Publications by authors named "Lauri A Hicks"

130 Publications

Total duration of antimicrobial therapy resulting from inpatient hospitalization.

Infect Control Hosp Epidemiol 2019 08 28;40(8):847-854. Epub 2019 May 28.

Duke Center for Antimicrobial Stewardship and Infection Prevention,Duke University School of Medicine,Durham, North Carolina.

Objective: To assess the feasibility of electronic data capture of postdischarge durations and evaluate total durations of antimicrobial exposure related to inpatient hospital stays.

Design: Multicenter, retrospective cohort study.

Setting: Two community hospitals and 1 academic medical center.

Patients: Hospitalized patients who received ≥1 dose of a systemic antimicrobial agent.

Methods: We collected and reviewed electronic data on inpatient and discharge antimicrobial prescribing from April to September 2016 in 3 pilot hospitals. Inpatient antimicrobial use was obtained from electronic medication administration records. Postdischarge antimicrobial use was calculated from electronic discharge prescriptions. We completed a manual validation to evaluate the ability of electronic prescriptions to capture intended postdischarge antibiotics. Inpatient, postdischarge, and total lengths of therapy (LOT) per admission were calculated to assess durations of antimicrobial therapy attributed to hospitalization.

Results: A total of 45,693 inpatient admissions were evaluated. Antimicrobials were given during 23,447 admissions (51%), and electronic discharge prescriptions were captured in 7,442 admissions (16%). Manual validation revealed incomplete data capture in scenarios in which prescribers avoided the electronic system. The postdischarge LOT among admissions with discharge antimicrobials was median 8 days (range, 1-360) with peaks at 5, 7, 10, and 14 days. Postdischarge days accounted for 38% of antimicrobial exposure days.

Conclusion: Discharge antimicrobial therapy accounted for a large portion of antimicrobial exposure related to inpatient hospital stays. Discharge prescription data can feasibly be captured through electronic prescribing records and may aid in designing stewardship interventions at transitions of care.
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http://dx.doi.org/10.1017/ice.2019.118DOI Listing
August 2019

Potential utility of pharmacy data to measure antibiotic use in nursing homes.

Infect Control Hosp Epidemiol 2019 07 24;40(7):819-820. Epub 2019 Apr 24.

Geriatric Research Education and Clinical Center (GRECC) and Specialty Care Center of Innovation at the Louis Stokes Cleveland, Department of Veterans Affairs Medical Center, Cleveland, Ohio,USA.

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http://dx.doi.org/10.1017/ice.2019.95DOI Listing
July 2019

Implementation of the Core Elements of Antibiotic Stewardship in Nursing Homes Enrolled in the National Healthcare Safety Network.

Clin Infect Dis 2019 09;69(7):1235-1238

Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

In 2016, 42% of nursing homes enrolled in the National Healthcare Safety Network reported meeting all 7 of the Centers for Disease Control and Prevention's Core Elements of Antibiotic Stewardship. Bivariate analyses suggested that implementation of all core elements differed by ownership type and amount of infection prevention staff hours.
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http://dx.doi.org/10.1093/cid/ciz102DOI Listing
September 2019

Changes in US Outpatient Antibiotic Prescriptions From 2011-2016.

Clin Infect Dis 2020 01;70(3):370-377

Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.

Background: While antibiotics are life-saving drugs, their use is not without risk, including adverse events and antibiotic resistance. The majority of US antibiotic prescriptions are prescribed in outpatient settings, making outpatient antibiotic prescribing an important antibiotic stewardship target. The primary objective of this study was to describe trends in US outpatient oral antibiotic prescriptions from 2011-2016.

Methods: We estimated annual oral antibiotic prescription rates using national prescription dispensing count data from IQVIA Xponent, divided by census estimates for 2011-2016. We calculated the ratio of broad- to narrow-spectrum prescriptions by dividing broad-spectrum prescription rates by narrow-spectrum prescription rates. We used Poisson models to estimate prevalence rate ratios, comparing 2011 and 2016 antibiotic prescription rates, and linear models to evaluate temporal trends throughout the study period.

Results: Oral antibiotic prescription rates decreased 5%, from 877 prescriptions per 1000 persons in 2011 to 836 per 1000 persons in 2016. During this period, rates of prescriptions dispensed to children decreased 13%, while adult rates increased 2%. The ratio of broad- to narrow-spectrum antibiotics decreased from 1.62 in 2011 to 1.49 in 2016, driven by decreases in macrolides and fluoroquinolones. The proportion of prescriptions written by nurse practitioners and physician assistants increased during the study period; in 2016, these providers prescribed over one-quarter of all antibiotic prescriptions.

