COMMENTARIES

Antibiotic Misuse in the Emergency

Department
 S
pecters of bioterrorism and flu pandemics have grabbed headlines in
recent years as dramatic, immediate, and potent threats to public
health. Although these events undeniably have the potential to cause
national health crises, a bona fide public health disaster has been
brewing in our backyard for decades. Widespread resistance of
bacteria to commonly used antimicrobial agents was cited in a 1998
Institute of Medicine report as one of the most immediate threats to
the nation’s health, and a top national healthcare priority.1 Unlike
bioterrorism or avian flu, antibiotic resistance is largely a problem
that we physicians have engendered ourselves. We cannot undo the
damage already done, but we may be able to dramatically mitigate
the problem in the future by developing judicious and rational
antibiotic prescribing habits. This may be more difficult than it
sounds.
Antimicrobial resistance inevitably occurs whenever bacteria are
exposed to antibiotics, and to some extent
theprocessisbeyondthecontrolofindividualphysicians.2 However,
when we prescribe antibiotics indiscriminately, we apply additional
and unnecessary selection pressure that markedly accelerates the
development of bacteria resistant to commonly used therapeutic
agents. Over 160 million antibiotic prescriptions are provided
annually in the United States, the equivalent of 30 prescriptions per
100 persons per year.3 Conservative estimates are that at least a
quarter of these prescriptions are unnecessary.4 Physicians are
therefore responsible for needlessly
dispensingenormousquantitiesofantibiotics,withstaggering costs. In
addition to the money wasted on unnecessary medication, far more
is spent on the consequences of indiscriminate antibiotic use. These
indirect costs include hospitalizations due to infections with multi-
drug–resistant organisms, morbidity associated with avoidable
adverse drug reactions, and the need to use newer and more
expensive antibiotics. Recently, the development of novel
antimicrobial agents has slowed considerably, increasing the
likelihood that we will be faced with
commonbacterialinfectionsforwhichthereisnoeffectiveantimicrobial
therapy.
Over half of all antibiotic prescriptions are provided for upper
respiratory infections (URI). The majority of these prescriptions are
provided to patients with colds and other uncomplicated viral
illnesses—situations in which antimicrobial therapy is considered to
be superfluous. A number of excellent studies performed in primary
care settings have documented that up to three-fourths of adults with
upper respiratory tract infections receive antibiotics, even while
primary care physicians believed
ª 2006 by the Society for Academic Emergency Medicine ISSN 1069-6563 doi: 10.1197/j.aem.2005.11.075
331 332 Karras ANTIBIOTIC MISUSE IN THE ED
represent a minority of patients in the non–antibioticresponsive group,
we cannot assume that every antibiotic prescription in this group was
unnecessary. Further, there was some disagreement between data
abstractors in rendering a diagnosis of upper respiratory infection and,
surprisingly, in determining whether an antibiotic prescription was
provided. These limitations do not detract from the study’s strengths
in documenting an unacceptably high rate of antibiotic prescription to
that only one fifth of these patients actually required therapy. 5 A
well-designed study found that pediatricians prescribe antibiotics to
almost half of children with common colds, and two thirds of
children with uncomplicated bronchitis.6 Other outpatient specialists
are no better at withholding antibiotic prescriptions when they are
not clearly indicated.
The article by Gonzales and colleagues in this issue of Academic
Emergency Medicine is one of few studies that attempt to assess the
scale of unnecessary antimicrobial prescription in the emergency
department (ED).7 The study documents that indiscriminate
antibiotic prescription is as prevalent in emergency medicine as it is
in primary care specialties. The authors examined charts of patients
seen in 14 EDs who were discharged with acute respiratory
infections. Using discharge diagnoses, patients were categorized as
having an antibiotic-responsive condition or non–antibiotic-
responsive condition. Only uncomplicated URI and acute bronchitis
(not representing an acute exacerbation of chronic bronchitis) were
considered to be non–antibiotic responsive conditions. In contrast,
many of the diagnoses included as the antibiotic-responsive
conditions, including pharyngitis and sinusitis, may not actually have
required antibiotic therapy. This categorization was chosen to
minimize the potential of erroneously including a patient in the non–
antibiotic-responsive group. The authors then assessed the rate of
antibiotic prescription in each group.
The results are striking. Of the 2,270 ED visits for acute
respiratory illness analyzed, 63% received antibiotic prescriptions.
Half of the prescriptions were provided to patients with non–
antibiotic-responsive illnesses. Antibiotic prescriptions were
provided to over two thirds of patients with uncomplicated URI and
over one third of
patientswithuncomplicatedacutebronchitis.Theauthors conclude that
EDs should be appropriately targeted for
programsthatminimizeinappropriateantibioticprescriptions.
