Acute respiratory tract infection: A practice examines its antibiotic prescribing habits

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Original Research

Acute respiratory tract infection: A practice examines its antibiotic prescribing habits

J Fam Pract. 2012 June;61(6):330-335

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References

1. Fendrick AM, Monto AS, Nightengale B, et al. The economic burden of non-influenza related viral respiratory tract infection in the United States. Arch Intern Med. 2003;163:487-494.

2. Werner K, Deasy J. Acute respiratory tract infections: when are antibiotics indicated? JAAPA. 2009;22:22–26.

3. US Department of Health and Human Services. Preventing emerging infectious diseases: a strategy for the 21st century. MMWR Morb Mortal Wkly Rep. 1998;47(RR-15). Available at: http://www.cdc.gov/MMWR/pdf/rr/rr4715.pdf. Accessed July 16, 2011.

4. Drug resistance threatens to reverse medical progress [press release]. Geneva, Switzerland: World Health Organization (WHO); June 12, 2000. Available at: http://www.who.int/inf-pr-2000/en/pr2000-41.html. Accessed July 16, 2011.

5. Smolinski MS, Hamburg MA, Lederberg J. eds. Institute of Medicine, Committee on Emerging Microbial Threats to Health in the 21st Century. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: National Academies Press; 2003. Available at: http://www.iom.edu/CMS/3783/3919/5381/6146.aspx. Accessed July 16, 2011.

6. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for treatment of acute respiratory tract infections in adults: background, specific aims, and methods. Ann Intern Med. 2001;134:479-486.

7. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults: background. Ann Intern Med. 2001;134:490-494.

8. Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Ann Intern Med. 2001;134:498-505.

9. Cooper RJ, Hoffman JR, Bartlett JG, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Intern Med. 2001;134:509-517.

10. Gonzales R, Bartlett JG, Bessnar RE, et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Intern Med. 2001;134:521-529.

11. CDC. Get smart: know when antibiotics work. Adult appropriate antibiotic use summary: physician information sheets (adult). Available at: http://www.cdc.gov/getsmart/campaign-materials/adult-treatment.html. Accessed July 16, 2011.

12. Grijalva CG, Nuorti JP, Griffin M. Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings. JAMA. 2009;302:758-766.

13. Steinman MA, Landefeld CS, Gonzales R. Predictors of broad spectrum antibiotic prescribing for acute respiratory tract infections in adult primary care. JAMA. 2003;289:719-725.

14. Wigton RS, Darr CA, Corbett KK, et al. How do community practitioners decide whether to prescribe antibiotics for acute respiratory tract infections? J Gen Intern Med. 2008;23:1615-1620.

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16. Colgan R, Powers JH. Appropriate antimicrobial prescribing: approaches that limit antibiotic resistance. Am Fam Physician. 2001;64:999-1004.

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TABLE 3
Historical features, exam findings associated with antibiotic prescribing

Historical feature	P value
Sinus pain	.0002
Duration of illness >8 days	.0110
Shortness of breath	.0427
Physical exam finding
Abnormal sinus exam	<.0001
Abnormal lung exam	.0005
Abnormal tympanic membrane	.0017
Abnormal pharynx	.0026
Cervical lymphadenopathy	.0141
Abnormal nasal exam	.0363

TABLE 4
Antibiotic prescription rates for ARTI varied by provider type, investigator status

Antibiotic prescription rate
Attending physicians	Nurse practitioners	Residents	P value
153/225 (68%)	97/115 (84%)	54/98 (55%)	<.001*
Investigator	Noninvestigator	P value
110/192 (57%)	194/246 (79%)	<.001
ARTI, acute respiratory tract infection. *The rate for residents is significantly lower than that for attending physicians and nurse practitioners. The rate for attending physicians is significantly lower than that for nurse practitioners. The P value applies to both rate comparisons among provider types.

Discussion

Providers in our practice had surprisingly high rates of antibiotic prescribing for ARTIs (69% overall). By comparison, the overall antibiotic use rate for ARTIs in the most recent National Ambulatory Medical Care Survey (NAMCS) analysis (1995-2006) was 58%.¹² The prescribing rate for office settings alone was just 52%. Steinman’s analysis of NAMCS data from 1997-1999 revealed an overall rate of 63%.¹³

Data analyzed from >4200 Medicare enrollees seen for ARTI visits revealed great variation in prescribing rates by office site: 21% to 88%, with a median rate of 54%.²⁰ The rate varied by final diagnoses: sinusitis, 69%; bronchitis, 59%; pharyngitis, 50%; and URI, 26%. A rate of 77% was recently reported in a Veterans Administration office setting.²¹ Those with sinusitis and bronchitis similarly received more prescriptions than those with acute pharyngitis and URI.

FAST TRACK

We diagnosed patients with sinusitis and bronchitis frequently, perhaps as false justification for prescribing antibiotics.

In addition to our high overall rate, we also diagnosed patients with sinusitis and bronchitis frequently (32% and 24% of all patients, respectively), perhaps as false justification for prescribing antibiotics (provided for 99% and 91%, respectively). Also noteworthy is that more than one-third of URI patients in our practice received antibiotics.

We had expected, but did not see, differences in prescribing rates between older and younger patients, as well as those with and without risk factors for complications. Our expectations were based on NAMCS data, which have demonstrated increasing use of antibiotics in older patients.²

FAST TRACK

We had expected, but did not see, differences in prescribing rates between older and younger patients, as well as those with and without risk factors for complications.

Treatment for those with bronchitis was surprisingly frequent; 91% received antibiotics. A Cochrane systematic review attributes slight symptom benefit to antibiotic use (improvement in cough by about one day).²² This benefit, however, is rarely seen in patients who have been ill for <1 week. The magnitude of this benefit must be weighed against the cost and adverse effects of antibiotics and the potential for promoting antimicrobial resistance. Most patients’ symptoms are mild and self-limited, and risks may exceed benefits.

Guidelines state, “The widespread use of antibiotics for the treatment of acute bronchitis is not justified and vigorous efforts to curtail their use should be encouraged.”²³ The CDC agrees, noting that “routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of duration of cough.”¹⁰

As observed in another study,¹⁴ a clinical factor associated with prescribing decisions at our practice was the duration of illness. Patients in our practice had been ill, on average, 8 days before presenting to the office. Over time, our encounters with regular patients may have taught them to wait until their symptoms are prolonged or progressive before seeking evaluation.

We saw large differences in prescribing rates between providers, and hope this means there is room for improvement by addressing reasons for variability. Education about individual prescribing behaviors may motivate those with the highest rates of use to improve.

FAST TRACK

Some patients reported that narrow-spectrum medicines “just don’t work,” given their experience with persistent cold symptoms.

We noted high rates of broad-spectrum antibiotic use. This is consistent with other research findings of a shift away from narrow-spectrum agents.¹² We did not determine the frequency of allergies to narrow-spectrum agents. Anecdotally, the opinion of some patients was that narrow-spectrum medicines “just don’t work,” given their experience of persistent cold symptoms when using such agents.

Quality-improvement processes such as DMAIC (Define, Measure, Analyze, Improve, Control) or PDSA (Plan, Do, Study, Act) require collection of baseline data so that interventions can be tailored to meet the root causes identified.²⁴ This project determined preintervention practice behaviors and allowed us to create quality metrics that could define our future success.

Study limitations. One obvious reason for the prescribing variability noted above is that those who helped plan and implement the project knew their practice behaviors were being reviewed and had studied the relevant practice guidelines. Whether non-investigator providers were up to date with recommendations and could carefully select appropriate treatment candidates is unclear.