Conclusions: Outpatient antibiotic prescription rates, especially of broad-spectrum agents, have decreased in recent years. Clinicians who prescribe to adults, including nurse practitioners and physician assistants, are important targets for antibiotic stewardship.
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http://dx.doi.org/10.1093/cid/ciz225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078491PMC
January 2020

Inappropriate ceftriaxone use in outpatient acute respiratory infection management.

Infect Control Hosp Epidemiol 2019 04 15;40(4):487-490. Epub 2019 Feb 15.

Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases,Centers for Disease Control and Prevention,Atlanta, Georgia.

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http://dx.doi.org/10.1017/ice.2019.21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6533902PMC
April 2019

Improving outpatient antibiotic prescribing.

BMJ 2019 02 12;364:l289. Epub 2019 Feb 12.

Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop A-31 Atlanta, GA 30329, USA.

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http://dx.doi.org/10.1136/bmj.l289DOI Listing
February 2019

Outpatient Antibiotic Prescribing for Acute Respiratory Infections During Influenza Seasons.

JAMA Netw Open 2018 06 1;1(2):e180243. Epub 2018 Jun 1.

Centers for Disease Control and Prevention, Atlanta, Georgia.

Importance: Acute respiratory infections (ARIs) are the syndrome for which antibiotics are most commonly prescribed; viruses for which antibiotics are ineffective cause most ARIs.

Objectives: To characterize antibiotic prescribing among outpatients with ARI during influenza season and to identify targets for reducing inappropriate antibiotic prescribing for common ARI diagnoses, including among outpatients with laboratory-confirmed influenza.

Design, Setting, And Participants: Cohort study enrolling outpatients aged 6 months or older with ARI evaluated at outpatient clinics associated with 5 US Influenza Vaccine Effectiveness Network sites during the 2013-2014 and 2014-2015 influenza seasons. All patients received influenza testing by real-time reverse transcriptase-polymerase chain reaction for research purposes only. Antibiotic prescriptions, medical history, and International Classification of Diseases, Ninth Revision diagnosis codes were collected from medical and pharmacy records, as were group A streptococcal (GAS) testing results in a patient subset.

Exposure: Visit for ARI, defined by a new cough of 7 days' duration or less.

Main Outcomes And Measures: Antibiotic prescription within 7 days of enrollment. Appropriateness of antibiotic prescribing was based on diagnosis codes, clinical information, and influenza and GAS testing results.

Results: Of 14 987 patients with ARI (mean [SD] age, 32 [24] years; 8638 [58%] women; 11 892 [80%] white), 6136 (41%) were prescribed an antibiotic. Among these 6136 patients, 2522 (41%) had diagnoses for which antibiotics are not indicated; 2106 (84%) of these patients were diagnosed as having a viral upper respiratory tract infection or bronchitis (acute or not otherwise specified). Among the 3306 patients (22%) not diagnosed as having pneumonia and who had laboratory-confirmed influenza, 945 (29%) were prescribed an antibiotic, accounting for 17% of all antibiotic prescriptions among patients with nonpneumonia ARI. Among 1248 patients with pharyngitis, 1137 (91%) had GAS testing; 440 of the 1248 patients (35%) were prescribed antibiotics, among whom 168 (38%) had negative results on GAS testing. Of 1200 patients with sinusitis and no other indication for antibiotic treatment who received an antibiotic, 454 (38%) had symptoms for 3 days or less prior to the outpatient visit, suggesting acute viral sinusitis not requiring antibiotics.

Conclusions And Relevance: Antibiotic overuse remains widespread in the treatment of outpatient ARIs, including among patients with laboratory-confirmed influenza, although study sites may not be representative of other outpatient settings. Identified targets for improved outpatient antibiotic stewardship include eliminating antibiotic treatment of viral upper respiratory tract infections and bronchitis and improving adherence to prescribing guidelines for pharyngitis and sinusitis. Increased access to sensitive and timely virus diagnostic tests, particularly for influenza, may reduce unnecessary antibiotic use for these syndromes.
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http://dx.doi.org/10.1001/jamanetworkopen.2018.0243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6324415PMC
June 2018

Antibiotic Prescribing for Children in United States Emergency Departments: 2009-2014.

Pediatrics 2019 02 8;143(2). Epub 2019 Jan 8.

Division of Infectious Diseases, Department of Pediatrics, University of Washington, Seattle, Washington.

