Antibiotic Resistance

CDC’s Office of Antibiotic Stewardship on the Recent Trends in US Oral Antibiotic Prescriptions

From 2011 to 2016, overall oral antibiotic prescription rates had decreased by 5% in the United States.1 During this period, rates of prescriptions to children had decreased by 13%, while rates to adults increased by 2%.1

These are just some of the recent trends in US outpatient oral antibiotic prescriptions found by a team of researchers from the Centers for Disease Control and Prevention (CDC) Office of Antibiotic Stewardship; the team included Laura M. King, MPH; Monina Bartoces, PhD; Katherine E. Fleming-Dutra, MD; Rebecca M. Roberts; and Lauri A. Hicks, DO. Using national prescription dispensing count data, the team estimated the annual oral antibiotic prescription rates in the United States from 2011 to 2016.

Answering Infectious Diseases Consultant’s questions, the team from CDC’s Office of Antibiotic Stewardship provides insight into its findings, highlighting the progress that has been made in antibiotic prescribing practices and suggesting what else needs to be done to abate the risks of adverse events and antibiotic resistance.

INFECTIOUS DISEASES CONSULTANT: What do your results reveal about the progress that has been made and the progress that is still needed in order to meet the goals in the National Action Plan for Combating Antibiotic-Resistant Bacteria? 

Office of Antibiotic Stewardship, CDC: One of the goals for improving outpatient antibiotic use in the National Action Plan for Combating Antibiotic-Resistant Bacteria2 is to reduce inappropriate antibiotic use by 50% by 2020. This corresponds to a decrease in total outpatient antibiotic prescribing of approximately 15%. In this study, we found that national population-based rates of outpatient antibiotic prescribing decreased by 5% from 2011 to 2016. These decreases were driven primarily by improvements in prescribing to children. Data through 2017 show these trends have continued.3 Although we have made progress toward the National Action Plan goal, we are working hard to continue to improve overall antibiotic prescribing, specifically to adults. 

ID CON: From 2011 to 2016, broad-spectrum antibiotic prescription rates had decreased among both adults and children. Why are practitioners’ prescribing preferences shifting in this way?

CDC: Broad-spectrum antibiotic prescription rates likely improved for several reasons, with 2 antibiotic classes accounting for most of the improvement: macrolides in both adults and children and fluoroquinolones in adults. Decreases in macrolide prescribing may be related to changes in treatment recommendations for sinusitis and acute otitis media (AOM), two of the most common conditions for which antibiotics are prescribed. These changes were made because one of the most common pathogens associated with these infections, Streptococcus pneumoniae, showed increasing macrolide resistance. Additionally, a 2013 FDA Drug Safety Communication4 warned about the risk of potentially fatal heart rhythms associated with the macrolide azithromycin, which may have also decreased prescribing. 

Similarly, fluoroquinolone prescribing rates may have decreased as a result of concerns about adverse events. Fluoroquinolone prescribing in adults remained relatively constant from 2011 to 2015 and then decreased in 2016, coinciding with a 2016 FDA Drug Safety Communication5 outlining adverse events such as tendinopathy and peripheral neuropathy. While it is encouraging that these broad-spectrum antibiotics were used less frequently during the study period, there are likely further opportunities to improve antibiotic agent choice when antibiotics are indicated. 

ID CON: What factors may have contributed to the decrease in antibiotic prescriptions among children but an increase among adults?

CDC: There are a number of reasons that could account for the decrease in antibiotic prescription rates seen in children during the study period. One factor could be decreasing disease incidence—especially of AOM—following the introduction of pneumococcal conjugate vaccines (PCV7 in 2000 and PCV13 in 2010). Another factor may be the introduction in 2013 of stricter diagnostic criteria for AOM6—the most common reason antibiotics are prescribed to US children—which likely resulted in fewer AOM diagnoses and subsequent antibiotic prescriptions among children. Decreases may also be related to improved prescribing practices among clinicians related to antibiotic stewardship interventions and messaging campaigns, which focused on increasing awareness to parents of the risks of antibiotics, as well as when antibiotics are needed. Finally, previous studies have shown that pediatricians, specifically, prescribe fewer inappropriate antibiotics than other providers, and so this group of clinicians who specifically prescribe to children could be driving down this use. 

