Too Many Antibiotics, Too Few Antivirals for Influenza

Larry Hand

July 17, 2014

Antiviral medications may have been underprescribed for patients presenting to outpatient clinics with influenza during the 2012-2013 influenza season, according to an article published online July 17 in Clinical Infectious Diseases. In contrast, the authors find that antibiotic medications were overprescribed, despite repeated calls for more appropriate use.

Fiona Havers, MD, MHS, from the Influenza Division, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, and colleagues from the CDC and other institutions analyzed data from 5 geographically diverse sites in the US Influenza Vaccine Effectiveness Network Study. Outpatients were 6 months of age or older with acute respiratory illness (ARI) of less than 7 days.

CDC recommendations call for prescribing antiviral medications for patients at high risk for complications from influenza who present early after symptom onset. In this study, antivirals include the neuraminidase inhibitors oseltamivir and zanamivir.

The researchers found that of the 6766 patients presenting with ARI between December 3, 2012, and April 5, 2013, 509 (7.5%) received antiviral prescriptions. Of 2366 (35%) patients with confirmed influenza by polymerase chain reaction (PCR) testing, 355 (15%) received antiviral prescriptions compared with 95 (4%) patients with a negative influenza test.

Moreover, among 1021 patients with ARI at high risk for influenza complications presenting at less than 2 days after symptom onset, 195 (19%) received antiviral prescriptions. Being younger than 2 years or older than 65 years and having at least 1 more chronic condition increased risk for complications.

Presenting to care earlier was a strong predictor of receiving antiviral prescriptions, with patients presenting 5 to 7 days after symptom onset having 92% lower odds of receiving antivirals than those presenting in less than 2 days, the researchers write.

Of 1825 patients with confirmed influenza and antibiotic data available, 540 (30%) received prescriptions for antibiotics and 297 (16%) received antiviral prescriptions.

Clinicians prescribed antibiotic medications more often than antivirals for all age groups, but "most frequently in very young children," the researchers write. Commonly prescribed antibiotics included amoxicillin-clavulanate, amoxicillin, and azithromycin.

"Our results suggest that during 2012–2013, antiviral medications were underprescribed and antibiotics may have been inappropriately prescribed to a large proportion of outpatients with influenza; continuing education on appropriate antibiotic and antiviral use is essential to improve healthcare quality," the researchers conclude.

In an accompanying editorial, Mark G. Ison, MD, from the Division of Infectious Diseases at Northwestern University Feinberg School of Medicine, Chicago, Illinois, writes that the study "clearly demonstrates that we are failing our patients by not providing antiviral therapy to patients with influenza consistent with current guidelines, while exposing many of the patients to antibiotics from which they likely derive little benefit.

"By providing early antiviral therapy to the majority of influenza-infected patients and reducing prescribing of unnecessary antibacterial therapy, we can contribute to improved outcomes and quality of life of our patients," he concludes.

This research was supported by the CDC through the University of Michigan, Group Health Research Institute, Marshfield Clinic Research Foundation, University of Pittsburgh, Scott & White Healthcare, and the National Institutes of Health. Several coauthors have reported various relationships with Medimmune, Novartis, Sanofi, Merck, Pfizer, Roche, Biocryst, Inviragen Cellex, Crucell, GlaxoSmithKline, NexBio, Genentech, Alios, Abbott, Biota, and NexBio.

Clin Infect Dis. Published online July 17, 2014.

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