The Implications of Antibiotic Overuse Warrant Attention to Guidelines

Up to half of antibiotics prescribed in the United States may be unnecessary, leading to avoidable adverse events and development of antibiotic resistance and attendant costs.

During the year 2010, 258 million courses of outpatient antibiotics were prescribed in the United States.¹ Geographically, those in the South were prescribed antibiotics at the highest rate, some 936 prescriptions per 1000 persons of all ages, compared to a rate of 638 per 1000 persons in the West. Prescriptions were most common for those under 10 years of age and those 65 years and older, with azithromycin and amoxicillin the most frequently ordered antibiotics. Unfortunately, up to 50% of these antibiotic courses may be unnecessary.^2,3 Consequences of unwarranted antibiotic use include avoidable adverse events and, perhaps most concerning, development of antimicrobial resistance and attendant costs.

All antibiotics carry the risk for adverse events. These events can range in severity from mild, acute gastrointestinal distress to severe, life-threatening anaphylactic reactions. A major risk factor for the development of Clostridium difficile infection and subsequent diarrhea is the use of antibiotics.⁴ Infection with C difficile leads to at least 250,000 illnesses and 14,000 deaths annually in the United States. More than 2 million infections are caused by antibiotic-resistant organisms in the United States each year, resulting in at least 23,000 deaths annually. Compared to treatment of non-resistant strains, antibiotic-resistant infections increase the use of health care resources due to prolonged hospitalizations, more expensive therapies, and overall poorer outcomes.^4,5 In fact, excessive costs associated with antibiotic resistant infections may be as high as $20 billion each year, according to one source.⁵

In 2013, the CDC detailed 18 antibiotic resistance threats in the United States in a report intended to increase awareness and prompt action.⁴ Contact precautions and appropriate hand hygiene are crucial in preventing the spread of resistant bacteria.⁶ In addition, antibiotics must be used judiciously.^4-6 Despite their predominantly viral origin, respiratory tract infections are the most common reason why antibiotics are prescribed in the outpatient setting.⁷ When antibiotics are warranted, care should be taken to select an agent that is effective against definite or suspected pathogens, while providing the narrowest spectrum of coverage possible. Current practice guidelines offer recommendations to aid in the decision to prescribe or withhold antibiotics in several commonly diagnosed infections.

Acute Bronchitis

Respiratory viruses account for more than 90% of cases of acute bronchitis.⁸ As such, the American College of Chest Physicians does not recommend the use of antibiotics to treat cough due to acute bronchitis. Acute bronchitis should be diagnosed only when there is no evidence of pneumonia and following exclusion of common cold, acute asthma, and exacerbation of chronic obstructive pulmonary disease as the etiology of cough. Acute bronchitis is self-limiting; however, a cough persisting for more than 3 weeks should prompt investigation of an alternative diagnosis.

Acute Sinusitis

Recently updated guidelines from the American Academy of Pediatrics offer an option for 3 days of additional observation without use of antibiotics in children with symptoms of persistent sinusitis (nasal discharge and/or cough) of more than 10 days duration.⁹ Antibiotics should not be withheld in children with severe onset of illness or worsening course of acute bacterial sinusitis. Similarly, the Infectious Diseases Society of America suggests parameters to distinguish bacterial rhinosinusitis requiring antibiotic therapy from viral illness. Patients presenting with symptoms for 10 or more days without clinical improvement and those with onset with severe symptoms (high fever, nasal discharge, or facial pain lasting 3 to 4 days) or worsening illness are more likely to have a bacterial etiology that requires antibiotic therapy.¹⁰

Acute Otitis Media

The guidelines from the American Academy of Pediatrics allow for either antibiotic therapy or close observation without antibiotics in children at least 6 months of age with nonsevere unilateral acute otitis media (ie, mild ear pain for less than 48 hours and temperature under 102.2 F) or in children at least 2 years of age with nonsevere unilateral or bilateral acute otitis media.¹¹ Patients should be monitored closely and antibiotics prescribed if clinical improvement is not seen within 48 to 72 hours of symptom onset.

Preventing the development of resistant antibiotic strains relies on the efforts of all health care providers. Education of patients and their families as to the appropriate role of antibiotics in routinely diagnosed infectious conditions is vital. In particular, current management guidelines empower patients and their families to participate in monitoring of their own health and thereby minimize potentially unnecessary, broad-spectrum antibiotic use.

Caitlin Turnbull is a PharmD candidate at the University of Michigan College of Pharmacy in Ann Arbor, Michigan. Janice L. Stumpf, PharmD, is a clinical pharmacy specialist — drug information service and clinical associate professor with the University of Michigan Health System and College of Pharmacy in Ann Arbor, Michigan.

Corresponding author: Janice L. Stumpf, Pharm.D., University of Michigan Health System Drug Information Service, Michigan House - Room 2202, 2301 Commonwealth Blvd., SPC 2967, Ann Arbor, MI 48105. Phone: (734) 936-8202. Fax: (734) 232-2410. Email: jlstumpf@umich.edu

Note: This article was adapted from an article that appeared in the February 2014 issue of the Pharmacy ForUM newsletter, an in-house publication of the Department of Pharmacy Services, University of Michigan Health System, Ann Arbor.

References

• Hicks LA, Hunkler RJ. U.S. outpatient antibiotic prescribing, 2010. N Engl J Med. 2013;368:1461-2. Letter.
• McCaig LF, Hicks LA, Roberts RM, Fairlie TA. Office-related antibiotic prescribing for persons aged < 14 years — United States, 1993-1994 to 2007-2008. MMWR 2011;60:1153-6.
• Pichichero ME. Dynamics of antibiotic prescribing for children. JAMA 2002;287:3133-5.
• Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. Report CS239559-B. www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf
• The Alliance for the Prudent Use of Antibiotics. The cost of antibiotic resistance to U.S. families and the health care system. 2010 Sept. www.tufts.edu/med/apua/consumers/personal_home_5_1451036133.pdf (Accessed 2014 Jan 31).
• Johnson B. Prevent the spread. Inside View. University of Michigan Health System. 2012 Feb 2. http://uminsideview.org/1861/prevent-the-spread/ (Accessed 2014 Jan 31).
• Shapiro DJ, Hicks LA, Pavia AT, Hersh AL. Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09. J Antimicrob Chemother 2014;69:234-40.
• Braman SS. Chronic cough due to acute bronchitis. ACCP evidence-based clinical practice guidelines. Chest. 2006;129:95S-103S.
• Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-80.
• Chow AW, Benninger MS, Brook I. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54:e71-112.
• Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131:e964-9.