: media-1vid110.1542/5972296744001PEDS-VA_2018-1056 OBJECTIVES: To characterize and compare ambulatory antibiotic prescribing for children in US pediatric and nonpediatric emergency departments (EDs).

Methods: A cross-sectional retrospective study of patients aged 0 to 17 years discharged from EDs in the United States was conducted by using the 2009-2014 National Hospital Ambulatory Medical Care Survey ED data. We estimated the proportion of ED visits resulting in antibiotic prescriptions, stratified by antibiotic spectrum, class, diagnosis, and ED type ("pediatric" defined as >75% of visits by patients aged 0-17 years, versus "nonpediatric"). Multivariable logistic regression was used to determine factors independently associated with first-line, guideline-concordant prescribing for acute otitis media, pharyngitis, and sinusitis.

Results: In 2009-2014, of the 29 million mean annual ED visits by children, 14% (95% confidence interval [CI]: 10%-20%) occurred at pediatric EDs. Antibiotics overall were prescribed more frequently in nonpediatric than pediatric ED visits (24% vs 20%, < .01). Antibiotic prescribing frequencies were stable over time. Of all antibiotics prescribed, 44% (95% CI: 42%-45%) were broad spectrum, and 32% (95% CI: 30%-34%, 2.1 million per year) were generally not indicated. Compared with pediatric EDs, nonpediatric EDs had a higher frequency of prescribing macrolides (18% vs 8%, < .0001) and a lower frequency of first-line, guideline-concordant prescribing for the respiratory conditions studied (77% vs 87%, < .001).

Conclusions: Children are prescribed almost 7 million antibiotic prescriptions in EDs annually, primarily in nonpediatric EDs. Pediatric antibiotic stewardship efforts should expand to nonpediatric EDs nationwide, particularly regarding avoidance of antibiotic prescribing for conditions for which antibiotics are not indicated, reducing macrolide prescriptions, and increasing first-line, guideline-concordant prescribing.
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http://dx.doi.org/10.1542/peds.2018-1056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6581044PMC
February 2019

Advances in optimizing the prescription of antibiotics in outpatient settings.

BMJ 2018 Nov 12;363:k3047. Epub 2018 Nov 12.

Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US.

The inappropriate use of antibiotics can increase the likelihood of antibiotic resistance and adverse events. In the United States, nearly a third of antibiotic prescriptions in outpatient settings are unnecessary, and the selection of antibiotics and duration of treatment are also often inappropriate. Evidence shows that antibiotic prescribing is influenced by psychosocial factors, including lack of accountability, perceived patient expectations, clinician workload, and habit. A varied and growing body of evidence, including meta-analyses and randomized controlled trials, has evaluated interventions to optimize the use of antibiotics. Interventions informed by behavioral science-such as communication skills training, audit and feedback with peer comparison, public commitment posters, and accountable justification-have been associated with improved antibiotic prescribing. In addition, delayed prescribing, active monitoring, and the use of diagnostics are guideline recommended practices that improve antibiotic use for some conditions. In 2016, the Centers for Disease Control and Prevention released the , which provides a framework for implementing these interventions in outpatient settings. This review summarizes the varied evidence on drivers of inappropriate prescription of antibiotics in outpatient settings and potential interventions to improve their use in such settings.
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http://dx.doi.org/10.1136/bmj.k3047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6511972PMC
November 2018

Variation in Outpatient Antibiotic Dispensing for Respiratory Infections in Children by Clinician Specialty and Treatment Setting.

Pediatr Infect Dis J 2018 12;37(12):1248-1254

Medical and Clinical Pharmacy Policy, Anthem, Inc, Chicago, Illinois.

Background: Antibiotics are commonly prescribed for children with acute respiratory infections (ARIs). This study describes the distribution of ARI diagnoses and specifically quantifies antibiotic dispensing for bronchitis and upper respiratory infection (URI) by treatment setting and specialty.

Methods: This retrospective, observational cross-sectional study used data from the HealthCore Integrated Research Environment containing claims from 14 commercial health plans for 2012 to 2014. Children (2-17 years) with first-episode ARI were identified by diagnosis of acute otitis media (AOM), sinusitis, pharyngitis, bronchitis or URI with no competing infections or chronic illnesses. Treatment setting was where diagnoses were made: primary care offices, urgent care centers (UCC), retail health clinics (RHCs) or emergency departments. Primary outcome measure was antibiotic prescription fills from pharmacies within 2 days of start of ARI episode.

