Michael Silverman, MD (*); Marcus Povitz, MDCM, MSc (*); Jessica M. Sontrop, PhD; Lihua Li, PhD; Lucie Richard, MA; Sonny Cejic, MD; Salimah Z. Shariff, PhD
Disclaimer: Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions, and statements expressed herein are those of the authors and not necessarily those of CIHI. This study was conducted at the ICES Western Site. ICES is funded by an annual grant from the Ontario Ministry of Health and Long-term Care. Core funding for ICES Western is provided by the Academic Medical Organization of Southwestern Ontario, the Schulich School of Medicine and Dentistry, Western University, and the Lawson Health Research Institute. The opinions, results, and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the funding agencies is intended or should be inferred.
Acknowledgment: The authors thank IMS Brogan for use of its drug information database.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1131.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Available from Dr. Silverman (e-mail, Michael.Silverman@sjhc.london.on.ca). Statistical code: The technical appendix and statistical code are available from Dr. Silverman (e-mail, Michael.Silverman@sjhc.london.on.ca). Data set: Ontario's health administrative data are legally restricted under the Personal Health Information Privacy Act. Data used in this study are maintained by ICES. A request for the data used in preparation of the results can be made through ICES' Data Analytical Service (www.ices.on.ca/Data-Services). Information on ICES and Ontario privacy regulations are available from the ICES Privacy Officer (e-mail, firstname.lastname@example.org). Additional contact information is available at www.ices.on.ca/Data-and-Privacy/Privacy at ICES/Questions-or-Complaints.
Requests for Single Reprints: Michael F. Silverman, MD, Division of Infectious Diseases, Department of Medicine, Schulich School of Medicine and Dentistry, St. Joseph's Hospital, Room B3-404. 268 Grosvenor, London, Ontario N6A 4V2, Canada; e-mail, email@example.com.
Current Author Addresses: Dr. Silverman: Division of Infectious Diseases, Department of Medicine, Schulich School of Medicine and Dentistry, St. Joseph's Health Care, Room B3-404, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada.
Drs. Povitz, Sontrop, Li, and Shariff and Ms. Richard: The Institute for Clinical Evaluative Sciences at Western, Victoria Hospital, Room ELL-215, 800 Commissioners Road East, London, Ontario N6A 5W9, Canada.
Dr. Cejic: Byron Family Medical Centre, 1228 Commissioners Road West, London, Ontario N6K 1C7, Canada.
Author Contributions: Conception and design: M. Silverman, M. Povitz, L. Richard, S.Z. Shariff.
Analysis and interpretation of the data: M. Silverman, M. Povitz, J.M. Sontrop, L. Li, L. Richard, S. Cejic, S.Z. Shariff.
Drafting of the article: M. Silverman, M. Povitz, J.M. Sontrop, L. Richard, S. Cejic.
Critical revision for important intellectual content: M. Silverman, M. Povitz, J.M. Sontrop, S.Z. Shariff.
Final approval of the article: M. Silverman, M. Povitz, J.M. Sontrop, L. Li, L. Richard, S. Cejic, S.Z. Shariff.
Statistical expertise: L. Li, L. Richard, S.Z. Shariff.
Obtaining of funding: M. Silverman, S.Z. Shariff.
Administrative, technical, or logistic support: L. Richard.
Collection and assembly of data: L. Li, S.Z. Shariff.
Reducing inappropriate antibiotic prescribing for acute upper respiratory tract infections (AURIs) requires a better understanding of the factors associated with this practice.
To determine the prevalence of antibiotic prescribing for nonbacterial AURIs and whether prescribing rates varied by physician characteristics.
Retrospective analysis of linked administrative health care data.
Primary care physician practices in Ontario, Canada (January–December 2012).
Patients aged 66 years or older with nonbacterial AURIs. Patients with cancer or immunosuppressive conditions and residents of long-term care homes were excluded.
Antibiotic prescriptions for physician-diagnosed AURIs. A multivariable logistic regression model with generalized estimating equations was used to examine whether prescribing rates varied by physician characteristics, accounting for clustering of patients among physicians and adjusting for patient-level covariates.
The cohort included 8990 primary care physicians and 185 014 patients who presented with a nonbacterial AURI, including the common cold (53.4%), acute bronchitis (31.3%), acute sinusitis (13.6%), or acute laryngitis (1.6%). Forty-six percent of patients received an antibiotic prescription; most prescriptions were for broad-spectrum agents (69.9% [95% CI, 69.6% to 70.2%]). Patients were more likely to receive prescriptions from mid- and late-career physicians than early-career physicians (rate difference, 5.1 percentage points [CI, 3.9 to 6.4 percentage points] and 4.6 percentage points [CI, 3.3 to 5.8 percentage points], respectively), from physicians trained outside of Canada or the United States (3.6 percentage points [CI, 2.5 to 4.6 percentage points]), and from physicians who saw 25 to 44 patients per day or 45 or more patients per day than those who saw fewer than 25 patients per day (3.1 percentage points [CI, 2.1 to 4.0 percentage points] and 4.1 percentage points [CI, 2.7 to 5.5 percentage points], respectively).
Physician rationale for prescribing was unknown.
In this low-risk elderly cohort, 46% of patients with a nonbacterial AURI were prescribed antibiotics. Patients were more likely to receive prescriptions from mid- or late-career physicians with high patient volumes and from physicians who were trained outside of Canada or the United States.
Ontario Ministry of Health and Long-term Care, Academic Medical Organization of Southwestern Ontario, Schulich School of Medicine and Dentistry, Western University, and Lawson Health Research Institute.
