Only half of patients seeking care for three common ailments in outpatient settings receive the right antibiotic, according to a new study.
The research from the Centers for Disease Control and Prevention (CDC) and the Pew Charitable Trusts found clinicians in four outpatient settings—physicians' offices, emergency departments, retail clinics and urgent care centers—did not prescribe patients the antibiotics recommended by medical guidelines or “first-line” antibiotics in about half of visits for sore throats, sinus infections and middle ear infections.
While rates varied, taken cumulatively across all settings, only half of patients with those conditions received first-line antibiotics, according to the study in the journal Antimicrobial Agents and Chemotherapy.
“There’s a lot of room for improvement for sure,” David Hyun, M.D., senior officer with Pew’s antibiotic resistance project and a study author, said in an interview with FierceHealthcare.
Choosing the right antibiotic helps protect public health by slowing the emergence of antibiotic resistance and ensures patient safety by using the medication most likely to treat the patient’s infection with the fewest side effects, said Hyun and Rachel Zetts, M.P.H., an officer for Pew’s antibiotic project and a co-author of the study. It’s a key target when it comes to the CDC’s antibiotic stewardship efforts.
“It really comes down to the whole goal of antibiotic stewardship, which is to make sure we optimize the best therapy and try to minimize the unintended consequences that relate to antibiotic therapy,” Hyun said.
Experts estimate that clinicians should prescribe recommended first-line antibiotics 80% of the time; however, all four outpatient settings fell below that mark. (Experts use the 80% figure to account for cases where patients need to be treated with non-first-line antibiotics, such as when they are allergic to penicillin or may return for another antibiotic after the first one failed.)
Using data from the 2014 IBM MarketScan Commercial Database, researchers found the rates of appropriate prescribing varied greatly depending on where patients receive care, but retail clinics came closest to the goal of 80%, prescribing first-line antibiotics 70% of the time. That was followed by emergency departments (57%), physicians' offices (50%) and urgent care clinics (49%).
First-line therapies include amoxicillin or penicillin for sore throats and amoxicillin or amoxicillin-clavulanate for sinus infections and middle ear infections. The most commonly prescribed non-first-line antibiotics for those conditions are macrolide-class antibiotics, such as azithromycin, which are less likely to be effective, the researchers said.
Clinicians in retail clinics may be selecting more appropriate antibiotics because of the use of protocols encouraging guideline-concordant prescribing, researchers said. “These settings really emphasize appropriate antibiotic prescribing. They are very protocol-based in how they evaluate and treat acute respiratory infections,” said Zetts, as well as taking on other antibiotic stewardship activities over the past few years.
While physicians' offices may be able to learn some lessons from retail clinics, Hyun said the delivery model is different in both. Improving prescribing may be more of a challenge in primary care doctors’ offices where the delivery system is much more fragmented, he said.
The study broke down prescribing rates for pediatric and adult patients. In all four settings, children were more likely to be prescribed the recommended first-line antibiotic (62%) than adults (41%). That trend may be due in part to public health efforts to improve antibiotic use among children.
“We do think there’s been some really great progress within the pediatric prescribing community, “said Zetts, making that another area where prescribers can look for lessons to improve prescribing across all outpatient settings.
Hyun said there’s a longer track record where experts have focused on antibiotic prescribing in children. A CDC campaign, for instance, placed a concerted effort on antibiotic stewardship among pediatricians. Pediatric professional societies have also made it a priority area, especially when formulating guidelines for treatment, he said.
The latest research builds on previous studies from Pew and the CDC. A study last year found urgent care clinics are prescribing unnecessary antibiotics at almost three times the rate of traditional physician offices. Urgent care clinics prescribed antibiotics for patients with respiratory diagnoses, including the flu, colds and other illnesses for which antibiotics are inappropriate, in almost 46% of visits.