Results: For URI, the highest proportions in antibiotic dispensing were ordered by office-based or UCC family physicians (28% and 30%, respectively) and office-based or UCC nurse practitioners/physician assistants (30% and 29%, respectively). Across all settings and specialties, there was high proportion of antibiotic dispensing for bronchitis (75%). Overall, 48% of 544,531 children diagnosed with ARI filled antibiotics. Nurse practitioners/physician assistants in RHC made the most diagnoses of AOM (24%) and streptococcal pharyngitis (22%).

Conclusions: Outreach efforts to decrease antibiotic dispensing for URI can be focused on office-based and UCC family physicians and nurse practitioners/physician assistants. All specialties need widespread interventions to reduce antibiotic dispensing for bronchitis. RHC nurse practitioners/physician assistants can be targeted to reduce high proportion of AOM and streptococcal pharyngitis diagnoses.
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http://dx.doi.org/10.1097/INF.0000000000002004DOI Listing
December 2018

Antibiotic Prescriptions Associated With Dental-Related Emergency Department Visits.

Ann Emerg Med 2019 07 2;74(1):45-49. Epub 2018 Nov 2.

Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Atlanta, GA.

Study Objective: The frequency of antibiotic prescribing and types of antibiotics prescribed for dental conditions presenting to the emergency department (ED) is not well known. The objective of this study is to quantify how often and which dental diagnoses made in the ED resulted in an antibiotic prescription.

Methods: From 2011 to 2015, there were an estimated 2.2 million (95% confidence interval [CI] 1.9 to 2.5 million) ED visits per year for dental-related conditions, which accounted for 1.6% (95% CI 1.5% to 1.7%) of ED visits. This is based on an unweighted 2,125 observations from the National Hospital Ambulatory Medical Care Survey in which a dental-related diagnosis was made.

Results: An antibiotic, most often a narrow-spectrum penicillin or clindamycin, was prescribed in 65% (95% CI 61% to 68%) of ED visits with any dental diagnosis. The most common dental diagnoses for all ages were unspecified disorder of the teeth and supporting structures (44%; 95% CI 41% to 48%; International Classification of Diseases, Ninth Revision, Clinical Modification[ICD-9-CM] code 525.9), periapical abscess without sinus (21%; 95% CI 18% to 25%; ICD-9-CM code 522.5), and dental caries (18%; 95% CI 15% to 22%; ICD-9-CM code 521.0). Recommended treatments for these conditions are usually dental procedures rather than antibiotics.

Conclusion: The common use of antibiotics for dental conditions in the ED may indicate the need for greater access to both preventive and urgent care from dentists and other related specialists as well as the need for clearer clinical guidance and provider education related to oral infections.
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http://dx.doi.org/10.1016/j.annemergmed.2018.09.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6943909PMC
July 2019

Outpatient Antibiotic Prescribing for Older Adults in the United States: 2011 to 2014.

J Am Geriatr Soc 2018 10 17;66(10):1998-2002. Epub 2018 Sep 17.

Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

Objectives: To characterize antibiotics prescribed to older adults to guide efforts to improve antibiotic use.

Design: Descriptive analysis.

Setting: Ambulatory.

Participants: Adults aged 65 and older in the United States.

Measurements: Information on outpatient antibiotic prescriptions dispensed for older adults from 2011 to 2014 was extracted from the IQVIA Xponent database. A chi-square trend analysis was conducted to assess annual changes in antibiotic prescribing rates. A descriptive analysis of prescribing rates by antibiotic, age group, sex, state, Census region, and provider specialty was conducted.

Results: From 2011 to 2014, outpatient antibiotic prescribing rates remained stable in older U.S. adults (P = .89). In 2014, older adults were dispensed 51.6 million prescriptions (1,115 prescriptions/1,000 persons). Persons aged 75 and older had a higher prescribing rate (1,157 prescriptions/1,000 persons) than those aged 65 to 74 (1,084 prescriptions/1,000 persons). Prescribing rates were highest in the South 1228 prescriptions/1,000 persons) and lowest in the West (854 prescriptions/1,000 persons). The most commonly prescribed class was quinolones, followed by penicillins and macrolides. Azithromycin was the most commonly prescribed drug, followed by amoxicillin and ciprofloxacin. Internists and family physicians prescribed 43% of antibiotic courses.

Conclusion: On average, in 2014, U.S. adults aged 65 and older received enough outpatient antibiotic courses for every older adult to receive at least 1. Quinolones and azithromycin are potential targets for assessing the appropriateness of antibiotic prescribing in this population. Interventions to improve use targeting internists and family physicians in the South Census region might have the potential to have the greatest effect.
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http://dx.doi.org/10.1111/jgs.15518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7909599PMC
October 2018

Further Considerations Regarding Duration of Antibiotic Therapy for Sinusitis-Reply.

