Acute respiratory tract infection: A practice examines its antibiotic prescribing habits

1. Fendrick AM, Monto AS, Nightengale B, et al. The economic burden of non-influenza related viral respiratory tract infection in the United States. Arch Intern Med. 2003;163:487-494.

2. Werner K, Deasy J. Acute respiratory tract infections: when are antibiotics indicated? JAAPA. 2009;22:22–26.

3. US Department of Health and Human Services. Preventing emerging infectious diseases: a strategy for the 21st century. MMWR Morb Mortal Wkly Rep. 1998;47(RR-15). Available at: http://www.cdc.gov/MMWR/pdf/rr/rr4715.pdf. Accessed July 16, 2011.

4. Drug resistance threatens to reverse medical progress [press release]. Geneva, Switzerland: World Health Organization (WHO); June 12, 2000. Available at: http://www.who.int/inf-pr-2000/en/pr2000-41.html. Accessed July 16, 2011.

5. Smolinski MS, Hamburg MA, Lederberg J. eds. Institute of Medicine, Committee on Emerging Microbial Threats to Health in the 21st Century. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: National Academies Press; 2003. Available at: http://www.iom.edu/CMS/3783/3919/5381/6146.aspx. Accessed July 16, 2011.

6. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for treatment of acute respiratory tract infections in adults: background, specific aims, and methods. Ann Intern Med. 2001;134:479-486.

7. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults: background. Ann Intern Med. 2001;134:490-494.

8. Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Ann Intern Med. 2001;134:498-505.

9. Cooper RJ, Hoffman JR, Bartlett JG, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Intern Med. 2001;134:509-517.

10. Gonzales R, Bartlett JG, Bessnar RE, et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Intern Med. 2001;134:521-529.

11. CDC. Get smart: know when antibiotics work. Adult appropriate antibiotic use summary: physician information sheets (adult). Available at: http://www.cdc.gov/getsmart/campaign-materials/adult-treatment.html. Accessed July 16, 2011.

12. Grijalva CG, Nuorti JP, Griffin M. Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings. JAMA. 2009;302:758-766.

13. Steinman MA, Landefeld CS, Gonzales R. Predictors of broad spectrum antibiotic prescribing for acute respiratory tract infections in adult primary care. JAMA. 2003;289:719-725.

14. Wigton RS, Darr CA, Corbett KK, et al. How do community practitioners decide whether to prescribe antibiotics for acute respiratory tract infections? J Gen Intern Med. 2008;23:1615-1620.

15. Macfarlane J, Holmes W, Macfarlane R, et al. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ. 1997;315:1211-1214.

16. Colgan R, Powers JH. Appropriate antimicrobial prescribing: approaches that limit antibiotic resistance. Am Fam Physician. 2001;64:999-1004.

17. Coco A, Mainous AG. Relation of time spent in an encounter with the use of antibiotics in pediatric office visits for viral respiratory infections. Arch Pediatr Adolesc Med. 2005;159:1145-1149.

18. Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev 2005;(4):CD003539-

19. Mainous AG, Hueston WJ, Love MM, et al. An evaluation of statewide strategies to reduce antibiotic overuse. Fam Med. 2000;32:22-29.

20. Gonzales R, Sauaia A, Corbett KK, et al. Antibiotic treatment of acute respiratory tract infections in the elderly: effect of a multidimensional educational intervention. J Am Geriatr Soc. 2004;52:39-45.

21. Franck A, Smith R. Antibiotic use for acute respiratory tract infections in a veteran population. J Am Pharm Assoc. 2010;50:726-729.

22. Smucny J, Fahey T, Becker L, et al. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2004;(4):CD000245-

23. Bramen SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest. 2006;129 (1 suppl):95S-103S.

24. Snee RD. Use DMAIC to make improvement part of “the way we work.” Quality Progress Web site. September 2007. Available at: http://asq.org/quality-progress/2007/09/process-managementment/use-dmaic-to-make-improvement-part-of-the-way-we-work.html. Accessed July 16, 2011.

Abstract

Purpose We wanted to better understand our practice behaviors by measuring antibiotic prescribing patterns for acute respiratory tract infections (ARTIs), which would perhaps help us delineate goals for quality improvement interventions. We determined (1) the distribution of ARTI final diagnoses in our practice, (2) the frequency and types of antibiotics prescribed, and (3) the factors associated with antibiotic prescribing for patients with ARTI.