Without challenging the conclusions, some limitations of the
study should be noted. Because of its retrospective nature, we cannot
determine why antibiotic prescriptions were provided to patients
who had non–antibioticresponsive discharge diagnoses. There are
times when antibiotics may be justified in patients with apparently
viral URIs. Some individuals presenting with acute bronchitis will
have infections such as pertussis, mycoplasma, and Chlamydia
pneumonia that are, in fact, antibiotic responsive.8 Antibiotics may
be justified when otherwise healthy patients have persistent or
progressively worsening bronchitis. Although such cases are likely
to
PII ISSN 1069-6563583
a group of patients who, in general, are unlikely to benefit from
antimicrobial therapy.
This study is reminiscent of a landmark analysis of antibiotic
prescriptions for ED patients with respiratory complaints published by
Stone and colleagues using data from the 1996 National Hospital
Ambulatory Medical Care Survey.9 That study also found high rates
of unnecessary antibiotic prescription, with antibiotics provided to
25% of patients with colds and 42% of those with acute bronchitis. In
both that study and the present investigation, EM residents wrote
fewer unnecessary prescriptions than did staff physicians. Perhaps
residents use better judgment than their seniors, or perhaps prescribing
habits change when senior physicians oversee patient management.
This finding raises the possibility that auditing physicians’ antibiotic
prescribing practices might effectively reduce the number of
inappropriate prescriptions provided in the ED.
Why do we prescribe antibiotics with apparently reckless abandon?
Although we do not yet have published data from ED-specific studies,
reports of physician behaviors in other practice settings can provide
some insights that may be applicable to our specialty. Many
investigators have documented that physicians feel pressured by
patients to prescribe antibiotics. Half of pediatricians in a large survey
stated that they often felt pressure from parents to prescribe antibiotics
to children with uncomplicated viral illnesses.10 Of greater concern, a
third of these pediatricians admitted that they generally comply with
such requests, even when they did not believe that antimicrobials were
warranted. Large studies of adult patients in family practice settings
also clearly demonstrate that physicians are much more likely to
prescribe antibiotics when they believe that the patient expects a
prescription.5
Why would a physician prescribe an unneeded antibiotic to fulfill
an anticipated patient expectation? A logical answer is that physicians
wish to satisfy their patients and believe that fulfilling medication
ACAD EMERG MED March 2006, Vol. 13, No. 3 www.aemj.org 333
expectations enhances patient satisfaction. Provision of an antibiotic
prescription, in this paradigm, results in a patient who is happier with
the physician encounter, responds positively to a customer satisfaction
survey, and is less likely to sue if a bad outcome follows. Surprisingly,
the assumptions underlying this logic have proven incorrect.
Physicians cannot correctly determine which patients expect an
antibiotic prescription.11 Furthermore, failure to provide the
prescription does not appreciably affect patient satisfaction.12 Multiple
studies have demonstrated that patients are satisfied when they believe
their physician understands their problem and the encounter lasts a
reasonable amount of time. Receipt of a prescription is unassociated
or only weakly associated with patient satisfaction.
There are many important differences between ED patients and
those in traditional clinic settings. Patients presenting to the ED may
well have different concerns, different expectations, and different
predictors of satisfaction than those seeking treatment in a primary
care office. Emergency physicians might alter their prescribing
habits to accommodate patients with whom they have no long-
standing relationship, may be sicker than those who go to the office,
or have less ability or less inclination to follow up with a primary
care physician. To date, there have been few attempts to get into the
minds of emergency physicians and ED patients to understand the
causes of antibiotic misuse in our setting. One EDbased study, albeit
investigating treatment of diarrheal illness rather than URIs, found
that physicians were more likely to prescribe antibiotics when they
believed patients expected them, but correctly identified patient
expectations in only one-third ofcases.13 Asseen in theoutpatient
studies, patient satisfaction was associated with the perception that
the physician understood the problem and the time spent with the
physician, and only weakly associated with receipt of an antibiotic
prescription. In these important aspects, emergency physicians
appear subject to the same misperceptions and errors in prescribing
antibiotics as our colleagues in primary care practices.