JAMA Intern Med 2018 08;178(8):1138-1139

Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.

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http://dx.doi.org/10.1001/jamainternmed.2018.3013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6541207PMC
August 2018

Characteristics of Primary Care Physicians Associated With High Outpatient Antibiotic Prescribing Volume.

Open Forum Infect Dis 2018 Jan 5;5(1):ofx279. Epub 2018 Jan 5.

Office of Antibiotic Stewardship, Centers for Disease Control and Prevention, Atlanta, Georgia.

Our objective was to identify characteristics associated with high-volume antibiotic prescribing among office-based primary care physicians to target antibiotic stewardship efforts. Physicians aged 40 years and older who were male, located in the South, and in solo or 2-physician practices prescribed higher volumes of antibiotics than their peers by specialty.
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http://dx.doi.org/10.1093/ofid/ofx279DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5788066PMC
January 2018

Mycoplasma pneumoniae Among Children Hospitalized With Community-acquired Pneumonia.

Clin Infect Dis 2019 01;68(1):5-12

Centers for Disease Control and Prevention, Atlanta, Georgia.

Background: The epidemiology of Mycoplasma pneumoniae (Mp) among US children (<18 years) hospitalized with community-acquired pneumonia (CAP) is poorly understood.

Methods: In the Etiology of Pneumonia in the Community study, we prospectively enrolled 2254 children hospitalized with radiographically confirmed pneumonia from January 2010-June 2012 and tested nasopharyngeal/oropharyngeal swabs for Mp using real-time polymerase chain reaction (PCR). Clinical and epidemiological features of Mp PCR-positive and -negative children were compared using logistic regression. Macrolide susceptibility was assessed by genotyping isolates.

Results: One hundred and eighty two (8%) children were Mp PCR-positive (median age, 7 years); 12% required intensive care and 26% had pleural effusion. No in-hospital deaths occurred. Macrolide resistance was found in 4% (6/169) isolates. Of 178 (98%) Mp PCR-positive children tested for copathogens, 50 (28%) had ≥1 copathogen detected. Variables significantly associated with higher odds of Mp detection included age (10-17 years: adjusted odds ratio [aOR], 10.7 [95% confidence interval {CI}, 5.4-21.1] and 5-9 years: aOR, 6.4 [95% CI, 3.4-12.1] vs 2-4 years), outpatient antibiotics ≤5 days preadmission (aOR, 2.3 [95% CI, 1.5-3.5]), and copathogen detection (aOR, 2.1 [95% CI, 1.3-3.3]). Clinical characteristics were non-specific.

Conclusions: Usually considered as a mild respiratory infection, Mp was the most commonly detected bacteria among children aged ≥5 years hospitalized with CAP, one-quarter of whom had codetections. Although associated with clinically nonspecific symptoms, there was a need for intensive care in some cases. Mycoplasma pneumoniae should be included in the differential diagnosis for school-aged children hospitalized with CAP.
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http://dx.doi.org/10.1093/cid/ciy419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6552676PMC
January 2019

National Estimates of Emergency Department Visits for Antibiotic Adverse Events Among Adults-United States, 2011-2015.

J Gen Intern Med 2018 07 20;33(7):1060-1068. Epub 2018 Apr 20.

Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, NE, Mailstop D-26, Atlanta, GA, 30333, USA.

Background: Detailed, nationally representative data describing high-risk populations and circumstances involved in antibiotic adverse events (AEs) can inform approaches to prevention.

Objective: Describe US burden, rates, and characteristics of emergency department (ED) visits by adults for antibiotic AEs.

Design: Nationally representative, public health surveillance of adverse drug events (National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance [NEISS-CADES]) and a nationally projected database of dispensed prescriptions (QuintilesIMS), 2011-2015.

Patients: Antibiotic-treated adults (≥ 20 years) seeking ED care.

Main Measures: Estimated annual numbers and rates of ED visits for antibiotic AEs among outpatients treated with systemically administered antibiotics.

