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

  1. Michael A. Steinman, MD;
  2. Ralph Gonzales, MD, MSPH;
  3. Jeffrey A. Linder, MD, MPH; and
  4. C. Seth Landefeld, MD
  1. 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.

    Abstract

    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.

    Article and Author Information

    • 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.

    Summary for Patients

    • Summaries for Patients:Changing Use of Antibiotics in Community-Based Outpatient Practice, 1991–1999 Ann Intern Med April 1, 2003 138:I-24
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    1. Ann Intern Med April 1, 2003 vol. 138 no. 7 525-533
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