BACKGROUND: Patients visiting the emergency department (ED) for nontraumatic dental conditions usually receive nondefinitive health care and are referred to treatment elsewhere. This may lead to potentially avoidable antibiotic and opioid use. METHODS: A retrospective study was conducted in IBM MarketScan Research Databases in Treatment Pathways from 2012 through 2014. This study included patients with commercial insurance or enrolled in Medicaid. Patients receiving a diagnosis of a dental condition in the ED with no secondary diagnosis warranting an antibiotic prescription were included. Patients were stratified on the basis of the primary payer and available demographics, as well as on the basis of repeat visits to the ED. RESULTS: A higher proportion of Medicaid beneficiaries (280,410, 4.9%) had dental-related visits compared with the commercially insured (159,066, 1.3%). The most common diagnoses were similar for both groups and included caries. In both cohorts, the 18- through 34-year age group had the highest rate of dental-related ED visits. Within 7 days of a dental-related ED visit, 54.9% of Medicaid beneficiaries and 55.0% of commercially insured beneficiaries filled a prescription for an antibiotic and 39.6% of Medicaid patients and 42.0% of commercially insured patients filled an opioid prescription. CONCLUSIONS: Antibiotics and opioids are frequently prescribed during ED visits for dental conditions. Access to preventive and acute oral health care for routine dental symptoms, such as caries, may reduce unnecessary prescriptions in both the commercially insured and Medicaid beneficiary populations. PRACTICAL IMPLICATIONS: Treatment of dental conditions in the ED often indicates a lack of access to preventive or acute oral health care. Data-driven solutions, such as guideline implementation, could improve oral health access, reduce medication-related harms, and avert health care expenditures.

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.

BACKGROUND: Inappropriate antibiotic use is common. Understanding how patients view antibiotic risks and/or benefits could inform development of patient education materials and clinician communication strategies. We explored current knowledge, attitudes, and behaviors related to antibiotics among populations with high antibiotic use. METHODS: We conducted 12 focus groups with adult patients and parents across the United States by telephone in March 2017. Purposive sampling was used to identify participants with high antibiotic use. We transcribed the discussions verbatim and performed thematic analysis. RESULTS: We identified 4 major themes. First, participants expressed uncertainty regarding which clinical syndromes required antibiotics, and emotion often influenced their desire for antibiotics. Second, they had a limited understanding of antibiotic risks. Antibiotic resistance was viewed as the primary risk but was seen as a "distant, future" issue, whereas immediate adverse events, such as side effects, were minimized; however, patients expressed concern when told about the risk of serious adverse events. Third, they prioritized antibiotic benefits over risks in their decision-making, both due to an inaccurate estimation of antibiotic risks and/or benefits and a tendency to prioritize instant gratification. Fourth, most participants were willing to defer to their clinicians' decisions about antibiotics, especially if their clinician provided symptomatic treatment and anticipatory guidance. CONCLUSIONS: Patients have a limited understanding of antibiotic risks, potentially explaining why they are willing to try antibiotics even if it is unclear antibiotics will help. Educating patients on the potential antibiotic risks versus benefits, rather than just antibiotic resistance, may have a bigger impact on their decision-making.

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.

STUDY OBJECTIVE: The frequency of antibiotic prescribing and types of antibiotics prescribed for dental conditions presenting to the emergency department (ED) is not well known. The objective of this study is to quantify how often and which dental diagnoses made in the ED resulted in an antibiotic prescription. METHODS: From 2011 to 2015, there were an estimated 2.2 million (95% confidence interval [CI] 1.9 to 2.5 million) ED visits per year for dental-related conditions, which accounted for 1.6% (95% CI 1.5% to 1.7%) of ED visits. This is based on an unweighted 2,125 observations from the National Hospital Ambulatory Medical Care Survey in which a dental-related diagnosis was made. RESULTS: An antibiotic, most often a narrow-spectrum penicillin or clindamycin, was prescribed in 65% (95% CI 61% to 68%) of ED visits with any dental diagnosis. The most common dental diagnoses for all ages were unspecified disorder of the teeth and supporting structures (44%; 95% CI 41% to 48%; International Classification of Diseases, Ninth Revision, Clinical Modification[ICD-9-CM] code 525.9), periapical abscess without sinus (21%; 95% CI 18% to 25%; ICD-9-CM code 522.5), and dental caries (18%; 95% CI 15% to 22%; ICD-9-CM code 521.0). Recommended treatments for these conditions are usually dental procedures rather than antibiotics. CONCLUSION: The common use of antibiotics for dental conditions in the ED may indicate the need for greater access to both preventive and urgent care from dentists and other related specialists as well as the need for clearer clinical guidance and provider education related to oral infections.