Key Results: Based on 10,225 cases, US adults aged ≥ 20 years made an estimated 145,490 (95% confidence interval, 115,279-175,701) ED visits for antibiotic AEs each year in 2011-2015. Antibiotics were implicated in 13.7% (12.3-15.2%) of all estimated adult ED visits for adverse drug events. Most (56.6%; 54.8-58.4%) antibiotic AE visits involved adults aged < 50 years, and 71.8% (70.4-73.1%) involved females. Accounting for prescriptions dispensed from retail and long-term care pharmacies, adults aged 20-34 years had twice the estimated rate of ED visits for oral antibiotic AEs compared with those aged ≥ 65 years (9.7 [7.6-11.8] versus 4.6 [3.6-5.7] visits per 10,000 dispensed prescriptions, respectively). Allergic reactions accounted for three quarters (74.3%; 70.0-78.6%) of estimated ED visits for antibiotic AEs. The three most frequently implicated antibiotic classes in ED visits for antibiotic AEs were oral sulfonamides (23.2%; 20.6-25.8%), penicillins (20.8%; 19.3-22.4%), and quinolones (15.7%; 14.2-17.1%). Per-prescription rates declined with increasing age group.

Conclusions: Antibiotics are a common cause of ED visits by adults for adverse drug events and represent an important safety issue. Quantifying risks of AEs from specific antibiotics for specific patient populations, such as younger adults, provides additional information to help clinicians assess risks versus benefits when making the decision to prescribe or not prescribe an antibiotic. AE rates may also facilitate communication with patients about antibiotic risks.
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http://dx.doi.org/10.1007/s11606-018-4430-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6025673PMC
July 2018

Reply to Mercuro et al.

Clin Infect Dis 2018 09;67(8):1307-1308

Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

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http://dx.doi.org/10.1093/cid/ciy275DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6160600PMC
September 2018

National Incidence of Pediatric Mastoiditis in the United States, 2000-2012: Creating a Baseline for Public Health Surveillance.

Pediatr Infect Dis J 2019 01;38(1):e14-e16

From the Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.

Between 2000 and 2012, the national estimated incidence rate of pediatric mastoiditis, a rare but serious complication of acute otitis media, was highest in 2006 (2.7/100,000 population) and lowest in 2012 (1.8/100,000 population). This measure provides a baseline for public health surveillance in the pneumococcal conjugate vaccine era as stewardship efforts target antibiotic use in acute otitis media.
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http://dx.doi.org/10.1097/INF.0000000000002049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6541217PMC
January 2019

Antibiotic Therapy Duration in US Adults With Sinusitis.

JAMA Intern Med 2018 07;178(7):992-994

Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.

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http://dx.doi.org/10.1001/jamainternmed.2018.0407DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5885211PMC
July 2018

Potential Impact of Antibiotic Stewardship Programs on Overall Antibiotic Use in Adult Acute-Care Hospitals in the United States.

Infect Control Hosp Epidemiol 2018 03 15;39(3):373-376. Epub 2018 Feb 15.

Division of Healthcare Quality Promotion,Centers for Disease Control and Prevention,Atlanta,Georgia.

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http://dx.doi.org/10.1017/ice.2017.273DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6699163PMC
March 2018

Opportunities to Improve Fluoroquinolone Prescribing in the United States for Adult Ambulatory Care Visits.

Clin Infect Dis 2018 06;67(1):134-136

Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

The Food and Drug Administration warned against fluoroquinolone use for conditions with effective alternative agents. An estimated 5.1% of adult ambulatory fluoroquinolone prescriptions were for conditions that did not require antibiotics, and 19.9% were for conditions where fluoroquinolones are not recommended first-line therapy. Unnecessary fluoroquinolone use should be reduced.
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http://dx.doi.org/10.1093/cid/ciy035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6005119PMC
June 2018

Reply to Dinh et al.

Clin Infect Dis 2018 06;66(12):1982-1983

Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

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http://dx.doi.org/10.1093/cid/ciy049DOI Listing
June 2018

Geographic Variability in Diagnosis and Antibiotic Prescribing for Acute Respiratory Tract Infections.

Infect Dis Ther 2018 Mar 22;7(1):171-174. Epub 2017 Dec 22.

Centers for Disease Control and Prevention, Atlanta, GA, USA.

Introduction: Antibiotic prescribing rates vary substantially across regions in the USA. Whether these differences are driven primarily by a greater tendency to treat certain infections (i.e., overtreatment) in certain regions or differences in the tendency to diagnose certain infections (i.e., overdiagnosis) is poorly understood.

Methods: We examined data from 2012 to 2013 using the National Ambulatory Medical Care Survey, which is a nationally representative sample of visits to office-based physicians. For each of nine geographic regions, we examined the relationship between the visit rate/1000 population for respiratory diagnoses for which antibiotics were prescribed to the visit rate/1000 population for selected respiratory diagnoses where antibiotic therapy may be warranted.

