BACKGROUND: In 2022-2023, 15- and 20-valent pneumococcal conjugate vaccines (PCV15/PCV20) were recommended for infants. We aimed to estimate the incidence of outpatient visits and antibiotic prescriptions in US children (≤17 years) from 2016-2019 for acute otitis media, pneumonia, and sinusitis associated with PCV15- and PCV20-additional (non-PCV13) serotypes to quantify PCV15/20 potential impacts. METHODS: We estimated the incidence of PCV15/20-additional serotype-attributable visits and antibiotic prescriptions as the product of all-cause incidence rates, derived from national health care surveys and MarketScan databases, and PCV15/20-additional serotype-attributable fractions. We estimated serotype-specific attributable fractions using modified vaccine-probe approaches incorporating incidence changes post-PCV13 and ratios of PCV13 versus PCV15/20 serotype frequencies, estimated through meta-analyses. RESULTS: Per 1000 children annually, PCV15-additional serotypes accounted for an estimated 2.7 (95% confidence interval, 1.8-3.9) visits and 2.4 (95% CI, 1.6-3.4) antibiotic prescriptions. PCV20-additional serotypes resulted in 15.0 (95% CI, 11.2-20.4) visits and 13.2 (95% CI, 9.9-18.0) antibiotic prescriptions annually per 1000 children. PCV15/20-additional serotypes account for 0.4% (95% CI, 0.2%-0.6%) and 2.1% (95% CI, 1.5%-3.0%) of pediatric outpatient antibiotic use. CONCLUSIONS: Compared with PCV15-additional serotypes, PCV20-additional serotypes account for > 5 times the burden of visits and antibiotic prescriptions. Higher-valency PCVs, especially PCV20, may contribute to preventing pediatric pneumococcal respiratory infections and antibiotic use.

OBJECTIVES: To describe acute respiratory illnesses (ARI) visits and antibiotic prescriptions in 2011 and 2018 across outpatient settings to evaluate progress in reducing unnecessary antibiotic prescribing for ARIs. DESIGN: Cross-sectional study. SETTING AND PATIENTS: Outpatient medical and pharmacy claims captured in the IBM MarketScan commercial database, a national convenience sample of privately insured individuals aged <65 years. METHODS: We calculated the annual number of ARI visits and visits with oral antibiotic prescriptions per 1,000 enrollees overall and by age category, sex, and setting in 2011 and 2018. We compared these and calculated prevalence rate ratios (PRRs). We adapted existing tiered-diagnosis methodology for International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. RESULTS: In our study population, there were 829 ARI visits per 1,000 enrollees in 2011 compared with 760 ARI visits per 1,000 enrollees in 2018. In 2011, 39.3% of ARI visits were associated with ≥1 oral antibiotic prescription versus 36.2% in 2018. In 2018 compared with 2011, overall ARI visits decreased 8% (PRR, 0.92; 99.99% confidence interval [CI], 0.92-0.92), whereas visits with antibiotic prescriptions decreased 16% (PRR, 0.84; 99.99% CI, 0.84-0.85). Visits for antibiotic-inappropriate ARIs decreased by 9% (PRR, 0.91; 99.99% CI, 0.91-0.92), and visits with antibiotic prescriptions for these conditions decreased by 32% (PRR, 0.68; 99.99% CI, 0.67-0.68) from 2011 to 2018. CONCLUSIONS: Both the rate of antibiotic prescriptions per 1,000 enrollees and the percentage of visits with antibiotic prescriptions decreased modestly from 2011 to 2018 in our study population. These decreases were greatest for antibiotic-inappropriate ARIs; however, additional reductions in inappropriate antibiotic prescribing are needed.

We appreciate the suggestion by Drs. Chang, Fatima, and Stevens in their response to our article, “Antibiotic Therapy Duration in US Adults with Sinusitis.”1 to evaluate prescribing for adults with sinusitis by specialty, particularly since previous studies have found that outpatient antibiotic prescribing practices vary by clinician specialty.2,3 | | We examined the duration of antibiotic courses prescribed for adult acute sinusitis visits to family practice, general practice, geriatrics, internal medicine, pediatrics, emergency medicine, and non-pediatric osteopathic primary care physicians. The non-pediatric osteopathic primary care physician category included both family practice and internal medicine specialties within the dataset, so we were unable to differentiate whether osteopathic medicine clinicians were family practitioners or internists. We described the duration of therapy for all oral antibiotics prescribed for sinusitis and for all oral antibiotics for sinusitis excluding azithromycin. We specifically excluded azithromycin due to its unique pharmacokinetics and persistent tissue concentration; a five-day course of azithromycin is equivalent to a 10-day course of erythromycin.4 In addition, the Infectious Diseases Society of America (IDSA) clinical practice guidelines specifically recommend against the use of azithromycin in acute sinusitis in adults.5