Study flow diagram.
AURI = acute upper respiratory infection.
* Multiple visits for the same patient were collapsed into a single episode if consecutive visits for any of these diagnoses occurred within 14 days of each other.
Table 1. Antibiotic Prescribing for Nonbacterial AURIs: Episode and Patient Characteristics*
Table 2. Characteristics of 8990 Primary Care Physicians*
Table 3. Antibiotic Prescribing Rates for Nonbacterial Acute Upper Respiratory Infections*
Appendix Table 1. Antibiotic Prescribing Rates for the Common Cold or Acute Laryngitis*
Appendix Table 2. Antibiotic Prescribing Rates for Nonbacterial Acute Upper Respiratory Infection Episode Managed by 1 Physician*
Appendix Table 3. Prescribing Rates for Broad-Spectrum (vs. Narrow-Spectrum) Antibiotics for Nonbacterial Acute Upper Respiratory Infection*
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Rambam Health Care Campus
May 9, 2017
Acute nasopharyngitis, acute sinusitis, acute laryngitis/tracheitis and acute bronchitis can be caused by viruses. But they can also be caused by bacteria. The authors' attempts to exclude bacterial infections are inappropriate. These infections are not microbiologically-confirmed (except maybe for pharyngitis, but it is unclear if the authors considered rapid testing for Strep). There is a Cochrane review showing benefit for antibiotic treatment of sinusitis. A Cochrane review showing modest benefit for antibiotics for acute bronchitis. There was no attempt to exclude Strep pharyngitis. Acute nasopharyngitis is not the common cold. I am all in favor of reducing unnecessary antibiotic use and studying how to achieve this. However, the term "nonbacterial" in the title and elsewhere is inappropriate. It is interesting to analyse who prescribed antibiotics for these conditions, but these infections cannot be called non-bacterial. As a very minimum this should have been stated as a limitation (in the abstract!). But more appropriate would have been to refrain from the designation of nonbacterial.
Michael Silverman, MD; Marcus Povitz, MDCM, MSc; Jessica M. Sontrop, PhD; Salimah Z. Shariff, PhD.
London Health Hospital
July 20, 2017
Dr. Paul may be reassured to know that we used several strategies to ensure that our study did not include AURIs that were bacterial or suspected to be bacterial. First, we limited our analysis to four viral AURIs: acute nasopharyngitis, acute sinusitis, acute laryngitis, and acute bronchitis. We did not include patients diagnosed with streptococcal pharyngitis; this condition has a specific billing code (034) enabling us to exclude these patients. Regarding acute nasopharyngitis, in our region the diagnostic code 460 is defined in the physician claims submission guide as “acute nasopharyngitis, common cold”. Although acute nasopharyngitis in adults has been hypothesized to be a rare separate condition from the common cold, there is no evidence of benefit of antibiotic therapy for either condition. Current guidelines from the American College of Physicians and the Centers for Disease Control and Prevention state that antibiotic therapy is never indicated for the common cold or acute bronchitis, and suggest that it only be used in select circumstances in acute sinusitis (1).
Second, we further excluded patients who would be at increased risk of bacterial infections or complications (those who were immunosuppressed, had active cancer, or were living in long-term care homes), and we excluded any patients who had any investigations, including rapid streptococcal testing, to assess for bacterial infections (Tables S4–S6; S8). Finally, we excluded patients who had prolonged episodes or who had an outpatient visit or hospital admission where a bacterial infection was diagnosed (Table S5).
Our study thus comprised a cohort of low-risk patients with a high probability of nonbacterial AURIs. It is therefore concerning that nearly half of these patients received antibiotic prescriptions, and further, that 70% of these prescriptions were broad-spectrum agents. Whereas aminopenicillins may sometimes be indicated in a minority of patients with acute sinusitis, broad-spectrum antibiotics are not recommended for any of the AURIs we studied (1).
To test the robustness of our findings, we conducted a sensitivity analysis where 97% of patients had the common cold and 3% had acute laryngitis, and yet over 30% of patients received antibiotic prescriptions. The high rate of antibiotic prescribing among these low-risk patients with a physician-diagnosed non-bacterial AURI is strongly suggestive of inappropriate prescribing.
Our findings are corroborated by several other studies which observed similarly high rates of antibiotic prescribing for nonbacterial AURIs (2–4). These results support the need for targeted interventions to help reduce inappropriate antibiotic prescribing.
1. Harris AM, Hicks LA, Qaseem A. Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. American College of Physicians; 2016 Jan 19;164(6):425–34.
2. Steinman MA, Landefeld CS, Gonzales R. Predictors of Broad-Spectrum Antibiotic Prescribing for Acute Respiratory Tract Infections in Adult Primary Care. JAMA. American Medical Association; 2003 Feb 12;289(6):719.
3. Jones BE, Sauer B, Jones MM, Campo J, Damal K, He T, et al. Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Infections in the Veteran Population: A Cross-sectional Study. Ann Intern Med. 2015 Jul 21;163(2):73–80.
4. Ebell MH, Radke T. Antibiotic use for viral acute respiratory tract infections remains common. Am J Manag Care. 2015 Jan;21(10):e567-75.
Silverman M, Povitz M, Sontrop JM, Li L, Richard L, Cejic S, et al. Antibiotic Prescribing for Nonbacterial Acute Upper Respiratory Infections in Elderly Persons. Ann Intern Med. 2017;166:765–774. doi: 10.7326/M16-1131
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Published: Ann Intern Med. 2017;166(11):765-774.
Published at www.annals.org on 9 May 2017
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