Physician education is vital to curtailing unnecessary
antimicrobial use in the ED. Surveys of healthcare providers have
generally shown that physicians know the indications for antibiotics
in common illnesses. The real deficit may lie in our failure to
appreciate the consequences of antibiotic misuse and the futility of
prescribing antibiotics to satisfy patients. Physicians often fail to
make a causal link between provision of an unnecessary antibiotic
prescription and the development of multidrug–resistant
infections.14 Although a physician may know that a patient does not
need an antibiotic, he or she nevertheless sees no real harm to the
patient or to society in prescribing an unnecessary medication.
Unfortunately,whenonemillionphysicianseachusethatrationale a
dozen times a day, a public health crisis follows.
Future studies should address methods to reduce unnecessary
antibiotic prescriptions in the ED. Some studies in primary care
settings have suggested that physiciandirected educational
initiatives are effective for this purpose.15,16 Our greatest successes
will probably come from efforts to enhance physicians’ awareness
of the consequences of indiscriminate prescribing habits. These
initiatives may be as simple as posting signs in the ED. Prompts
could appear when physicians enter non–antibiotic-responsive
diagnoses in computerized discharge instruction forms. The most
drastic, labor-intensive, and probably most effective intervention
would be to audit ED charts and flag physicians who fail to
document a valid rationale for prescribing an antibiotic. Whatever
the intervention, the present study by Gonzales and colleagues
provides an excellent model for measuring the efficacy of any ED-
based program to reduce unnecessary antimicrobial prescriptions.
David Karras, MD
( david.karras@tuhs.temple.edu )
Temple University School of Medicine
Philadelphia, PA
References
1. Harrison PF, Lederberg J, editors. Institute of Medicine
Workshop Report. Antimicrobial Resistance: Issues and
Options. Washington: National Academy Press, 1998.
2. Gold HS, Moellering RC. Antimicrobial-drug resistance. N
Engl J Med. 1996; 335:1445–53.
3. Wenzel RP, Edmond MB. Managing antibiotic resistance. N
Engl J Med. 2000; 343:1961–3.
4. McCraig LF, Hughes JM. Trends in antimicrobial drug
prescribing among office-based physicians in the US. JAMA.
1995; 273:214–9.
5. Macfarlane J, Holmes W, Macfarlane R, Britten N. Influence
of patients’ expectations on antibiotic management of acute
lower respiratory tract illness in general practice. Brit Med J.
1997; 315:1211–4.
6. Nyquist A-C, Gonzales R, Steiner JF, Sande MA. Antibiotic
prescribing for children with colds, upper respiratory tract
infections, and bronchitis. JAMA. 1998; 279:875–7.
7. Gonzales R, Camargo CA, MacKenzie T, et al., and the
IMPAACT Trial Investigators. Antibiotic treatment of acute
respiratory infections in acute care settings. Acad Emerg Med.
2006; 13:288–94.
8. AagaardE.Managementofacutebronchitisinhealthy adults.
Infect Dis Clin North Am. 2004; 18:919–37.
9. Stone S, Gonzales R, Maselli J, Lowenstein SR. Anti-
biotic prescribing for patients with colds, upper respiratory tract
infections, and bronchitis: a national study of hospital-based
emergency departments. Ann Emerg Med. 2000; 36:320–7.
10. Bauchner H, Pelton SI, Klein JO. Parents, physicians, and prescribing practices, patient expectations, and patient
antibiotic use. Pediatr. 1999; 103:395–401. satisfaction. Ann Emerg Med. 2003; 42:835–42.
11. Mangione-Smith R, McGlynn EA, Elliott MN, et al. The 14. Levy SB. Confronting multidrug resistance. JAMA. 1996;
relationship between perceived parental expectations and 269:1840–2.
pediatrician antimicrobial prescribing behavior. Pediatr. 1999; 15. Gilderman A. Effectiveness of an antibiotic use program.
103:711–8. Managed Care Interface. 1999; 23:73–6.
12. Hamm RM, Hicks RJ, Bemben DA. Antibiotics and 16. Mainous AG, Hueston WJ, Davis MP, Pearson WS. Trends in
respiratory infections: are patients more satisfied when antimicrobial prescribing for bronchitis and upper respiratory
expectations are met? J Fam Pract. 1996 ; infections among adults and children. Am J Public Health.
43:56–62. 2003; 93:1910–4.
13. Karras DJ, Ong S, Moran GJ, et al. Antibiotic use for
emergency department patients with acute diarrhea:
Where to Find AEM Instructions for Authors
For complete instructions for authors, see the January or July issue of Academic
Emergency Medicine; visit http://ees.elsevier.com/acaeme/ default.asp and click
on ‘‘Guide for Authors’’; or contact SAEM via e-mail at aem@saem.org, via
phone at 517-485-5484, or via fax at
517-485-0801.