Results: The visit rate for all respiratory conditions resulting in an antibiotic prescription was lowest (109/1000 population) in the Pacific Region and highest (176/1000, 95% CI 138-213) in the East South Central Region. The diagnosis rate for selected respiratory conditions where antibiotic therapy may be warranted was also lowest (119/1000, 95% CI 91-147) in the Pacific Region and highest (189/1000, 95% CI 153-225) in the East South Central Region.

Conclusion: Antibiotic prescribing rates for respiratory conditions vary by region and are strongly associated with the rate with which selected respiratory conditions are diagnosed.
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http://dx.doi.org/10.1007/s40121-017-0181-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5840100PMC
March 2018

Outpatient Macrolide Antibiotic Prescribing in the United States, 2008-2011.

Open Forum Infect Dis 2017 8;4(4):ofx220. Epub 2017 Oct 8.

Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.

National Ambulatory Medical Care Survey data were used to assess outpatient macrolide prescribing and selection. Conditions for which macrolides are firstline therapy represented 5% of macrolide prescribing. Family practitioners selected macrolides for children more frequently than pediatricians. Macrolides are an important antibiotic stewardship target.
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http://dx.doi.org/10.1093/ofid/ofx220DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5729700PMC
October 2017

Duration of Antibiotic Use Among Adults With Uncomplicated Community-Acquired Pneumonia Requiring Hospitalization in the United States.

Clin Infect Dis 2018 04;66(9):1333-1341

Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

Background: Previous studies suggest that duration of antibiotic therapy for community-acquired pneumonia (CAP) often exceeds national recommendations and might represent an important opportunity to improve antibiotic stewardship nationally. Our objective was to determine the average length of antibiotic therapy (LOT) for patients treated for uncomplicated CAP in US hospitals and the proportion of patients with excessive durations.

Methods: Records of retrospective cohorts of patients aged 18-64 years with private insurance and aged ≥65 years with Medicare hospitalized for CAP in 2012-2013 were used. Inpatient LOT was estimated as a function of length of stay. Outpatient LOT was based on prescriptions filled post discharge based on data from outpatient pharmacy files. Excessive duration was defined as outpatient LOT >3 days.

Results: Inclusion criteria were met for 22128 patients aged 18-64 years across 2100 hospitals and 130746 patients aged ≥65 years across 3227 hospitals. Median total LOT was 9.5 days. LOT exceeded recommended duration for 74% of patients aged 18-64 years and 71% of patients aged ≥65 years. Patients aged 18-64 years had a median (quartile 1-quartile 3) 6 (3-7) days outpatient LOT and those aged ≥65 years had 5 (3-7) days.

Conclusions: In this nationwide sample of patients hospitalized for CAP, median total LOT was just under 10 days, with more than 70% of patients having likely excessive treatment duration. Better adherence to recommended CAP therapy duration by improving prescribing at hospital discharge may be an important target for antibiotic stewardship programs.
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http://dx.doi.org/10.1093/cid/cix986DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6474781PMC
April 2018

Effectiveness of β-Lactam Monotherapy vs Macrolide Combination Therapy for Children Hospitalized With Pneumonia.

JAMA Pediatr 2017 12;171(12):1184-1191

Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee.

Importance: β-Lactam monotherapy and β-lactam plus macrolide combination therapy are both common empirical treatment strategies for children hospitalized with pneumonia, but few studies have evaluated the effectiveness of these 2 treatment approaches.

Objective: To compare the effectiveness of β-lactam monotherapy vs β-lactam plus macrolide combination therapy among a cohort of children hospitalized with pneumonia.

Design, Setting, And Participants: We analyzed data from the Etiology of Pneumonia in the Community Study, a multicenter, prospective, population-based study of community-acquired pneumonia hospitalizations conducted from January 1, 2010, to June 30, 2012, in 3 children's hospitals in Nashville, Tennessee; Memphis, Tennessee; and Salt Lake City, Utah. The study included all children (up to 18 years of age) who were hospitalized with radiographically confirmed pneumonia and who received β-lactam monotherapy or β-lactam plus macrolide combination therapy. Data analysis was completed in April 2017.

Main Outcomes And Measures: We defined the referent as β-lactam monotherapy, including exclusive use of an oral or parenteral second- or third-generation cephalosporin, penicillin, ampicillin, ampicillin-sulbactam, amoxicillin, or amoxicillin-clavulanate. Use of a β-lactam plus an oral or parenteral macrolide (azithromycin or clarithromycin) served as the comparison group. We modeled the association between these groups and patients' length of stay using multivariable Cox proportional hazards regression. Covariates included demographic, clinical, and radiographic variables. We further evaluated length of stay in a cohort matched by propensity to receive combination therapy. Logistic regression was used to evaluate secondary outcomes in the unmatched cohort, including intensive care admission, rehospitalizations, and self-reported recovery at follow-up.