Our objective was to identify characteristics associated with high-volume antibiotic prescribing among office-based primary care physicians to target antibiotic stewardship efforts. Physicians aged 40 years and older who were male, located in the South, and in solo or 2-physician practices prescribed higher volumes of antibiotics than their peers by specialty.

BACKGROUND: Improving antibiotic use has the potential to decrease health care costs by reducing the incidence of antibiotic-resistant infections, antibiotic-associated adverse events, and expenditures due to unnecessary prescriptions. Antibiotic expenditures in 2009 totaled $10.7 billion in the United States. Since then, national and local antibiotic stewardship initiatives have grown. The purpose of this study was to assess trends in antibiotic expenditures by health care setting in the United States between 2010 and 2015. METHODS: Systemic (non-topical) antibiotic expenditures from January 2010 to December 2015 were extracted from the QuintilesIMS National Sales Perspectives database. These data represent a statistically valid projection of U.S. medication purchases. Regression analyses evaluated trends in expenditures over the study period. RESULTS: Antibiotic expenditures totaled $56.0 billion over the six-year period; the majority (59.1%) of expenditures were associated with the outpatient setting. Overall antibiotic expenditures in 2015 ($8.8 billion) were 16.6% lower than in 2010 ($10.6 billion). Antibiotic expenditures similarly decreased in the community by 25.5% (p=0.05), but outpatient clinics and mail service pharmacy expenditures experienced significant growth (148% and 67% increase, respectively; p<0.01 for both). In 2015, 16.5% of antibiotic expenditures in the community were for parenteral formulations, an increase of 25%. CONCLUSIONS: From 2010 to 2015 antibiotic expenditures decreased. The majority of antibiotic expenditures were in the outpatient setting, specifically community pharmacies. Expenditures for intravenous agents in the community are increasing and may represent increased use. These results reinforce the importance of antibiotic stewardship efforts across the spectrum of healthcare.

BACKGROUND: Using antibiotics appropriately is critical to slow spread of antibiotic resistance, a major public health problem. Children, especially young children, receive more antibiotics than other age groups. Our objective was to describe antibiotic use in children in the United States (US) and use of azithromycin, which is recommended infrequently for pediatric conditions. METHODS: We used QuintilesIMS Xponent 2013 data to calculate the number and rate of oral antibiotic prescriptions for children by age (0-2, 3-9 and 10-19 years) and agent. We used log-binomial regression to calculate adjusted prevalence rations (PR) and 95% confidence intervals (CI) to determine if specialty and patient age were associated with azithromycin selection when an antibiotic was prescribed. RESULTS: In 2013, 66.8 million antibiotics were prescribed to US children aged ≤19 years (813 antibiotic prescriptions per 1000 children). Amoxicillin and azithromycin were the two most commonly prescribed agents (23.1 million courses, 35% of all antibiotics; 12.2 million, 18%; respectively). Most antibiotics for children were prescribed by pediatricians (39%) and family practitioners (15%). Family practitioners were more likely to select azithromycin when an antibiotic was prescribed in all age groups than pediatricians (for children aged 0-2 years: PR 1.79, 95% CI, 1.78-1.80; 3-9 years: 1.40, 1.40-1.40; and 10-19 years: 1.18, 1.18-1.18). CONCLUSION: Despite infrequent pediatric recommendations, variations in pediatric azithromycin use may suggest inappropriate antibiotic selection. Public health interventions focused on improving antibiotic selection in children as well as reducing antibiotic overuse are needed.

