192

Upper Respiratory, Head, and Neck Infections

occurred. It seems, therefore, that despite attempts to educate clinicians in reducing antimicrobial use, a punitive approach that disregards the utility of effective antimicrobials can be counterproductive. The message discouraging the use of AC was especially unwise because of the susceptibility pattern of Streptococcus pneumoniae in Australia. S. pneumoniae is the principal causative agent for sinusitis, otitis media, and lower respiratory tract infection. The most recent Australian study analyzing isolates obtained from multiple centers documented the following rates of resistance in 1997 [5]: for AC and amoxicillin, 0.1% of isolates were resistant and 0.2% had intermediate resistance; for cefaclor, the rates were 4.0% and 17.4%, respectively; for erythromycin, 15.6% and 0.7%, respectively; for tetracyclines, 15.7% and 0.2%, respectively; and for cotrimoxazole, 33.4% and 12.4%,

respectively. On the basis of these resistance patterns, it seemed logical that the therapeutic shift to cefaclor and the macrolides produced poorer patient outcomes. The study was able to measure the effectiveness of prescribing for common conditions among practioners during a time when a policy-driven letter influenced their behavior. The letter was sent by a government agency and did not provide information regarding drug substitution choices. The letter ignored consensus guidelines that were devised to assist clinicians in treating common infections. Complex changes occurred that seem to have resulted in more conservative practioner behavior, increased cost to government, and a general trend toward poorer patient outcomes. It seems that national policies aimed at changing the prescribing behavior of clinicians need to carefully analyze the likely effect on clinicians, patients, and the health system before being initiated.

Excessive Antibiotic Use for Acute Respiratory Infections Gonzales R, Malone DC, Maselli JH, et al.: Excessive antibiotic use for acute respiratory infections in the United States.Clin Infect Dis 2001, 33:757–762. Rating: •Of importance. Introduction: The excessive use of antibiotics in ambulatory practice has contributed to the emergence and spread of antibiotic-resistant bacteria in communities [6–8]. Numerous studies have been performed to characterize the current epidemic of penicillin-resistant Streptococcus pneumoniae. A consistent finding in all reports [6] is that the most important risk factor for transmission of and infection with penicillin-resistant S. pneumoniae is current or recent antibiotic use. Aims: Estimating the amount and cost of excess antibiotic use in ambulatory practice and identifying the conditions that account for most excess use are necessary to guide intervention and policy decisions. The authors determined target (or ideal) antibiotic prescription rates, based on what proportion of patients diagnosed with a specific acute respiratory infection would be expected to have a bacterial infection, and compared these targets with actual antibiotic prescription rates. Methods: Data from the 1998 National Ambulatory Medical Care Survey, a sample survey of United States ambulatory physician practices, was used to estimate primary care office visits and antibiotic prescription rates for acute respiratory infections. Weight-averaged antibiotic costs were calculated with use of 1996 prescription marketing data and adjusted for inflation. Results: In 1998, an estimated 76 million primary care office visits for acute respiratory infections resulted in 41

million antibiotic prescriptions. Antibiotic prescriptions in excess of the number expected to treat bacterial infections amounted to 55% (22.6 million) of all antibiotics prescribed for acute respiratory infections, at a cost of approximately $726 million. Upper respiratory tract infections (not otherwise specified), pharyngitis, and bronchitis were the conditions associated with the greatest amount of excess use. Discussion: The study results suggest that 1) interventions to decrease total (excess) antibiotic use should focus on upper respiratory infections, pharyngitis, and bronchitis; and 2) interventions relating to acute otitis media and sinusitis should assess to what degree clinicians use narrow-spectrum and broad-spectrum antibiotics. This study also documented that the amount and cost of excessive antibiotic use for acute respiratory infections by primary care physicians are substantial, and established potential target rates for antibiotic treatment of selected conditions.

Editor’s comments This study documents that overuse of antibiotics for acute respiratory infections is substantial and occurs at a very high price. Reducing excess antibiotic use for upper respiratory infections and bronchitis is possible through innovative educational intervention strategies that include patient and clinician education and focus on the lack of benefit of antibiotic treatment of the vast majority of these patients [9]. Reducing total antibiotic use for otitis media, pharyngitis, and sinusitis, however, will require increased use of available diagnostic algorithms and tests, the development of improved diagnostic tests for determining which patients are likely to derive benefit from antibiotic

Clinical Trials Report

treatment, and the generation of adequate flexible therapeutic guidelines by competent experts.

References 1.

2.

3.

Ehrenkranz NJ, Nerenberg DE, Shultz JM, Slater KC: Intervention to discontinue parenteral antimicrobial therapy in patients hospitalized with pulmonary infections: effect on shortening patient stay. Infect Control Hosp Epidemiol 1992, 13:21–32. Marchbanks CR, Graham KK, Barnes J, Dudley MN: Pharmacoepidemiology of ciprofloxacin: analysis of use patterns and cost impact. Pharmacotherapy 1991, 11:50–55. Mosdell DM, Morris DM, Voltura A, et al.: Antibiotic treatment for surgical peritonitis. Ann Surg 1991, 214:543–549.

4. 5.

6.

7. 8. 9.

193

Therapeutic Guidelines: Antibiotics, 10th edn. Melbourne: Therapeutic Guidelines; 1997. Turnidge J, Bell J, Collignon P, et al.: Rapidly emerging antimicrobial resistances in Streptococcus pneumoniae in Australia. Med J Aust 2000, 173(Suppl):S58–S64. Dowell SF, Schwartz B: Resistant pneumococci: protecting patients through judicious use of antibiotics. Am Fam Physician 1997, 55:1647–1654. Kunin CM: Resistance to antimicrobial drugs: a worldwide calamity. Ann Intern Med 1993, 118:557–561. Neu HC: The crisis in antibiotic resistance. Science 1992, 257:1064–1073. Gonzales R, Steiner JF, Lum A, Barrett PHJ: Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. JAMA 1999, 281:1512–1519.