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ARTICLE

Changing Use of Antibiotics in Community-Based Outpatient Practice, 1991–1999

Michael A. Steinman, MD; Ralph Gonzales, MD, MSPH; Jeffrey A. Linder, MD, MPH; and C. Seth Landefeld, MD

1 April 2003 | Volume 138 Issue 7 | Pages 525-533

Background: Judicious use of antibiotics can slow the spread of antimicrobial resistance. However, overall patterns of antibiotic use among ambulatory patients are not well understood.

Objective: To study patterns of outpatient antibiotic use in the United States, focusing on broad-spectrum antibiotics.

Design: Cross-sectional survey in three 2-year periods (1991–1992, 1994–1995, and 1998–1999).

Setting: The National Ambulatory Medical Care Survey, a nationally representative sample of community-based outpatient visits.

Patients: Patients visiting community-based outpatient clinics.

Measurements: Rates of overall antibiotic use and use of broad-spectrum antibiotics (azithromycin and clarithromycin, quinolones, amoxicillin–clavulanate, and second- and third-generation cephalosporins). All comparisons were made between the first study period (1991–1992) and the final study period (1998–1999).

Results: Between 1991–1992 and 1998–1999, antibiotics were used less frequently to treat acute respiratory tract infections, such as the common cold and pharyngitis. However, use of broad-spectrum agents increased from 24% to 48% of antibiotic prescriptions in adults (P < 0.001) and from 23% to 40% in children (P < 0.001). Use of broad-spectrum antibiotics increased across many conditions, increasing two- to threefold as a percentage of total antibiotic use for a variety of diagnoses in both adults and children. By 1998–1999, 22% of adult and 14% of pediatric prescriptions for broad-spectrum antibiotics were for the common cold, unspecified upper respiratory tract infections, and acute bronchitis, conditions that are primarily viral.

Conclusions: Antibiotic use in ambulatory patients is decreasing in the United States. However, physicians are increasingly turning to expensive, broad-spectrum agents, even when there is little clinical rationale for their use.

Editors' Notes Context Indiscriminate use of antibiotics promotes the development of antibiotic-resistant strains of bacteria. Contribution This survey of patient visits to community-based clinics shows that antibiotic use for ambulatory infections, especially upper respiratory tract infections, decreased from 1991–1992 to 1998–1999. However, the use of broad-spectrum antibiotics rose over this period. Implications Efforts to encourage rational use of antibiotics should focus on which antibiotic to use as well as whether or not to use antibiotics. –The Editors

 

Author and Article Information

From San Francisco Veterans Affairs Medical Center and University of California, San Francisco, San Francisco, California; and Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.

Acknowledgment: The authors thank Eric Vittinghoff, PhD, Division of Epidemiology and Biostatistics, University of California, San Francisco, for his helpful assistance with statistical issues.

Grant Support: By the VA National Quality Scholars Program (Drs. Steinman and Landefeld); the Robert Wood Johnson Foundation Minority Medical Faculty Development Program (Dr. Gonzales); National Research Service Award 5T32PE11001-12 (Dr. Linder); and grants from the National Institute on Aging, the John A. Hartford Foundation, Dartmouth College, and a grant to Dartmouth College from the Pfizer Foundation (Dr. Landefeld).

Potential Financial Conflicts of Interest:Honoraria: R. Gonzales (SmithKline Beecham); Grants received: R. Gonzales (Abbott Laboratories, SmithKline Beecham, and Roche).

Requests for Single Reprints: Michael A. Steinman, MD, Division of Geriatrics, Box 181-G, San Francisco Veterans Affairs Medical Center, 4150 Clement Street, San Francisco, CA 94121; e-mail, mstein{at}itsa.ucsf.edu.

Current Author Addresses: Drs. Steinman and Landefeld: Division of Geriatrics, Box 181-G, San Francisco Veterans Affairs Medical Center, 4150 Clement Street, San Francisco, CA 94121.

Dr. Gonzales: Department of Medicine, Box 1211, University of California, San Francisco, San Francisco, CA 94143-1211.

Dr. Linder: Division of General Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.

Author Contributions: Conception and design: M.A. Steinman, J.A. Linder.

Analysis and interpretation of the data: M.A. Steinman, R. Gonzales, J.A. Linder, C.S. Landefeld.

Drafting of the article: M.A. Steinman, R. Gonzales, J.A. Linder.

Critical revision of the article for important intellectual content: M.A. Steinman, R. Gonzales, J.A. Linder, C.S. Landefeld.

Final approval of the article: M.A. Steinman, R. Gonzales, J.A. Linder, C.S. Landefeld.

Statistical expertise: M.A. Steinman, R. Gonzales, J.A. Linder.

Collection and assembly of data: M.A. Steinman.

Related articles in Annals:

Editorials
Antimicrobial Prescribing in the United States: Good News, Bad News
Richard E. Besser

Annals 2003 138: 605-606. [Full Text]  

Summaries for Patients
Changing Use of Antibiotics in Community-Based Outpatient Practice, 1991–1999

Annals 2003 138: I-24. [Full Text]  

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