Outpatient Antibiotic Prescribing for Acute Respiratory Infections During Influenza Seasons
Outpatient Antibiotic Prescribing for Acute Respiratory Infections During Influenza Seasons
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DOI：
10.1001/jamanetworkopen.2018.0243
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发表时间：
2018-06-01
影响因子：
13.8
通讯作者：
Fry, Alicia M.
中科院分区：
文献类型：
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作者：
Havers, Fiona P.;Hicks, Lauri A.;Fry, Alicia M.
急性呼吸道感染（阿里斯）是最常使用抗生素的综合征;抗生素对其无效的病毒引起大多数阿里斯。目的描述流感季节期间ARI门诊患者的抗生素处方，并确定减少常见ARI诊断的不适当抗生素处方的目标，包括实验室确诊流感的门诊患者。设计，设置，队列研究招募年龄6个月或以上的ARI门诊患者，在2013-2014年和2014-2015年流感季节期间，在与5个美国流感疫苗有效性网络站点相关的门诊诊所进行评估。所有患者均接受实时逆转录聚合酶链反应流感检测，仅用于研究目的。抗生素处方、病史和国际疾病分类第九次修订版诊断代码从医疗和药房记录中收集，A组链球菌（GAS）检测结果也从患者亚组中收集。ARI的暴露访视，定义为持续7天或更短时间的新发咳嗽。抗生素处方的适当性是基于诊断代码、临床信息、流感和GAS检测结果。结果在14987例ARI患者中（平均[SD]年龄32 [24]岁; 8638 [58%]女性; 11892 [80%]白色），6136（41%）例被开抗生素处方。在这6136例患者中，2522例（41%）诊断为不适用抗生素;其中2106例（84%）诊断为病毒性上呼吸道感染或支气管炎（急性或未另行说明）。在3306例（22%）未被诊断为肺炎且实验室确诊为流感的患者中，945例（29%）处方了抗生素，占非肺炎ARI患者所有抗生素处方的17%。在1248例咽炎患者中，1137例（91%）进行了GAS检测; 1248例患者中有440例（35%）接受了抗生素治疗，其中168例（38%）GAS检测结果为阴性。在1200例鼻窦炎患者中，454例（38%）在门诊就诊前3天或更短时间内出现症状，表明急性病毒性鼻窦炎不需要抗生素。结论和相关性抗生素过度使用在门诊阿里斯的治疗中仍然很普遍，包括实验室确诊的流感患者，尽管研究地点可能不代表其他门诊设置。已确定的改善门诊抗生素管理的目标包括消除病毒性上呼吸道感染和支气管炎的抗生素治疗，并提高对咽炎和鼻窦炎处方指南的依从性。增加敏感和及时的病毒诊断检测，特别是流感，可以减少这些综合征的不必要的抗生素使用。
IMPORTANCE Acute respiratory infections (ARIs) are the syndrome for which antibiotics are most commonly prescribed; viruses for which antibiotics are ineffective cause most ARIs.OBJECTIVES To characterize antibiotic prescribing among outpatients with ARI during influenza season and to identify targets for reducing inappropriate antibiotic prescribing for common ARI diagnoses, including among outpatients with laboratory-confirmed influenza.DESIGN, SETTING, AND PARTICIPANTS Cohort study enrolling outpatients aged 6 months or older with ARI evaluated at outpatient clinics associated with 5 US Influenza Vaccine Effectiveness Network sites during the 2013-2014 and 2014-2015 influenza seasons. All patients received influenza testing by real-time reverse transcriptase-polymerase chain reaction for research purposes only. Antibiotic prescriptions, medical history, and International Classification of Diseases, Ninth Revision diagnosis codes were collected from medical and pharmacy records, as were group A streptococcal (GAS) testing results in a patient subset.EXPOSURE Visit for ARI, defined by a new cough of 7 days' duration or less.MAIN OUTCOMES AND MEASURES Antibiotic prescription within 7 days of enrollment. Appropriateness of antibiotic prescribing was based on diagnosis codes, clinical information, and influenza and GAS testing results.RESULTS Of 14 987 patients with ARI (mean [SD] age, 32 [24] years; 8638 [58%] women; 11892 [80%) white), 6136 (41%) were prescribed an antibiotic. Among these 6136 patients, 2522 (41%) had diagnoses for which antibiotics are not indicated; 2106 (84%) of these patients were diagnosed as having a viral upper respiratory tract infection or bronchitis (acute or not otherwise specified). Among the 3306 patients (22%) not diagnosed as having pneumonia and who had laboratory-confirmed influenza, 945 (29%) were prescribed an antibiotic, accounting for 17% of all antibiotic prescriptions among patients with nonpneumonia ARI. Among 1248 patients with pharyngitis, 1137 (91%) had GAS testing; 440 of the 1248 patients (35%) were prescribed antibiotics, among whom 168 (38%) had negative results on GAS testing. Of 1200 patients with sinusitis and no other indication for antibiotic treatment who received an antibiotic, 454 (38%) had symptoms for 3 days or less prior to the outpatient visit, suggesting acute viral sinusitis not requiring antibiotics.CONCLUSIONS AND RELEVANCE Antibiotic overuse remains widespread in the treatment of outpatient ARIs, including among patients with laboratory-confirmed influenza, although study sites may not be representative of other outpatient settings. Identified targets for improved outpatient antibiotic stewardship include eliminating antibiotic treatment of viral upper respiratory tract infections and bronchitis and improving adherence to prescribing guidelines for pharyngitis and sinusitis. Increased access to sensitive and timely virus diagnostic tests, particularly for influenza, may reduce unnecessary antibiotic use for these syndromes.