Four in 10 Antibiotic Prescriptions for Acute Respiratory Infections Are Unnecessary

Antibiotics are most commonly prescribed for one clinical category—acute respiratory infections—but these illnesses are most often viral. In a new study, a team of researchers examines antibiotic prescribing during influenza season, with the objective of identifying targets for reducing inappropriate prescribing.

Acute respiratory infections mostly occur from infections such as the common cold, which can be caused by about 200 viral pathogens. These viruses include rhinovirus, parainfluenza, adenovirus, and Respiratory syncytial virus, and cannot be treated with an antibiotic. Symptoms of these infections include congestion, runny nose, sore throat, and cough, and may last up to 14 days. The Centers for Disease Control and Prevention (CDC) notes that treating such a respiratory infection with an antibiotic does not resolve or shorten the duration of illness, and may also increase a patient’s risk of developing an antibiotic-resistant infection. At least 2 million individuals experience infections from antibiotic-resistant bacteria each year, leading to 23,000 deaths. Yet, as many as half of all outpatient antibiotic prescriptions are unnecessary.

The CDC’s recommendations for treating respiratory tract infections include decongestants combined with a first-generation antihistamine to provide short-term symptom relief of nasal symptoms and cough. In a new multi-institutional study led by CDC researchers and published in the journal JAMA Network Open, the authors report that more than 4 in 10 antibiotics prescribed during 2 flu seasons were given for illnesses for which antibiotics are not indicated. For the study, researchers analyzed data collected by the US Influenza Vaccine Effectiveness Network during the 2013-2014 and 2014-2015 influenza seasons.

In total, the study identified 14,987 patients with acute respiratory infections, of whom 6,136 received an antibiotic prescription. Of those receiving antibiotics, 2,522 (41%) had diagnoses for which antibiotics are not indicated, including 2,106 patients diagnosed as having a viral upper respiratory tract infection or bronchitis. Among the 3,306 patients with laboratory-confirmed influenza, 945 (29%) were prescribed an antibiotic, which accounted for 17% of all antibiotic prescriptions among patients with non-pneumonia acute respiratory infections.

In an interview with Contagion^®, study lead author Fiona P. Havers, MD, said that it’s challenging to answer why antibiotic overprescribing among doctors persists, as the problem has been well publicized.

“I think that it’s a combination of both patients requesting it, and also doctors or other providers wanting to do the right thing and concerned about the patient, but perhaps being unaware of how unlikely antibiotics actually are to be helpful in that setting,” she said. “In clinical settings when you have a patient in front of you, these decisions are not always cut and dry, but there has been a lot of guidance developed and we’re hoping providers think about what is appropriate and what is not. Unfortunately, from this study, it looks like in many settings they’re not necessarily following that guidance. There’s a lot of room for improvement, which is a good thing.”

To improve outpatient antibiotic prescribing, the authors identified targets including eliminating antibiotic treatment of viral upper respiratory tract infections and bronchitis and improving adherence to prescribing guidelines for pharyngitis and sinusitis. In addition, they called for increased access to sensitive and timely viral diagnostic tests, particularly for influenza.

“One of the things that we highlight in this study is that a large proportion of antibiotics were prescribed to people who actually have laboratory-confirmed flu. Unfortunately, the point-of-care diagnostics that are available to doctors during flu season aren’t that good,” Dr Havers said, noting that the test is not particularly reliable and yield a lot of false negatives. “If doctors had a more reliable test, they would actually pick up most influenza cases and then think twice about prescribing them antibiotics that may not benefit patients.”