BACKGROUND: Dentists prescribe approximately 10% of outpatient antibiotics, but little is known about dentists' antibiotic prescribing patterns. The authors conducted a study to characterize prescribing by dentists according to antibiotic agent and category, patient demographic characteristics, and geographic region in the United States. METHODS: The authors identified oral antibiotic prescriptions dispensed during 2013 in the Xponent (QuintilesIMS) database. The authors used the total number of prescriptions and county-level census population denominators to calculate prescribing rates. In addition, the authors analyzed prescribing according to individual agent, drug category, and patient demographic characteristics and the total number of prescriptions calculated for general dentists overall. RESULTS: Dentists prescribed 24.5 million courses of antibiotics in 2013, a prescribing rate of 77.5 prescriptions per 1,000 people. Penicillins were the most commonly prescribed antibiotic category. Dentists prescribed most antibiotics for adults older than 19 years. The Northeast census region had the highest prescribing rate per 1,000 people. The District of Columbia had the highest prescribing rate of 99.5 per 1,000 people, and Delaware had the lowest prescribing rate of 50.7 per 1,000 people. CONCLUSIONS: Dentists prescribe large quantities of antibiotics in outpatient settings, and there is considerable geographic variability. Additional study is needed to better understand the reasons for this variability and identify areas of possible intervention and improvement. PRACTICAL IMPLICATIONS: Continued efforts to combat antibiotic resistance will require all prescribers, including dentists, to examine prescribing behaviors for appropriateness and the effectiveness of guidelines to identify opportunities to optimize antibiotic use.

The Core Elements of Outpatient Antibiotic Stewardship provides a framework for antibiotic stewardship for outpatient clinicians and facilities that routinely provide antibiotic treatment. This report augments existing guidance for other clinical settings. In 2014 and 2015, respectively, CDC released the Core Elements of Hospital Antibiotic Stewardship Programs and the Core Elements of Antibiotic Stewardship for Nursing Homes. Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing involves implementing effective strategies to modify prescribing practices to align them with evidence-based recommendations for diagnosis and management. The four core elements of outpatient antibiotic stewardship are commitment, action for policy and practice, tracking and reporting, and education and expertise. Outpatient clinicians and facility leaders can commit to improving antibiotic prescribing and take action by implementing at least one policy or practice aimed at improving antibiotic prescribing practices. Clinicians and leaders of outpatient clinics and health care systems can track antibiotic prescribing practices and regularly report these data back to clinicians. Clinicians can provide educational resources to patients and families on appropriate antibiotic use. Finally, leaders of outpatient clinics and health systems can provide clinicians with education aimed at improving antibiotic prescribing and with access to persons with expertise in antibiotic stewardship. Establishing effective antibiotic stewardship interventions can protect patients and improve clinical outcomes in outpatient health care settings.

OBJECTIVES: Antibiotic prescribing has become increasingly viewed as an issue related to patient safety and quality of care. The objective of this study was to better understand the differences between health plan reporting and the geographic variation seen in quality measures related to antibiotic use. STUDY DESIGN: We focused on 3 measures from the Healthcare Effectiveness Data and Information Set (HEDIS) related to antibiotic prescribing and testing to guide antibiotic prescribing. METHODS: We analyzed data for 3 relevant measures for the years 2008 to 2012, including only commercial health plans. We analyzed the following 3 HEDIS measures: 1) "Appropriate Testing for Children With Pharyngitis," 2) "Appropriate Treatment for Children With Upper Respiratory Infections," and 3) "Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis." RESULTS: Out of these 3 measures, health plans consistently performed poorly on the adult bronchitis measure. Performance was better on the 2 measures focused on the pediatric population. We also saw geographic variation between measures when looking at Census divisions across all years. CONCLUSIONS: There is wide variation between individual health plan performance on the measures related to antibiotic use. Geographic differences were also observed on these measures, with health plans in the South Central Census division performing worse than other parts of the country. Stakeholders, such as public health, advocacy groups, foundations, and professional societies, interested in improving the quality of care that patients receive related to antibiotic use in the outpatient setting should consider how existing measures and working with health plans could be used to improve prescribing.