ID CON: Moving forward, what antibiotic stewardship elements/interventions should be made as key targets to improve prescribing?

CDC: Although we continue to prioritize improving antibiotic prescribing in all outpatient settings, this study revealed the particular need for improvement in prescribing to adult patients. In 2016, the CDC released the Core Elements of Outpatient Antibiotic Prescribing7 to provide a framework for improving antibiotic use for clinicians and facilities that routinely provide outpatient antibiotic treatment. This document summarizes effective interventions that can be used to improve use, including providing prescribers with timely feedback about their prescribing behavior, education on improving prescribing, and opportunities to improve clinician-patient communication. As more clinicians, facilities, and public health agencies become engaged in outpatient antibiotic stewardship work, key priorities are focusing on reducing unnecessary antibiotic use for conditions for which antibiotics are not indicated (eg, viral respiratory infections) and improving antibiotic selection in conditions where they are.

ID CON: How would you recommend clinicians implement these findings into their everyday practice? Any difference of recommendations for providers working with adults vs children?

CDC: Antibiotic stewardship has often been described as prescribing the right drug at the right time at the right dose for the right duration. Although this may feel like a big task, clinicians can prioritize stewardship to any patient—adult or child—even in small ways each time they consider prescribing an antibiotic by:

  • Considering whether an antibiotic is even indicated: Is this a viral infection for which antibiotics will not help?
  • Considering the choice of antibiotic: Is there a first-line recommended antibiotic for this condition?

 

Communication training, which provides clinicians with a framework to communicate with parents and patients about antibiotics, has been shown to improve prescribing and improve parent satisfaction. A module on communications is included in CDC’s Training on Antibiotic Stewardship.8

Reducing unnecessary antibiotic use among patients with conditions that do not need antibiotics and improving antibiotic selection for common conditions can make a big impact and lead to improvements in overall antibiotic use.

 

References:

  1. King LM, Bartoces M, Fleming-Dutra KE, Roberts RM, Hicks LA. Changes in US outpatient antibiotic prescriptions from 2011–2016. Clin Infect Dis. 2020;70(3):370-377. https://doi.org/10.1093/cid/ciz225.
  2. National action plan for combating antibiotic-resistant bacteria. Centers for Disease Control and Prevention. Published March 2015. Accessed February 19, 2020. https://www.cdc.gov/drugresistance/pdf/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf. 
  3. Antibiotic resistance, use & stewardship. Centers for Disease Control and Prevention. Accessed February 19, 2020. https://arpsp.cdc.gov/profile/antibiotic. 
  4. FDA drug safety communication: azithromycin (Zithromax or Zmax) and the risk of potentially fatal heart rhythms. US Food and Drug Administration. Published March 12, 2013. Updated February 14, 2018. Accessed February 19, 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-azithromycin-zithromax-or-zmax-and-risk-potentially-fatal-heart. 
  5. FDA drug safety communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur together. US Food and Drug Administration. Published May 12, 2016. Updated September 25, 2018. Accessed February 19, 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-advises-restricting-fluoroquinolone-antibiotic-use-certain. 
  6. Harmes KM, Blackwood RA, Burrows HL, Cooke JM, Van Harrison R, Passamani PP. Otitis media: diagnosis and treatment. Am Fam Physician. 2013;88(7):435-440. https://www.aafp.org/afp/2013/1001/p435.html.
  7. Core elements of outpatient antibiotic stewardship. Centers for Disease Control and Prevention. Updated November 14, 2019. Accessed February 19, 2020. https://www.cdc.gov/antibiotic-use/core-elements/outpatient.html. 
  8. CDC’s antibiotic stewardship training series. CDC Train. Centers for Disease Control and Prevention. Accessed February 19, 2020. https://www.train.org/cdctrain/training_plan/3697.