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Antibiotic Use in the United States, 2017: Progress and Opportunities

Antibiotic Use By Healthcare Setting

What Do We Know About Antibiotic Use in Outpatient Settings?

Outpatient settings include healthcare providers (e.g., physicians, dentists, nurse practitioners, and physician assistants) and clinic leaders in primary care, medical and surgical specialties, emergency departments, retail health and urgent care settings, and dental offices. In 2015 alone, approximately 269 million antibiotic prescriptions were dispensed from outpatient pharmacies in the United States, enough for five out of every six people to receive one antibiotic prescription each year. At least 30 percent of these antibiotic prescriptions were unnecessary.7

Graphic: Improve antibiotic use to combat antibiotic resistance. Necessary prescription rate: 70% (still need to improve drug selection, dose and duration). Unnecessary prescription rate: 30%. Cdc is working to reduce unnecessary antibiotic use with the national action plan to combat antibiotic-resistant bacteria (carb) goal: by 2020, reduce inappropriate outpatient antibiotic use by 50%. Find out when antibiotics are necessary. Visit: http://www.cdc.gov/getsmart

 

Percent of Antibiotic Prescriptions That Were Unnecessary

Age group All Conditions* Acute respiratory conditions**
0-19 year olds 29% 34%
20-64 year olds 35% 70%
≥65 year olds 18% 54%
All ages 30% 50%

*All conditions included acute respiratory conditions, urinary tract infections, miscellaneous bacterial infections, and other conditions.
**Acute respiratory conditions included ear infections, sinus infections, sore throats, pneumonia, acute bronchitis, bronchiolitis, upper respiratory infections (i.e., common colds), influenza, asthma, allergy, and viral pneumonia.

Graphic: Community antibiotic prescriptions per 1,000 population by state in 2015. At least 30% of antibiotics prescribed in doctor's offices, emergency departments and hospital clinics are unnecessary According to Fleming-Dutra, K. et al. (2016)

 

Each year, there are 47 million unnecessary antibiotic prescriptions written in U.S. doctors’ offices and emergency departments.7 Most of these unnecessary prescriptions are for respiratory conditions most commonly caused by viruses (including common colds, viral sore throats, and bronchitis) which do not respond to antibiotics, or for bacterial infections that do not always need antibiotics (like many sinus and ear infections). CDC estimated that at least 50 percent of antibiotic prescriptions for these acute respiratory conditions are unnecessary.8–10 These excess prescriptions each year put patients at needless risk for reactions to drugs or other problems, including C. difficile infections. In 2011 alone, one-third of the nearly 500,000 C. difficile infections in the United States were community-associated, or happening in patients who had no recent overnight stay in a healthcare facility.1–4

The good news is that antibiotic prescribing nationally has improved with a five percent decrease from 2011 to 2014. However, while there have been noticeable declines in antibiotic prescribing in children (0–19) (the population targeted by the Get Smart program) from 75 million prescriptions in 2011 to about 64 million prescriptions in 2014, antibiotic prescription rates for adults have risen slightly from about 192 million in 2011 to 198 million in 2014. Children under two and adults 65 and older still receive the most antibiotic prescriptions. Data also show that antibiotics are prescribed more frequently in states in the Southern and
Appalachian regions.

Prescribing the correct antibiotic is another area that requires attention. A CDC and Pew Charitable Trusts study found among outpatient visits in 2010– 2011, when an antibiotic was needed, patients were often prescribed an antibiotic not recommended by current clinical guidelines. For example, for sinus and middle ear infections and sore throats, recommended first-line antibiotics were only used half (52 percent) of the time.11

Percent of Patients Receiving The Recommended First-Line Antibiotic by Condition, United States, 2010-2011*

Condition Adults
(20+ years of age)
Children
(0–19 years of age)
Sinus infection 37% 52%
Pharyngitis (sore throat) 37% 60%
Middle ear infection n/a 67%

*Based on the prevalence of allergy to first-line antibiotics and estimated treatment failures after first-line antibiotics, at least 80% of patients presenting with these conditions should receive first-line antibiotics. Analysis is based on NAMCS and NHAMCS data.

 

CDC’s Antibiotic Resistance Patient Safety Atlas contains data on antibiotic prescriptions dispensed in outpatient pharmacies per 1,000 people. This interactive database provides information on how antibiotic prescribing varies by state, age group, and over time from 2011–2014.

