1. From a cross-sectional study, the proportion of acute respiratory infection visits prescribed antibiotics increased significantly between 2005 and 2012.
2. During this time period, 68% of visits to outpatient VA clinics for acute respiratory infections were prescribed antibiotics.
Evidence Rating Level: 2 (Good)
Study Rundown: Unnecessary prescribing of antibiotics has contributed to the rapid development of antibiotic-resistant bacterial infections. In the outpatient setting, acute respiratory infections (ARIs) represent the most common reason for antibiotic prescriptions. To understand the factors associated with antibiotic prescribing for ARIs, this cross-sectional study examined ARI visits for the Veterans Affairs Healthcare System (VAHS) between 2005 and 2012. During the study period, there was a mild increase in the proportion of ARIs being prescribed antibiotics overall. However, when looking at specific antibiotic families, the macrolide prescription rate was most significantly increased, while penicillins and fluoroquinolones were prescribed at decreasing proportions. Factors associated with the highest proportions of prescribing were sinusitis, bronchitis, high fever and visits at VA urgent care clinics. Interestingly, the number of comorbid conditions other than those in the exclusion criteria had no association with prescribing. Provider level analyses showed that the 10% of highest prescribing providers gave antibiotics to >95% of ARIs, compared to <40% for the least prescribing providers. This study is strengthened by the large number of visits included in the study and the wide geographic distribution of clinics. The generalizability of this study is limited by its inclusion of only VAHS patients. Overall, it is clear that antibiotic prescription may occur in the majority of ARI patients, and may be increasing.
In-Depth [retrospective cohort]: This study examined nearly 2.5 million ARI visits that occurred in the VAHS at over 1000 clinical sites by 45 619 providers between 2005 and 2012. Exclusion criteria included recent non-ARI infections and people with comorbid conditions that increase risk for serious infections, such as diabetes, COPD, and HIV. Of the 1 044 523 ARI visits that met these criteria, antibiotics were prescribed at 68.4% of visits (n = 714 552). Over the 8-year study, there was an increase in overall proportion of antibiotics prescribed for ARIs from 67.5% to 69.2% (p < 0.001). Macrolide prescriptions increased from 36.8% to 47.0% (p < 0.001). Conversely, penicillin and fluoroquinolone prescriptions decreased from 36.0% to 32.1% (p < 0.001) and 15% to 12.7% (p <0.001), respectively. VA medical centers in the highest decile had prescribing proportions of >86%, compared to <57% for the lowest decile. Midlevel providers prescribed more frequently than physicians (70% vs. 68%).
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