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Several studies in recent years have documented a significant amount of antibiotics prescribed in outpatients for respiratory infections usually caused by viruses and not requiring antibiotics. In emergency rooms, doctor's offices and emergency care clinics, one-third to nearly half of the antibiotics prescribed for coughs, sore throats and other respiratory conditions have proved useless.
Jeffrey Linder, MD, MPH, a general internist at the Feinberg School of Medicine at Northwestern University, says that these studies, which looked at the type of discomfort that drives people to seek help from a provider, have revealed that An aspect of the problem.
"The way we considered the prescription of antibiotics in an outpatient setting, focusing only on in-person visits and on a limited number of diagnoses, was lacking in many antibiotic prescriptions," she said. he told reporters today at IDWeek 2018.
Linder presented the results of a new study conducted with researchers from the University of Michigan Medical School and Harvard Medical School, which found that 46% of antibiotics prescribed in 514 clinics External consultation was prescribed without diagnosis related to the infection. Even more troubling, 20% of all antibiotic prescriptions were given to patients without an appointment.
"You should almost never receive an antibiotic without getting treatment in conditions such as colds or flu, symptoms such as a cough or sore throat," he said. "As doctors, we need to do certain things, especially for coughs and sore throats, to determine whether an antibiotic is actually indicated or not."
Diagnostic codes and diagnostics related to infections
Using the electronic health records system of an integrated health system, the researchers evaluated 509,534 antibiotic prescriptions made to 279,169 unique patients by 2,413 clinicians. They then sorted these prescriptions into three baskets, based on the same day's diagnosis code associated with the prescriptions. The idea was to see if there was a diagnostic code that could explain why an antibiotic was prescribed.
Prescriptions were considered infection-related if they were associated with a diagnostic code that could indicate an infection, while prescriptions with diagnostic codes not indicating an infection were considered not to be relevant. related to the infection. The third basket consisted of prescriptions associated with the lack of diagnosis.
The researchers found that 54% of the prescriptions concerned diagnoses related to an infection. Of the 46% without diagnosis related to the infection, 29% were not related to the infection and 17% were associated with the lack of diagnosis. Linder explained that some of the antibiotics prescribed for non-infection diagnoses were viral rather than bacterial infections. But in others, the diagnostic codes were "absolutely irrelevant" for the prescription of antibiotics, indicating conditions such as hypertension or an annual wellness visit.
Recognizing that all prescriptions are not written the day the diagnosis is recorded in the electronic health record, Linder and his colleagues expanded their analysis to include diagnoses made 30 days before and 30 days after the prescription. Even then, they still found that 35% of the prescriptions did not have any diagnosis code related to the infection.
Linder suggested that part of the problem could be attributed to a botched diagnostic coding that does not accurately reflect what happened when visiting a patient at a provider. But he does not think it diminishes the results. "Even if it's poor record keeping, it's a big problem," he said.
Linder also acknowledged that some of the 54% of prescriptions associated with infection-related diagnoses involved viral conditions such as sinusitis and probably did not require an antibiotic. "We forgave doctors so much in terms of what we thought was appropriate," he said.
The most commonly prescribed antibiotic classes were penicillins (30%), macrolides (23%), cephalosporins (14%), fluoroquinolones (11%), tetracyclines (10%) and sulfonamides ( 6%).
Prescriptions without visits to the patient
Of the 20% of antibiotic prescriptions prescribed outside of an in-person visit, half (10%) were over the phone, 4% were simply seized in the electronic health record, 4% were renewals and 1% were made via an online portal. .
According to Linder, it is sometimes appropriate to take an antibiotic without consulting a doctor, citing as an example women with recurrent urinary tract infections and adolescents taking antibiotics to treat acne. "There is an example where people could call, not be seen in person, and an antibiotic prescription might be reasonable," he said.
But he was particularly concerned that 4% of antibiotic prescriptions that did not include visits were renewals. Although drugs for chronic medications, such as blood pressure or cholesterol, are commonly used over the phone, Linder said the system should not allow antibiotic replacement. "It's a little worrying that we're seeing a refill for an antibiotic prescription," he said.
For those who think that taking an antibiotic without consulting a doctor is not a big problem, Linder warned that blind use of antibiotics could promote antibiotic resistance. He also pointed out the potential adverse effects of antibiotics, ranging from allergic reactions to diarrhea to Clostridium difficile infection.
According to Dr. Linder, the study indicates that outpatient antibiotic prescription problems, which account for 80% of all prescriptions for antibiotics prescribed in health care, are much deeper than what had been understood before and illustrate the amount of antibiotics taken for granted. He called on providers to adopt a more "fair" attitude about antibiotics.
"We have been pretty cavalier with regard to the use of antibiotics, do not evaluate the harmful effects as much as possible and do not educate patients as much as we should," Linder said. "I am not an antibiotic, but I would like us to use them responsibly so that we can use them effectively, if necessary."
Dr. Linder said the next steps would be to look at the data more closely to understand what was happening in the three prescription categories and to review the provider's notes in the electronic health record. And they set up a prospective study in which they call a subgroup of doctors a week after an unexplained antibiotic prescription to better understand the decision.
The study was funded by the Agency for Health Research and Quality.
See also:
Summary IDWeek # 1632
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