Between 2006 and 2012, overall rates of antibiotic use in hospitalized patients did not change significantly, according to data published in JAMA Internal Medicine.
However, James Braggs, PhD, from the CDC, and colleagues identified increases in certain antibiotic classes, including broad-spectrum antibiotics, which they noted could have significant impact on antibiotic-resistant infections.
“Owing to the rising threat of antibiotic resistance and other consequences resulting from unnecessary antibiotic use, ensuring appropriate antibiotic usage in the United States has become a national priority,” they wrote. “In response, the U.S. government has developed The National Strategy for Combating Antibiotic-Resistant Bacteria. Antibiotic use surveillance is a key objective within that strategy and a core element of hospital antibiotic stewardship programs identified by the CDC. Appropriate antibiotic prescribing improves patient safety, slows development of antibiotic resistance, and reduces wasted resources.”
Braggs and colleagues conducted a retrospective analysis of inpatient antibiotic use from the Truven Health MarketScan Hospital Drug Database to estimate antibiotic use in the United States between 2006 and 2012. Their data included pediatric and adult admissions to 300 acute care hospitals, which yielded 34 million discharges and 166 million patient-days.
Results showed that 55.1% of patients received at least one dose of antibiotics during their hospital stay. Braggs and colleagues reported that overall national days of therapy was 755 per 1000 patient-days.
Overall antibiotic use did not change significantly during the time period, with total days of therapy increasing by 5.6 days (95% CI, 18.9 to 30.1).
The researchers noted that several antibiotic classes increased significantly: tetracyclines, 3.3 (2-4.7); carbapenems, 7.4 (4.6-10.2); -lactam/-lactamase inhibitor combinations, 18 (13.3-22.6); glycopeptides, 22.4 (17.5-27.3); macrolides, 4.8 (2-7.6); and third- and fourth-generation cephalosporins, 10.3 (3.1-17.5).
“Improved monitoring of antibiotic use is critical to direct the work of antibiotic stewardship programs in the United States,” Braggs and colleagues concluded. “In 2012, the CDC launched the Antibiotic Use Option of the National Healthcare Safety Network that provides real-time monitoring of antibiotics administered in U.S. hospitals. As enrollment in the antibiotic use option grows, it will provide ongoing systematic assessment at the hospital, state, regional, and national levels. Because inappropriate antibiotic use increases the risk of antibiotic resistance and other adverse patient outcomes, continued monitoring of antibiotic use is critical to future improvements in patient safety.”
Mehrotra, MD, MPH, and Jeffrey A. Linder, MD, MPH, both from Harvard Medical School, wrote in an accompanying editorial that efforts to curb antibiotic overuse “have stalled, rates of outpatient antibiotic prescribing have remained stagnant, and, most troubling, an increasing fraction of prescriptions are for broad-spectrum antibiotics.”
They suggested that antibiotic overuse is a psychological problem, not a diagnostic or knowledge problem and acknowledged that there is an imbalance in factors involved in prescribing antibiotics.
“We, as physicians, want to appear capable to our patients and not give the impression they have wasted either our time or their own,” Mehrotra and Linder wrote. “In addition, it feels easier for us as physicians to do something now rather than wait for a problem to arise. In circumstances of diagnostic uncertainty, prescribing antibiotics ‘just to be safe’ feels like it decreases the chance of serious complications. Physicians also perceive that patients want an antibiotic prescribed, and in a rushed visit it seems faster to write the prescription than explain to the patient why an antibiotic is not necessary. In contrast, the reasons against antibiotic prescribing such as antibiotic resistance and concerns about complications are remote and less emotionally salient. Given the clear imbalance in this tradeoff, it is not surprising that many physicians inappropriately prescribe an antibiotic.”
They recommended three strategies to restore the balance and minimize inappropriate prescribing: Shift antibiotic overprescribing as an issue from a public health concern to an individual patient concern, more widespread use of interventions for physicians such as order entry systems and peer comparison feedback, and the prevention of wasteful ambulatory care visits for issues such as colds and sinusitis.
“Growing patterns of antibiotic resistance have driven calls for more physician education and new diagnostics,” Mehrotra and Linder concluded. “While these efforts may help, it is important to recognize that many emotionally salient factors are driving physicians to inappropriately prescribe antibiotics. Future interventions need to counterbalance these factors using tools from behavioral science to reduce the use of inappropriate antibiotics.” – by Chelsea Frajerman Pardes
Disclosure: The authors report no relevant financial disclosures.