OBJECTIVE: To describe national antibiotic prescribing for acute gastroenteritis (AGE). SETTING: Ambulatory care. METHODS: We included visits with diagnoses for bacterial and viral gastrointestinal infections from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (NAMCS/NHAMCS; 2006-2015) and the IBM Watson 2014 MarketScan Commercial Claims and Encounters Database. For NAMCS/NHAMCS, we calculated annual percentage estimates and 99% confidence intervals (CIs) of visits with antibiotics prescribed; sample sizes were too small to calculate estimates by pathogen. For MarketScan, we used Poisson regression to calculate the percentage of visits with antibiotics prescribed and 95% CIs, including by pathogen. RESULTS: We included 10,210 NAMCS/NHAMCS AGE visits; an estimated 13.3% (99% CI, 11.2%-15.4%) resulted in antibiotic prescriptions, most frequently fluoroquinolones (28.7%; 99% CI, 21.1%-36.3%), nitroimidazoles (20.2%; 99% CI, 14.0%-26.4%), and penicillins (18.9%; 99% CI, 11.6%-26.2%). In NAMCS/NHAMCS, antibiotic prescribing was least frequent in emergency departments (10.8%; 99% CI, 9.5%-12.1%). Among 1,868,465 MarketScan AGE visits, antibiotics were prescribed for 13.8% (95% CI, 13.7%-13.8%), most commonly for Yersinia (46.7%; 95% CI, 21.4%-71.9%), Campylobacter (44.8%; 95% CI, 41.5%-48.1%), Shigella (39.7%; 95% CI, 35.9%-43.6%), typhoid or paratyphoid fever (32.7%; (95% CI, 27.2%-38.3%), and nontyphoidal Salmonella (31.7%; 95% CI, 29.5%-33.9%). Antibiotics were prescribed for 12.3% (95% CI, 11.7%-13.0%) of visits for viral gastroenteritis. CONCLUSIONS: Overall, 13% of AGE visits resulted in antibiotic prescriptions. Antibiotics were unnecessarily prescribed for viral gastroenteritis and some bacterial infections for which antibiotics are not recommended. Antibiotic stewardship assessments and interventions for AGE are needed in ambulatory settings.

Using a machine-learning model, we examined drivers of antibiotic prescribing for antibiotic-inappropriate acute respiratory illnesses in a large US claims data set. Antibiotics were prescribed in 11% of the 42 million visits in our sample. The model identified outpatient setting type, patient age mix, and state as top drivers of prescribing.

Time constraints have been suggested as a potential driver of antibiotic overuse for acute respiratory tract infections. In this cross-sectional analysis of national data from visits to offices and emergency departments, we identified no statistically significant association between antibiotic prescribing and the duration of visits for acute respiratory tract infections.

BACKGROUND: The objective of our study was to describe trends in U.S. outpatient antibiotic prescriptions from January through May 2020 and compare with trends in previous years (2017-2019). METHODS: We used data from the IQVIA Total Patient Tracker to estimate the monthly number of patients dispensed antibiotic prescriptions from retail pharmacies in January 2017-May 2020. We averaged estimates from 2017-2019 and defined expected seasonal change as the average percent change from January to May 2017-2019. We calculated percentage point and volume changes in the number of patients dispensed antibiotics from January to May 2020 exceeding expected seasonal changes. We also calculated average percent change in number of patients dispensed antibiotics per month in 2017- 2019 versus 2020. Data were analyzed overall and by agent, class, patient age, state, and prescriber specialty. RESULTS: From January to May 2020, the number of patients dispensed antibiotic prescriptions decreased from 20.3 to 9.9 million, exceeding seasonally expected decreases by 33 percentage points and 6.6 million patients. The largest changes in 2017-2019 versus 2020 were observed in April (-39%) and May (-42%). The number of patients dispensed azithromycin increased from February to March 2020 then decreased. Overall, beyond-expected decreases were greatest among children (≤19 years) and agents used for respiratory infections, dentistry, and surgical prophylaxis. CONCLUSIONS: From January 2020 to May 2020, the number of outpatients with antibiotic prescriptions decreased substantially more than would be expected due to seasonal trends alone, possibly related to the COVID-19 pandemic and associated mitigation measures.

