial infections if the guideline-recommended first-line therapy was used.
Kelly M. Percival
There was a high rate of inappropriate antibiotic prescribing among 3.2 million eligible adults, with 43% to 56% receiving inappropriate antibiotics for bacterial infections and 7% to 66% receiving antibiotics for viral infections. Inappropriate prescribing for viral infections was highest for bronchitis and lowest for influenza. Those treated inappropriately for bacterial pharyngitis had an increased risk for Clostridioides difficile infection (HR = 2.9; 95% CI, 1.31-6.41) and nausea/vomiting/abdominal pain (HR = 1.1; 95% CI, 1.03-1.18). Inappropriate antibiotics for viral infections were associated with a higher risk for non-C. difficile diarrhea, vulvovaginal candidiasis/vaginitis and unspecified allergy.
In addition to increased ADEs for patients, inappropriate antibiotics lead to increases in direct health care expenditures. From 2016 to 2018, these increases were highest for pharyngitis ($49.6 million), sinusitis ($19.1 million) and viral upper respiratory infection URI ($2.7 million).
Researchers evaluated the impact of inappropriate outpatient antibiotic prescriptions among healthy children aged 6 months to 17 years and found that the rate of inappropriate antibiotic prescribing for bacterial infections was 31% to 36%, and it was 4% to 70% for viral infections. Inappropriate prescribing for viral infections was highest for bronchitis, followed by nonsuppurative OM, and was lowest for influenza. The rate of ADEs varied from 0.00 to 0.01 cases per 10,000 person-days for Stevens-Johnson syndrome or toxic epidermal necrolysis to 1.49 to 9.55 cases per 10,000 person-days for skin rash or urticaria.
Inappropriate antibiotics for bacterial infections were associated with an increased risk for ADEs, including C. difficile infection and severe allergic reactions. Antibiotic treatment for viral infections was associated with higher risk for skin rash or urticaria, along with unspecified allergy for viral URI and nonsuppurative OM. The 30-day attributable health care expenditure was generally higher among children with inappropriate antibiotics compared with those who received appropriate antibiotics.
The impact of inappropriate prescribing on ADEs and C. difficile varied in these studies based on infection type, which may be due to different first-line recommendations and the ADEs and impact to the microbiome that are associated with those antimicrobials.
These studies offer valuable insight into ADEs associated with inappropriate antibiotic prescribing but probably significantly underappreciate the true incidence because many ADEs are not reported by patients or coded in follow-up visits with medical professionals. The studies demonstrate an opportunity to improve quality of care by reducing inappropriate antibiotic prescribing, which could be done through enhanced outpatient antimicrobial stewardship.
Role of stewardship
Even though the act and consequences of inappropriately prescribing outpatient antibiotics are documented, there has been limited improvement in reducing inappropriate outpatient antibiotics over time. This led the CDC to develop the Core Elements of Outpatient Antimicrobial Stewardship in 2016 to improve antibiotic use and reduce secondary consequences of inappropriate antibiotic use. The Core Elements include leadership commitment, accountability, drug expertise, action, tracking, reporting and education.
The impact of outpatient antimicrobial stewardship remains largely unknown because it still has not been implemented on a wide scale. There have been many studies looking at potential approaches to outpatient antimicrobial stewardship with mixed results. Data are vulnerable to being changed when providers know their antibiotic prescribing is being monitored.
A recent randomized controlled trial conducted in Switzerland that assessed automated quarterly antibiotic prescribing audit and feedback with peer benchmarking did not find a reduction in antibiotic prescribing in the intervention group compared with baseline or the control group, although the result may have been due to the intervention being passive and possibly demonstrates that a more active or multifaceted intervention is needed.
Intermountain Healthcare, which is based in Salt Lake City, was able to demonstrate an improved and sustained reduction in inappropriate antibiotic prescribing for respiratory conditions in 38 urgent care clinics and one telemedicine clinic. The multifaceted intervention was based on the CDC’s Core Elements and included education for clinicians and patients, the creation of tools in the electronic health record to assist with antibiotic prescribing and documentation, a clinician benchmarking dashboard, and a media campaign for patients and clinicians.
In addition to the stewardship interventions, the urgent care leadership introduced antibiotic prescribing measures into the bundle of quality measures, incorporating financial incentives for clinicians who met a set goal for antibiotic prescriptions from a respiratory encounter. Antibiotic prescribing for all respiratory conditions decreased from 47.8% at baseline to 33.3% during the intervention year and was sustained for 1 year after the intervention. Antibiotic prescribing for respiratory conditions that should never require an antibiotic decreased by 47%. This demonstrates that outpatient antimicrobial stewardship can improve antibiotic prescribing and sustain the improvement for at least 1 year, although it probably requires dedicated resources and a multifaceted approach, including all the Core Elements and potentially payer incentivization.
Currently, most health care systems in the United States have not implemented outpatient antimicrobial stewardship, especially using a multifaceted approach.
Inappropriate use of antimicrobials for upper URIs comes with large societal, personal and monetary costs. There is a need for increased resources to allow adequate time and expertise for enhanced outpatient antimicrobial stewardship to reduce inappropriate antibiotic prescribing.
References:
Kelly M. Percival, PharmD, BCPS, BCIDP, is a clinical pharmacy specialist in infectious diseases at the University of Iowa Hospitals & Clinics. Percival can be reached at [email protected].