IMPORTANCE: The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotic use by 50% by 2020, but the extent of inappropriate outpatient antibiotic use is unknown. OBJECTIVE: To estimate the rates of outpatient oral antibiotic prescribing by age and diagnosis, and the estimated portions of antibiotic use that may be inappropriate in adults and children in the United States. DESIGN, SETTING, AND PARTICIPANTS: Using the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, annual numbers and population-adjusted rates with 95% confidence intervals of ambulatory visits with oral antibiotic prescriptions by age, region, and diagnosis in the United States were estimated. EXPOSURES: Ambulatory care visits. MAIN OUTCOMES AND MEASURES: Based on national guidelines and regional variation in prescribing, diagnosis-specific prevalence and rates of total and appropriate antibiotic prescriptions were determined. These rates were combined to calculate an estimate of the appropriate annual rate of antibiotic prescriptions per 1000 population. RESULTS: Of the 184,032 sampled visits, 12.6% of visits (95% CI, 12.0%-13.3%) resulted in antibiotic prescriptions. Sinusitis was the single diagnosis associated with the most antibiotic prescriptions per 1000 population (56 antibiotic prescriptions [95% CI, 48-64]), followed by suppurative otitis media (47 antibiotic prescriptions [95% CI, 41-54]), and pharyngitis (43 antibiotic prescriptions [95% CI, 38-49]). Collectively, acute respiratory conditions per 1000 population led to 221 antibiotic prescriptions (95% CI, 198-245) annually, but only 111 antibiotic prescriptions were estimated to be appropriate for these conditions. Per 1000 population, among all conditions and ages combined in 2010-2011, an estimated 506 antibiotic prescriptions (95% CI, 458-554) were written annually, and, of these, 353 antibiotic prescriptions were estimated to be appropriate antibiotic prescriptions. CONCLUSIONS AND RELEVANCE: In the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate, supporting the need for establishing a goal for outpatient antibiotic stewardship.

Appropriate antibiotic use, in particular avoidance of antibiotics for upper respiratory infections likely to be caused by viruses, is a key component of efforts to slow the increase in antibiotic-resistant infections. Studies suggest that Hispanic consumers might differ from non-Hispanic consumers in their knowledge and attitudes regarding antibiotic use. To better understand health care provider and consumer knowledge and attitudes that influence antibiotic use, CDC analyzed national internet survey data collected from participants living in the United States during 2012-2013. The participants represented three groups: 1) the total population of adult consumers (all ethnicities); 2) adult Hispanic consumers; and 3) health care providers. Hispanic consumers were more likely than all consumers to believe that if they have a cold, antibiotics would help them to get better more quickly (48% versus 25%), and more likely to obtain antibiotics not prescribed by a clinician, such as antibiotics left over from a previous illness (25% versus 9%), obtained from a neighborhood grocery store (23% versus 5%), or obtained from a friend or family member (17% versus 6%). Most providers surveyed (54%) reported that they believed their patients expect antibiotics during visits for a cough or cold, whereas 26% of all consumers reported this expectation. To maximize knowledge about appropriate antibiotic use among outpatients in the United States, public health initiatives should target Hispanic as well as general audiences.

BACKGROUND: Appropriate antibiotic prescribing is an essential strategy to reduce the spread of antibiotic resistance. US prescribing practices have not been thoroughly characterized. We analyzed outpatient antibiotic prescribing data to identify where appropriate antibiotic prescribing interventions could have the most impact. METHODS: Oral antibiotic prescriptions dispensed during 2011 were extracted from the IMS Health Xponent database. The number of prescriptions and census denominators were used to calculate prescribing rates. Prescription totals were calculated for each provider specialty. Regression modeling was used to examine the association between socioeconomic and population health factors and prescribing rates. RESULTS: Healthcare providers prescribed 262.5 million courses of antibiotics in 2011(842 prescriptions per 1000 persons). Penicillins and macrolides were the most common antibiotic categories prescribed. The most commonly prescribed individual antibiotic agent was azithromycin. Family practitioners prescribed the most antibiotic courses (24%). The prescribing rate was higher in the South census region (931 prescriptions per 1000 persons) than in the West (647 prescriptions per 1000 persons; P < .001); this pattern was observed among all age groups, including children ≤2 and persons ≥65 years of age. Counties with a high proportion of obese persons, infants and children ≤2 years of age, prescribers per capita, and females were more likely to be high prescribing by multivariable analysis (adjusted odds ratio, >1.0). CONCLUSIONS: Efforts to characterize antibiotic prescribing practices should focus on the South census region and family practitioners. Further understanding of the factors leading to high prescribing among key target populations will inform appropriate prescribing interventions.

