Who Overprescribes Antibiotics? The Data Tell All

Stephen Y. Liang, MD, MPHS


December 15, 2015

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Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Infections in the Veteran Population: A Cross-sectional Study

Jones BE, Sauer B, Jones MM, et al
Ann Intern Med. 2015;163:73-80

Investigating Antibiotic Prescribing Patterns

A retrospective, cross-sectional study of patients in the Veterans Affairs (VA) health system shows that antibiotic prescriptions for acute respiratory infection continue to rise, with significant variation in prescribing practices among providers nationally.

We know that viruses account for most upper respiratory infections in ambulatory care settings, and that most of these infections resolve on their own. Yet, empirical antibiotic therapy for common viral ailments, including pharyngitis, bronchitis, and sinusitis, remains a practice that has proven stubborn to shake.

Jones and colleagues assessed national trends in antibiotic prescribing for acute respiratory infections (ARIs), targeting all emergency department and primary and urgent care clinic patient visits between 2005 and 2012 throughout the VA health system. In total, more than 1 million visits to 45,619 providers were examined across 990 clinics and emergency departments in 130 VA medical centers.

Antibiotics were prescribed in more than two thirds of visits with ARI diagnoses, with almost one half of these prescriptions being for a macrolide agent. Predictors of antibiotic prescribing included a diagnosis of sinusitis or bronchitis, high fever (temperature ≥ 102°F), and visits occurring in an urgent care setting.

Patient visits in southern and central geographic regions of the United States also resulted in more frequent antibiotic prescribing. Although mid-level providers prescribed slightly more antibiotics than physicians, the greatest source of variability was the individual providers and their established practice patterns.

Among providers who saw at least 100 patients with ARIs during the study period, the proportion of visits with and without antibiotic prescribing was calculated. The highest 10% of providers prescribed antibiotics during ≥ 95% of their ARI visits, whereas the lowest 10% prescribed antibiotics during ≤ 40% of visits. This provider-level variation remained dominant even after adjustment for clinic- and medical center-level antibiotic prescribing trends.


Although the study used administrative data with limited insight into other key factors that can drive clinical decision-making (eg, duration of symptoms, physical examination findings), it provides a population-level snapshot of antibiotic prescribing patterns across a large health system, demonstrating high rates of potentially unnecessary antibiotic use for ARIs. Furthermore, the study demonstrates the importance of looking at individual provider prescription data when it comes to antibiotic overuse.

Although some may question the generalizability of these findings to the US population as a whole, the realization that ARI management is strongly influenced by the unique prescribing practices of individual providers (which may not always align with the practice trends of their peers within a parent institution or group) is likely to hold true.

This has important implications for national campaigns, such as Choosing Wisely. The Centers for Disease Control and Prevention recently partnered with the Infectious Diseases Society of America to advocate reductions in unnecessary antibiotic therapy for ARIs. And although broad recommendations aimed at all practicing clinicians are crucial, targeted strategies to identify "superutilizers" of antibiotics and modify individual provider practices are equally important if we hope to gain the upper hand in curbing inappropriate and ineffective antibiotic use and safeguard against future antibiotic resistance.



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