A May 2016 study led by researchers from the Centers for Disease Control and Prevention (CDC) found that about a third of all oral antibiotics prescribed in US outpatient settings were inappropriate, with most of the inappropriate prescriptions related to respiratory infections.

Now, new research using a similar methodology has found the problem extends to government clinics as well, but with higher rates in non-teaching clinics.

In a research letter published recently in Antimicrobial Resistance and Infection Control, investigators with the Providence Veterans Affairs (VA) Medical Center in Providence, RI, found that the rate of inappropriate prescribing for acute respiratory infections (sinusitis, pharyngitis, bronchitis, and pneumonia) in the hospital's outpatient primary care department was 38.4%.

That compares with 34.2% in the CDC study, which did not include federal facilities. National guidelines largely advocate against antibiotic treatment for these conditions, which tend to be viral in nature.

Problem less severe in teaching clinics

The study was conducted from March 2013 through February 2015 in adult veterans. As in the CDC study, the investigators looked both at overall prescribing rates and inappropriate prescribing rates, basing their estimates of appropriate prescribing on national guidelines. They then compared their data with the numbers in the CDC study.

The authors of the study note that the rate of inappropriate prescribing they found was similar to what the CDC study found in non-government healthcare settings, and that similar rates of inappropriate antibiotic prescribing have been found at other VA facilities. But their study dug a little deeper by stratifying the data and comparing the rate of antibiotic prescribing in the hospital's two teaching clinics—where medical residents are under the supervision of attending physicians—to the rate at its six non-teaching clinics.

That analysis revealed that the teaching clinics had both a significantly lower rate of overall antibiotic prescribing for acute respiratory conditions than the non-teaching clinics (37% vs 65.9%), and a much lower rate of inappropriate prescribing (17.6% vs 44%).

Across the board, patients seen at the VA's non-teaching clinics were far more likely to receive an inappropriate antibiotic for a respiratory condition. In cases of pharyngitis, for example, only 2 of 53 patients (3.8%) seen at one of the teaching clinics received an inappropriate antibiotic, compared with 77 of the 191 patients (40.3%) treated at a non-teaching clinic.

Prospective audit and feedback approach

The Providence VA Medical Center implemented an antibiotic stewardship program (ASP) in 2012. The ASP is based on a prospective audit and feedback strategy, in which members of the ASP team—which includes infectious disease (ID) physicians and ID pharmacists—review all inpatient antibiotic use daily.

Previous studies by researchers at the hospital indicate the program has helped reduce broad-spectrum antibiotic use, length of stay, and adverse events. This study, the authors write, indicates the hospital's non-teaching outpatient clinics represent a possible target of expansion for the program.

"Our findings are unique in suggesting that outpatient ASPs may benefit from focusing their efforts in non-teaching clinics, at least among VA clinics," the authors write.

See also:

Mar 29 Antimicrob Resist Infect Control study