Antibiotic-resistant bacteria are an increasing threat to the effectiveness of antibiotics. The majority of antibiotics are prescribed in primary care settings for upper respiratory tract infections. The purpose of this study was to describe seasonal trends in outpatient antibiotic prescriptions (Rx) in the United States over a 5-year period. This study was a retrospective, cross-sectional observation of systemic antibiotic prescriptions in the outpatient setting from 2006 to 2010. Winter months were defined as the first and fourth quarters of the calendar year. Antibiotic prescribing rates were calculated (prescriptions/1,000 population) using annual U.S. Census Bureau population data. Over 1.34 billion antibiotic prescriptions were dispensed over the 5-year period. The antibiotic prescription (Rx) rate decreased from 892 Rx/1,000 population in 2006 to 867 Rx/1,000 population in 2010. Penicillins and macrolides were the primary antibiotic classes prescribed, but penicillin prescribing decreased while macrolide prescribing increased over the study period. Overall, antibiotic prescriptions were 24.5% higher in winter months than in the summer, with the largest difference (28.8%) in 2008 and the smallest (20.4%) in 2010. This seasonality was consistently drug class dependent, driven by 75% and 100% increases in penicillin and macrolide prescriptions, respectively, in the winter months. The mean outpatient antibiotic prescription rate decreased in the United States from 2006 to 2010. More antibiotic prescribing, predominately driven by the macrolide and penicillin classes, in the outpatient setting was observed in the winter months. Understanding annual variability in antibiotic use can assist with designing interventions to improve the judicious use of antibiotics.

OBJECTIVES: Promoting appropriate antibiotic use has the potential to decrease healthcare costs by reducing unnecessary prescriptions and the incidence of resistant infections. However, little is known about where antibiotic costs are incurred in the US healthcare system. We evaluated antibiotic expenditures by healthcare setting and antibiotic class in the USA. METHODS: Systemic antibiotic expenditures in 2009 were extracted from the IMS Health((c)) National Sales Perspectives database. These data represent a statistically valid projection of all medication purchases in the USA from 1 January 2009 to 31 December 2009. RESULTS: Antibiotic expenditures totalled $10.7 billion. The majority (61.5%) of expenditures were associated with the outpatient setting, especially from community pharmacies. Inpatient and long-term care settings accounted for 33.6% and 4.9% of expenditures, respectively. The class of antibiotics that accounted for the most antibiotic expenditure overall was the quinolones, followed by the penicillins. CONCLUSIONS: Over $10.7 billion was spent in 2009 on antibiotic therapy in the USA. Differences were observed in antibiotic expenditures by healthcare setting, with the majority in the outpatient setting, 87% of which was in community pharmacies.

In this issue of American Family Physician, Zoorob and colleagues summarize guidelines for the treatment of acute upper respiratory tract infections (URIs).1 Visits for acute URIs account for more than one-half of all antibiotic prescriptions for outpatients, and these infections lead to more unnecessary and inappropriate antibiotic prescriptions than any other infectious syndrome.2–4 All antibiotic use, whether indicated or not, exerts selective pressure on bacteria that can lead to resistance. Studies have shown that geographic areas with high antibiotic prescribing rates also tend to have a higher prevalence of antibiotic-resistant infections.5–7 Every antibiotic prescription matters. Given their continuity of care, family physicians are well poised to minimize the spread of antibiotic resistance by practicing antibiotic stewardship and educating patients about the importance of using antibiotics appropriately. | Patients have a role in this growing problem. Too many patients and parents expect their physicians to prescribe antibiotics for viral URIs. Physicians are more likely to prescribe an antibiotic if they think a patient or parent expects one.8 Clearly, there is a need to facilitate communication between physicians and patients, but ultimately, physicians have the power to make the right decision.