Emergency Medicine

Studies examine prescribing of antibiotics for respiratory infections in hospital emergency departments

National efforts to reduce inappropriate use of antibiotics are having some success. From 1995 to 2002, inappropriate antibiotic prescribing for acute respiratory infections, which are usually caused by viruses and thus are not responsive to antibiotics, declined from 61 to 49 percent. However, the use of broad-spectrum antibiotics such as the fluoroquinolones, jumped from 41 to 77 percent from 1995 to 2001. Overuse of these antibiotics will eventually render them useless for treating antibiotic-resistant infections, for which broad-spectrum antibiotics are supposed to be reserved.

A new study found that antibiotic prescribing for upper respiratory infections (URIs) in the emergency department (ED), a common source of antibiotic overuse, declined from 55 to 35 percent between 1993 and 2004. A second study revealed lower ED prescribing of fluoroquinolone antibiotics for acute respiratory infections (ARIs) when hospital formularies restricted their use. Both studies were supported by the Agency for Healthcare Research and Quality (HS13915) and are briefly discussed here.

Vanderweil, S.G., Pelletier, A.J., Hamedani, A., and others (2007, April). "Declining antibiotic prescriptions for upper respiratory infections, 1993-2004." Academic Emergency Medicine 14, pp. 366-269.

This study used data from the National Hospital Ambulatory Medical Care Survey to examine ED antibiotic prescriptions for URIs between 1993 and 2004. The authors also examined sociodemographic and geographic factors associated with receipt of an antibiotic for URIs. There were about 23.4 million ED visits diagnosed as URIs between 1993 and 2004.

Although the proportion of URI diagnoses remained relatively stable, ED antibiotic prescriptions for URIs declined from 55 percent to 35 percent during the 12-year period. Patients who were prescribed antibiotics were more likely to be white than black (73 vs. 62 percent) and to have been treated in EDs located in the southern United States (43 vs. 36 percent) and from a nonurban area (78 vs. 71 percent).

Despite the improvement in ED antibiotic prescribing for URIs, there is room for further improvement. Future efforts to reduce inappropriate antibiotic prescribing should focus on patients and doctors in southern U.S. EDs, as well as race-related disparities in prescribing, suggest the researchers.

Aspinall, S.L., Metlay, J.P., Maselli, J.M., and Gonzales, R. (2007, May). "Impact of hospital formularies on fluoroquinolone prescribing in emergency departments." American Journal of Managed Care 13(5), pp. 241-248.

Hospital formulary policies that restrict the use of fluoroquinolones (FQs) can lead to more appropriate prescribing, according to this study. Researchers analyzed data from nine Veterans Affairs medical centers and seven non-Federal U.S. hospitals. At each hospital, the researchers randomly sampled 200 adult ARI visits for nonspecific URIs, acute bronchitis, pharyngitis, sinusitis, and pneumonia over a 4-month period.

Researchers found that FQs (such as levofloxacin, gatifloxacin, and moxifloxacin) accounted for 14 percent of hospital ED prescriptions for ARIs in 2003 and 2004. However, at hospitals where at least one FQ was unrestricted on the hospital formulary, the average FQ prescription rate for ARIs was 17 percent compared with 6 percent at hospitals where FQ access was restricted by the hospital formulary. Restricted FQs were prescribed for many ARIs that are commonly nonbacterial, such as nonspecific URIs and acute bronchitis.

In other words, they were more likely to be inappropriate, note the researchers. Patients who were admitted to the hospital were nearly twice as likely to receive an FQ. The likelihood of receiving an FQ was 2.3, 2.6, and 6.4 times greater for patients diagnosed with acute bronchitis, acute exacerbations of chronic bronchitis, or pneumonia, respectively.

The percentage of ARI visits where a restricted FQ was prescribed was lower when the patient was evaluated by a nurse practitioner or physician assistant (4 percent) compared with house staff (20 percent) or an attending physician (74 percent). Hospital formulary policies appear to affect outpatient antibiotic prescribing patterns, even though ED physicians do not need to comply with formulary policies for prescriptions filled in outpatient pharmacies.

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