Methods We looked at office visits for adults with ARTI symptoms that occurred between December 14, 2009, and March 4, 2010. We compiled a convenience sample of 438 patient visits, collecting historical information, physical examination findings, diagnostic impressions, and treatment decisions.

Results Among the 438 patients, cough was the most common presenting complaint (58%). Acute sinusitis was the most frequently assigned final diagnosis (32%), followed by viral upper respiratory tract infection (29%), and acute bronchitis (24%). Sixty-nine percent of all ARTI patients (304/438) received antibiotic prescriptions, with macrolides being most commonly prescribed (167/304 [55%]). Prescribing antibiotics was associated with a complaint of sinus pain or shortness of breath, duration of illness ≥8 days, and specific abnormal physical exam findings. Prescribing rates did not vary based on patient age or presence of risk factors associated with complication. Variations in prescribing rates were noted between individual providers and groups of providers.

Conclusions We found that we prescribed antibiotics at high rates. Diagnoses of acute sinusitis and bronchitis may have been overused as false justification for antibiotic therapy. We used broad-spectrum antibiotics frequently. We have identified several gaps between current and desired performance to address in practice-based quality improvement interventions.

Most acute respiratory tract infections (ARTIs) are caused by viruses, do not require antibiotics, and resolve spontaneously.^1,2 And yet, unnecessary prescribing of antibiotics for ARTIs continues—accounting for approximately half of all such prescriptions²—despite its well-known contribution to antimicrobial resistance, a public health threat as declared by the Institute of Medicine, the Centers for Disease Control and Prevention (CDC), and the World Health Organization (WHO).^3-5

Even though the CDC has widely disseminated clinical guidelines for ARTI^6-10 and annually publicizes recommendations for ARTI management during “Get Smart About Antibiotics Week,”¹¹ it appears that providers have difficulty implementing the guidelines.^12-14 Granted, antibiotic prescription rates in general have declined somewhat, but the use of broad-spectrum antibiotics (macrolides and fluoroquinolones) and antibiotics for older Americans has increased.¹²

There are several plausible reasons for overprescribing. Patients have expectations for treatment based on prior experience or on a false assumption that their illness is bacterial in origin.¹⁴ Providers may be concerned that certain individuals are at risk of complications if not treated. Patient race, health maintenance organization membership, and insurance status have all been implicated as factors related to antimicrobial overutilization.^12-16 It can be perceived as time consuming to educate patients about the likely viral nature of their illness and the lack of utility and increased risks in taking unneeded antibiotics.¹⁷ Furthermore, attempts at patient and physician education (eg, physician performance feedback) do not always reduce antibiotic overuse.^18-20

We wanted to know the state of ARTI antibiotic use in our practice and whether we could identify goals for improvement through quality interventions. We sought to determine the distribution of ARTI final diagnoses in our practice, the frequency and types of antibiotics prescribed, and factors associated with antibiotic prescribing.

Methods

Setting and subjects
Subjects were adult patients seen at Mayo Clinic Family Medicine offices in Arizona between December 14, 2009, and March 4, 2010. We created a convenience sample from visits scheduled for patients with ARTI symptoms. We encouraged, but did not require, clinic staff to use a standardized data collection form to document symptoms, physical examination findings, diagnostic impressions, and prescription decisions that were then entered into an Excel spreadsheet. At one of our 2 sites, clinicians (attending physicians, nurse practitioners, and resident physicians) used the form at the point of care to enroll a portion of the sample population. A retrospective chart audit (with or without use of the form) was the means of selecting the remainder of the sample at this site and the entire sample at our second site. We obtained informed consent from all patients enrolled with the data collection form. The Mayo Foundation Institutional Review Board approved the project.

We defined an ARTI as a new illness occurring within the previous 3 weeks, associated with cough, sinus pain, nasal congestion or rhinorrhea, sore throat, or fever. We excluded patients who had a longer duration of symptoms, a previous evaluation, or a noninfectious diagnosis. We included ARTI patients with concomitant asthma or chronic obstructive pulmonary disease (COPD).