Antibiotics are not indicated for the treatment of bronchitis and bronchiolitis. Using a nationally representative database from 2006-2015, we found that antibiotics were prescribed in 58% of outpatient visits for bronchitis and bronchiolitis in children, serving as a possible baseline for the expanded HEDIS 2020 measure regarding antibiotic prescribing for bronchitis.

Our objective was to describe the duration of antibiotic therapy for the management of common outpatient conditions. The median duration of antibiotic courses for most common conditions, except acute cystitis, was 10 days, in many cases exceeding guideline-recommended durations.

The proportion of antibiotic prescriptions prescribed in US physician offices and emergency departments that were unnecessary decreased slightly, from 30% in 2010-2011 to 28% in 2014-15. However, a greater decrease occurred in children: 32% in 2010-11 to 19% in 2014-15. Unnecessary prescribing in adults did not change during this period.

BACKGROUND: Group A Streptococcus (GAS) is a leading cause of acute respiratory infections frequently resulting in antibiotic prescribing. Vaccines against GAS are currently in development. METHODS: We estimated the incidence of healthcare visits and antibiotic prescribing for pharyngitis, sinusitis, and acute otitis media (AOM) in the United States using nationally-representative surveys of outpatient care provision, supplemented by insurance claims data. We estimated the proportion of these episodes attributable to GAS, and to GAS emm types included in a proposed 30-valent vaccine. We used these outputs to estimate the incidence of outpatient visits and antibiotic prescribing preventable by GAS vaccines with various efficacy profiles under infant and school-age dosing schedules. RESULTS: GAS pharyngitis causes 19.1 (95%CI: 17.3-21.1) outpatient visits and 10.2 (9.0-11.5) antibiotic prescriptions per 1,000 US persons aged 0-64 years, annually. GAS pharyngitis causes 93.2 (82.3-105.3) visits and 53.2 (45.2-62.5) antibiotic prescriptions per 1,000 children ages 3-9 years, annually, representing 5.9% (5.1-7.0%) of all outpatient antibiotic prescribing in this age group. Collectively, GAS-attributable pharyngitis, sinusitis, and AOM cause 26.9 (23.9-30.8) and 16.1 (14.0-18.7) outpatient visits and antibiotic prescriptions per 1,000 population, annually. A 30-valent GAS vaccine meeting the WHO 80% efficacy target could prevent 5.4% (4.6-6.4%) of outpatient antibiotic prescriptions among children aged 3-9 years. If vaccine prevention of GAS pharyngitis made routine antibiotic treatment of pharyngitis unnecessary, up to 17.1% (15.0-19.6%) of outpatient antibiotic prescriptions among children aged 3-9 years could be prevented. CONCLUSIONS: An efficacious GAS vaccine could prevent substantial incidence of pharyngitis infections and associated antibiotic prescribing in the United States.

Pharyngitis is a common reason for outpatient antibiotic prescribing in the United States.1,2 With few exceptions, antibiotics should be prescribed for pharyngitis only after confirmation of group A Streptococcus (GAS) by laboratory testing.3 Since rapid antigen detection tests (RADTs) have a specificity of greater than 95% but a sensitivity that is often less than 90% compared to throat cultures, national guidelines recommend performing cultures when RADTs are negative in children but not in adults.3,4 Inappropriate antibiotic prescribing for pharyngitis occurs when antibiotics are prescribed without testing or when antibiotics other than narrow-spectrum penicillins are chosen for non-allergic patients.3,5 Since the prevalence of GAS among cases of pharyngitis is estimated to be 20–30% in children and 5–15% in adults, prescription rates higher than these thresholds suggest overuse.1,3 Appropriate laboratory testing for pharyngitis in patients who are prescribed antibiotics is a Healthcare Effectiveness Data and Information Set (HEDIS) performance measure in children, and it will be expanded in 2020 to include adults.5 Our objectives were to describe use of laboratory testing and antibiotic prescribing for GAS in the United States.