Graphic: Screenshot of CDC's Antibiotic Resistance Patient Safety Atlas website.

 

Geographic Variability in HEDIS Measures Related to Appropriate Antibiotic Use

Avoidance of antibiotic treatment in adults with acute bronchitis (average), by Census division, 2008–2012

Graphic: Avoidance of antibiotic treatment in adults with acute bronchitis (average), by U.S. Census division, 2008–2012 is lowest in the Pacific census division with a value of 29.7 and highest in the New England division with a value of 21.9.

CDC experts found that healthy adults with acute bronchitis only received the right treatment—meaning they did not get an antibiotic—just over 20 percent of the time. This shows that nearly 80 percent of the time, patients were getting an antibiotic unnecessarily.

Over the years there has been little progress made in prescribing for adults, indicating a clear need to better support healthcare providers who prescribe for adults. Family practice physicians prescribe the most antibiotics, but nurse practitioners, physician assistants, internal medicine physicians, pediatricians, and dentists also prescribe antibiotics, making these providers important audiences to reach. Because antibiotics are prescribed more frequently in the Southern and Appalachian regions, there is a need to target antibiotic stewardship efforts to providers and patients in these areas.

Oral Antibiotic Prescribing by Provider Type in the United States In 2014

Provider type Number of antibiotic prescriptions in 2014
(millions)
 Family Practice Physicians  58.1
 Physician Assistants & Nurse Practitioners 54.4
 Internal Medicine 30.1
 Pediatricians 25.4
 Dentistry 24.9
 Surgical Specialties 19.9
 Emergency Medicine 14.2
 Dermatology 7.6
 Obstetrics/Gynecology 6.6
 Other 25.0
 All Providers 266.1

Graphic cover: Core Elements of Outpatient Antibiotic Stewardship
Improving antibiotic prescribing involves implementing effective strategies that follow evidence-based recommendations for diagnosis and management. In 2016, CDC released The Core Elements of Outpatient Antibiotic Stewardship, which were published in the Morbidity and Mortality Weekly Report (MMWR) Recommendations and Reports. The Core Elements provides a framework for antibiotic stewardship for outpatient providers and facilities that routinely provide antibiotic treatment. This report augments existing guidance for other clinical settings and is intended for any outpatient provider, clinic or health system interested in improving antibiotic prescribing and use.

 


Core Elements of Outpatient Antibiotic Stewardship

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Commitment

Demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety.


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Action for Policy And Practice

Implement at least one policy or practice to improve antibiotic prescribing, assess whether it is working, and modify as needed.


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Tracking and Reporting

Monitor antibiotic prescribing practices and offer regular feedback to providers, or have providers assess their own antibiotic prescribing practices themselves.


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Education and Expertise

Provide educational resources to providers and patients on antibiotic prescribing, and ensure access to needed expertise on optimizing antibiotic prescribing.

Intended Audiences for Outpatient Antibiotic Stewardship

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Primary care clinics and providers: These clinics and providers prescribe approximately half of all outpatient antibiotics in the United States. This includes providers specializing in family practice, pediatrics, and internal medicine, all of whom treat a wide variety of patients and conditions that might benefit from antibiotic treatment.
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Outpatient specialty and subspecialty clinics and providers: These clinics and providers focus on treatment and  management of patients with specialized medical conditions that sometimes benefit from antibiotic therapy. These specialty clinics include gastroenterology, dermatology, urology, obstetrics, and otolaryngology.
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Emergency departments (EDs) and emergency medicine providers: EDs and emergency medicine providers are  positioned between acute care hospitals and the community and encounter unique challenges, including lack of continuity of care and higher concentration of patients who might need urgent or even immediate care, as well as unique opportunities for stewardship interventions, such as greater provider access to diagnostic resources and the expertise of pharmacists and consultants.

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Retail health clinics and providers: These clinics and providers provide treatment for routine conditions in retail stores or pharmacies and represent a growing category of healthcare delivery in the United States.

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Urgent care clinics and providers: These clinics and providers specialize in treating patients who might need immediate attention or need to be seen after hours but might not need to be seen in EDs.

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Dental clinics and dentists: Dental clinics and dentists use antibiotics as prophylaxis before some dental procedures and for treatment of dental infections.

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Nurse practitioners and physician assistants: These providers work in every medical specialty and subspecialty involved in antibiotic prescribing and should be included in antibiotic stewardship efforts.

