Despite efforts to curb the inappropriate use of antibiotics, overuse remains a major problem — especially for minority and older patients. Approximately 64% of antibiotics prescribed for Black patients and 58% of those for Hispanic/LatinX patients were deemed inappropriate, according to the results of a study analyzing antibiotic prescribing habits of clinicians during office, hospital clinics, and emergency department visits in the United States.
In addition, 74% of antibiotic prescriptions written for patients aged 65 years or older were deemed inappropriate, according to Eric Young, PharmD, PhD, from the University of Texas Health Science Center, San Antonio. Dr Young and colleagues presented their research at this year’s European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) held April 23 to 26 in Lisbon, Portugal.1
An estimated 80% to 90% of antibiotic use occurs in the outpatient setting, and in 2020 almost 202 million courses of antibiotics were dispensed to outpatients in the US.2 The Centers for Disease Control and Prevention (CDC) estimates that at least 30% of outpatient antibiotics are unnecessary and up to 50% of antibiotics are inappropriately prescribed (unnecessary use and inappropriate selection, dosing, and duration).3
The CDC released outpatient and inpatient guidelines on antimicrobial stewardship, highlighting the roles that all health care providers have in judicious antibiotic prescribing, including PAs and NPs, noted Dr Young. “I personally believe that guideline-driven recommendations as well as collaboration with those specializing in stewardship can help alleviate the high incidence of inappropriate antibiotic prescribing,” he said.
While efforts have been made to improve antibiotic use in the overall patient population, few studies have explored how antibiotic prescribing is influenced by patient demographics, such as race/ethnicity, age, and gender. To provide more evidence on prescribing patterns, the researchers analyzed prescribing data from the National Ambulatory Medical Care Survey (NAMCS) covering more than 5.7 billion adults and 1.3 billion children visits to outpatient practices between 2009 and 2016.
Of these visits, 11% (almost 8 million) resulted in antibiotic prescriptions. The most common reasons for inappropriate prescriptions were for illnesses that were not caused by a bacterial infection such as nonbacterial skin conditions, viral respiratory tract infections, and bronchitis. The findings raise questions about the effectiveness of efforts to curb inappropriate prescribing and highlight the need to address inappropriate prescribing in primary care, the researchers said.
Antibiotic use was defined as at least 1 oral antibiotic prescription ordered during a physician visit. Antibiotic prescribing was defined as visits that included an antibiotic per 1000 total patient visits, and researchers used official diagnostic codes to identify whether each antibiotic prescription was appropriate, possibly appropriate, or inappropriate.
Overall antibiotic prescribing rates were highest in Black and Hispanic/LatinX patients (122 and 139 prescriptions per 1000 visits, respectively) and in patients younger than 18 years and females (114 and 170 prescriptions per 1000 visits, respectively). Almost two-thirds (64%) of antibiotic prescriptions written to Black patients were inappropriate and as were over half (58%) of those written to Hispanic/LatinX patients. Similarly, three-quarters (74%) of prescriptions dispensed to patients aged 65 years and older, and over half (58%) to males of any age, were deemed inappropriate.
“Our results suggest that Black and Hispanic/LatinX patients may not be properly treated and are receiving antibiotic prescriptions even when not indicated,” said Dr Young. “We know that physicians typically send patients home with antibiotics if they suspect their symptoms may lead to an infection. This practice becomes more common when patients are unlikely to return for a follow-up visit [no established care within a clinic or hospital system], which more frequently happens in minority populations,” said Dr Young.
“I believe patient education may be one of the most important and effective tools we could use among minority and low-income populations [to reduce inappropriate prescriptions]. A lot of times, patients may expect that their symptoms will be cured by antibiotic use. However, they are unaware of the potentially harmful side effects of antibiotics,” Dr Young said in an interview.
“In older adults, inappropriate prescribing in primary care is associated with a wide range of adverse outcomes, including emergency hospital attendances and admissions, adverse drug events, and poorer quality of life. Our results underscore that strategies to reduce inappropriate prescribing must be tailored for outpatient settings,” he said.
“As a pharmacist, we are also trained in antibiotic stewardship, so we could also increase outpatient collaboration by providing medication counseling services in the retail setting to further justify whether the patient has a need for an antibiotic. I really hope that we could improve point-of-care testing in community pharmacies to improve outpatient antimicrobial stewardship,” Dr Young said.
The findings are limited by the observational study design from which cause and effect cannot be ascertained and inclusion of data on outpatient visits only. In addition, specific pertinent information such as patient allergies, antibiotic-indicated diagnoses, and physician characteristics was not available. The researchers could rule out the possibility that other unmeasured factors may have affected the results.
Going forward, Dr Young hopes to evaluate more of the outcomes of inappropriate antimicrobial stewardship. “My research team specializes in Clostridioides difficile infection, so to see how inappropriate antibiotic use could correlate with increased C difficile infection rates would probably be our next step,” he concluded.
The study authors did not receive any funding. The authors declare no conflicts of interest.
1. Young E, Strey K, Yap A, et al. Differences seen in race/ethnicity, age, and sex seen in overall and inappropriate antibiotic prescribing in U.S. physician offices, 2009 to 2016. Presented at: 32nd European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) 2022; April 24, 2022: Poster 1430, Abstract 1758.
2. Centers for Disease Control and Prevention. Outpatient antibiotic prescriptions — United States, 2022. Accessed May 4, 2022. https://www.cdc.gov/antibiotic-use/data/report-2020.html
3. Centers for Disease Control and Prevention. Measuring outpatient antibiotic prescribing. Accessed May 4, 2022. https://www.cdc.gov/antibiotic-use/data/outpatient-prescribing/index.html