BACKGROUND: While antibiotics are life-saving drugs, their use is not without risk, including adverse events and antibiotic resistance. The majority of US antibiotic prescriptions are prescribed in outpatient settings, making outpatient antibiotic prescribing an important antibiotic stewardship target. The primary objective of this study was to describe trends in US outpatient oral antibiotic prescriptions from 2011-2016. METHODS: We estimated annual oral antibiotic prescription rates using national prescription dispensing count data from IQVIA Xponent divided by census estimates for 2011-2016. We calculated the ratio of broad- to narrow-spectrum prescriptions by dividing broad-spectrum prescription rates by narrow-spectrum prescription rates. We used Poisson models to estimate prevalence rate ratios comparing 2011 and 2016 antibiotic prescription rates and linear models to evaluate temporal trends throughout the study period. RESULTS: Oral antibiotic prescription rates decreased 5% from 877 prescriptions per 1,000 persons in 2011 to 836 per 1,000 persons in 2016. During this period, rates of prescriptions dispensed to children decreased 13% while adult rates increased 2%. The ratio of broad- to narrow-spectrum antibiotics decreased from 1.62 in 2011 to 1.49 in 2016, driven by decreases in macrolides and fluoroquinolones. The proportion of prescriptions written by nurse practitioners and physician assistants increased during the study period; in 2016, these providers prescribed over one-quarter of all antibiotic prescriptions. CONCLUSIONS: Outpatient antibiotic prescription rates, especially of broad-spectrum agents, have decreased in recent years. Clinicians who prescribe to adults, including nurse practitioners and physician assistants, are important targets for antibiotic stewardship.

Ceftriaxone, a parenteral third-generation cephalosporin, is used to treat serious bacterial infections and sexually transmitted diseases.1 Inappropriate ceftriaxone use contributes to resistance to this important antibiotic and threatens patient safety due to antibiotic-associated adverse events and Clostridioides difficile infections.2 Previous studies of inappropriate antibiotic prescribing in outpatient acute respiratory infections (ARIs) have focused on oral, rather than parenteral, antibiotics.3,4 Our objective was to describe ceftriaxone use in adult outpatient ARI visits.

Outpatient prescriptions account for an estimated 85-95% of the volume of antibiotics used in people, and antibiotics are frequently overused and misused in outpatient settings.123 Optimizing antibiotic use in outpatient settings is increasingly recognized as an opportunity to improve patient safety.4 Two studies in The BMJ illustrate how to harness the power of outpatient antibiotic prescribing data to inform quality improvement.56 Data are critical to identify opportunities for improvement to inform action, track and report antibiotic use, and evaluate the impact of interventions.4

The inappropriate use of antibiotics can increase the likelihood of antibiotic resistance and adverse events. In the United States, nearly a third of antibiotic prescriptions in outpatient settings are unnecessary, and the selection of antibiotics and duration of treatment are also often inappropriate. Evidence shows that antibiotic prescribing is influenced by psychosocial factors, including lack of accountability, perceived patient expectations, clinician workload, and habit. A varied and growing body of evidence, including meta-analyses and randomized controlled trials, has evaluated interventions to optimize the use of antibiotics. Interventions informed by behavioral science-such as communication skills training, audit and feedback with peer comparison, public commitment posters, and accountable justification-have been associated with improved antibiotic prescribing. In addition, delayed prescribing, active monitoring, and the use of diagnostics are guideline recommended practices that improve antibiotic use for some conditions. In 2016, the Centers for Disease Control and Prevention released the Core Elements of Outpatient Antibiotic Stewardship, which provides a framework for implementing these interventions in outpatient settings. This review summarizes the varied evidence on drivers of inappropriate prescription of antibiotics in outpatient settings and potential interventions to improve their use in such settings.

Between 2000-2012, the national estimated incidence rate of pediatric mastoiditis, a rare but serious complication of acute otitis media (AOM), was highest in 2006 (2.7 per 100,000 population) and lowest in 2012 (1.8 per 100,000 population). This measure provides a baseline for public health surveillance in the pneumococcal conjugate vaccine era as stewardship efforts target antibiotic use in AOM.

This study evaluates the duration of antibiotic therapy prescribed for US adults with sinusitis.