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Healthcare systems: Healthcare systems plan, deliver, and promote healthcare services and often involve a network of primary and specialty outpatient clinics, urgent care centers, EDs, acute care hospitals, and other facilities that provide healthcare services. Healthcare systems can use existing antibiotic stewardship programs or develop new ones to promote appropriate antibiotic prescribing practices in their outpatient facilities as well as across the system.

CDC collaborates with partners to implement appropriate antibiotic use efforts at a local level. CDC funds and supports many state and local health departments and other partners across the country to implement targeted antibiotic stewardship improvements in outpatient settings.

Illinois Department of Public Health: Precious Drugs and Scary Bugs 

In 2015, the Illinois Department of Public Health (IDPH) developed the Precious Drugs and Scary Bugs program to improve the appropriate use of antibiotics, particularly for acute respiratory infections, in primary care, urgent care, and community health centers. IDPH asked healthcare providers to:

  • Display a poster in exam rooms stating their commitment to appropriate antibiotic prescribing.
  • Participate in educational webinars.
  • Track their antibiotic prescribing data.
  • Complete baseline and follow-up surveys.

Thirty-eight outpatient practices participated representing 239 healthcare providers. More than 500 commitment posters were printed and distributed. Participating healthcare providers reported that the poster improved communication, addressed patient expectations regarding antibiotics for acute respiratory infections, and reinforced a uniform message.

New York State Department of Health: Commitments to Appropriate Antibiotic Prescribing

In 2016, the New York State Department of Health (NYSDOH) offered a “Get Smart Guarantee” poster [PDF – 1 page] for healthcare providers to pledge to only prescribe antibiotics when they are needed. The “Guarantee” poster could be personalized with the provider’s photo and signature. Some providers indicate patients expect antibiotics even if the illness is viral (where antibiotics would not be effective) so NYSDOH developed a “Get Smart Guarantee” palm card [PDF – 1 page]. This takeaway serves in lieu of a prescription for antibiotics so patients understand their concerns have been heard and validated. The poster and palm card are offered in English and Spanish.

Utah Department of Health: Using Data to Identify Best and Worst Performing Clinics 

The Utah Health Department shared data publicly on the Open Data Catalog website to show which clinics in the state had the best and worst performance on the HEDIS® measure: Avoidance of antibiotic treatment in adults with acute bronchitis (which usually does not require antibiotics). Utah used its All Payer Claims Database, which combines eligibility, medical claims, pharmacy claims, and provider files each month, to compile 2013-2014 data.

Healthcare Providers, Patients, and Families Play a Critical Role in Supporting Optimal Antibiotic Use and Preventing Infections in Outpatient Settings.

Photo: Doctor explaining to a patient why antibiotics are not appropriate to treat her illness.

What can healthcare providers do to support appropriate antibiotic use and prevent infections in outpatient settings?

  • Follow clinical guidelines when prescribing antibiotics.
    • Use the right antibiotic, at the right dose, for the right duration, and at the right time.
  • Place written commitments in support of improving antibiotic use in exam rooms to help facilitate patient communication about appropriate antibiotic use.
  • Talk to patients and families about when antibiotics are and are not needed, and discuss possible harms such as allergic reactions, C. difficile, and antibiotic-resistant infections.
    • Ask patients if they have ever had a C. difficile infection, and tailor antibiotic treatment accordingly.
  • For patients with conditions that usually resolve without antibiotic treatment:
    • Talk to patients about ways to relieve their symptoms without antibiotics.
    • Discuss a clear plan for follow-up if symptoms worsen or do not improve.
  • Be aware of antibiotic resistance patterns in your community; use the data to inform prescribing decisions.
  • Follow hand hygiene and other infection prevention measures with every patient.

What can patients and families do to support appropriate antibiotic use and prevent infections in outpatient settings?

  • Talk to your healthcare provider about when antibiotics will and won’t help, and ask about antibiotic resistance.
  • Talk to your healthcare provider about how to relieve symptoms.
  • Take antibiotics only when prescribed and exactly as prescribed.
  • Don’t save an antibiotic for later or share the drugs with someone else.
  • Insist that everyone cleans their hands before touching you.
  • Stay healthy and keep others healthy by cleaning hands, covering coughs, staying home when sick, and getting recommended vaccines.

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