Inappropriate Prescribing of Antibiotics Associated with Increased Costs, Adverse Events


Six respiratory infections are among the most common diagnoses for which antibiotics often are inappropriately prescribed, and new research sheds light on the effects, both in increased risk of adverse events and excess health care costs.

Inappropriate prescribing of antibiotics for adults with common respiratory infections was associated with up to a fourfold increase in the risk of adverse drug events and nearly $69 million in excess health care costs, according to a new study from Washington University in St. Louis and The Pew Charitable Trusts.

The study, published in Clinical Infectious Diseases and described in a fact sheet published by The Pew Charitable Trusts, analyzed data on more than 3 million commercially insured adults between ages 18 and 64 who were diagnosed in outpatient settings with six common bacterial or viral respiratory infections between April 1, 2016, and Sept. 30, 2018.

The study found that 43% to 56% of patients received inappropriate antibiotics for bacterial infections and 7% to 66% received inappropriate antibiotics for viral infections.

Inappropriate antibiotic selection—which refers to selecting a drug not recommended as a first-line treatment per guidelines—resulted in $49.7 million in excess health care costs for pharyngitis and $19.1 million for sinus infection in 2017, the study found.

Those numbers are just a sample of the overall impact of inappropriate prescribing of antibiotics and don’t include such groups as people over age 65, those on Medicare or Medicaid, or those with diagnoses outside of the focus of the study.

“This builds upon our previous research looking at pediatric patients that found around $74 million in excess cost in a year resulting from inappropriate antibiotic prescribing,” Rachel Zetts, MPH, senior officer of the Antibiotic Resistance Project at the Pew Charitable Trusts, told Contagion.

Prescribing broad-spectrum antibiotics, such as azithromycin and cefdinir, may have contributed to increased occurrence of adverse events, such as nausea, vomiting, abdominal pain and diarrhea. Patients who received an inappropriate antibiotic prescription for pharyngitis had a nearly threefold increase in the risk of Clostridioides difficile infection, which the Centers for Disease Control and Prevention has identified as an urgent threat of antibiotic resistance.

“We know that anytime an antibiotic is prescribed, it can lead to the development of resistance, which is a critical public health threat that must be addressed,” Zetts said. “I think what this research adds to the conversation is also looking beyond the public health threat of resistance. What other impacts is this inappropriate prescribing having within the health care system? This really demonstrates both the real impact on patients through adverse events as well as the excess health care costs, which can be reduced through improving antibiotic prescribing through stewardship implementation.”

The study also found unnecessary antibiotic prescribing for nonsuppurative middle ear infection, bronchitis, influenza and viral upper respiratory infection, for which antibiotics aren’t recommended or are recommended against.

No cost differences were reported for those who received unnecessary antibiotics for influenza, viral upper respiratory infections or nonsuppurative middle ear infections. A cost saving was noted among those who received unnecessary antibiotics for bronchitis, which the authors suggested may have been due to patients seeking follow-up care if they didn’t receive a prescription.

Patients who received unnecessary antibiotics for viral upper respiratory infection, bronchitis and nonsuppurative middle ear infections had a nearly fourfold increase in the risk of allergic reaction.

The research underscores the urgency to adopt antibiotic stewardship practices in outpatient settings, David Hyun, MD, project director for the Antibiotic Resistance Project at the Pew Charitable Trusts told Contagion®.

“In the past, a lot of the discussions of the benefits around improving antibiotic use have been framed around reducing antibiotic resistance and trying to head off the potential public health crisis—and that’s still very much important—but at the same time, this research contextualizes the adverse outcomes related to inappropriate antibiotic use at the patient level,” Hyun said. “Hopefully, this will provide an added level of urgency for health care providers as well as health care stakeholders that are in positions to support health care providers to adopt antibiotic stewardship practices so that we can reduce inappropriate antibiotic use.”

The study authors advocated for health systems and payers to support antibiotic stewardship to help overcome barriers to antibiotic stewardship practices by implementing such measures as assessing prescribing practices, educating patients and providers, and incentivizing antibiotic stewardship efforts.

“There are a considerable amount of barriers and resource challenges for a lot of practices, which is why we, in our publication, were highlighting two major stakeholders, the health systems and the payers, and advocating for them to step up to provide the resources and support, the technical assistance that outpatient providers really need if they’re going to do meaningful stewardship activity,” Hyun said.

The Pew Charitable Trusts has examined barriers to antibiotic stewardship in outpatient settings and strategies for reducing inappropriate antibiotic use in past research. The current study adds important context to the discussion.

“Being able to visualize and actually see the concrete dollar figure numbers was eye opening,” Hyun said. “I think we always had an inkling and suspicion that there were direct individual patient adverse outcomes associated with inappropriate antibiotic use, but this really crystalized it.”

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