Results: Our study included 1418 children (693 girls and 725 boys) with a median age of 27 months (interquartile range, 12-69 months). This cohort was 60.1% of the 2358 children enrolled in the Etiology of Pneumonia in the Community Study with radiographically confirmed pneumonia in the study period; 1019 (71.9%) received β-lactam monotherapy and 399 (28.1%) received β-lactam plus macrolide combination therapy. In the unmatched cohort, there was no statistically significant difference in length of hospital stay between children receiving β-lactam monotherapy and combination therapy (median, 55 vs 59 hours; adjusted hazard ratio, 0.87; 95% CI, 0.74-1.01). The propensity-matched cohort (n = 560, 39.5%) showed similar results. There were also no significant differences between treatment groups for the secondary outcomes.

Conclusions And Relevance: Empirical macrolide combination therapy conferred no benefit over β-lactam monotherapy for children hospitalized with community-acquired pneumonia. The results of this study elicit questions about the routine empirical use of macrolide combination therapy in this population.
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http://dx.doi.org/10.1001/jamapediatrics.2017.3225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583650PMC
December 2017

Antibiotic Expenditures by Medication, Class, and Healthcare Setting in the United States, 2010-2015.

Clin Infect Dis 2018 01;66(2):185-190

Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago.

Background: Improving antibiotic use has the potential to decrease healthcare costs by reducing the incidence of antibiotic-resistant infections, antibiotic-associated adverse events, and expenditures due to unnecessary prescriptions. Antibiotic expenditures in 2009 totaled $10.7 billion in the United States. Since then, national and local antibiotic stewardship initiatives have grown. The purpose of this study was to assess trends in antibiotic expenditures by healthcare setting in the United States between 2010 and 2015.

Methods: Systemic (nontopical) antibiotic expenditures from January 2010 to December 2015 were extracted from the QuintilesIMS National Sales Perspectives database. These data represent a statistically valid projection of US medication purchases. Regression analyses evaluated trends in expenditures over the study period.

Results: Antibiotic expenditures totaled $56.0 billion over the 6-year period; the majority (59.1%) of expenditures were associated with the outpatient setting. Overall antibiotic expenditures in 2015 ($8.8 billion) were 16.6% lower than in 2010 ($10.6 billion). Antibiotic expenditures similarly decreased in the community by 25.5% (P = .05), but outpatient clinics and mail service pharmacy expenditures experienced significant growth (148% and 67% increase, respectively; P < .01 for both). In 2015, 16.5% of antibiotic expenditures in the community were for parenteral formulations, an increase of 25%.

Conclusions: From 2010 to 2015, antibiotic expenditures decreased. The majority of antibiotic expenditures were in the outpatient setting, specifically community pharmacies. Expenditures for intravenous agents in the community are increasing and may represent increased use. These results reinforce the importance of antibiotic stewardship efforts across the spectrum of healthcare.
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http://dx.doi.org/10.1093/cid/cix773DOI Listing
January 2018

Antimicrobial Drug Prescription and Neisseria gonorrhoeae Susceptibility, United States, 2005-2013.

Emerg Infect Dis 2017 10;23(10):1657-1663

We investigated whether outpatient antimicrobial drug prescribing is associated with Neisseria gonorrhoeae antimicrobial drug susceptibility in the United States. Using susceptibility data from the Gonococcal Isolate Surveillance Project during 2005-2013 and QuintilesIMS data on outpatient cephalosporin, macrolide, and fluoroquinolone prescribing, we constructed multivariable linear mixed models for each antimicrobial agent with 1-year lagged annual prescribing per 1,000 persons as the exposure and geometric mean MIC as the outcome of interest. Multivariable models did not demonstrate associations between antimicrobial drug prescribing and N. gonorrhoeae susceptibility for any of the studied antimicrobial drugs during 2005-2013. Elucidation of epidemiologic factors contributing to resistance, including further investigation of the potential role of antimicrobial drug use, is needed.
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http://dx.doi.org/10.3201/eid2310.170488DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5621530PMC
October 2017

Variations in Antibiotic and Azithromycin Prescribing for Children by Geography and Specialty-United States, 2013.

Pediatr Infect Dis J 2018 Jan;37(1):52-58

From the *Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, National Center for Emerging and Infectious Diseases, Centers for Disease Control and Prevention, †Epidemic Intelligence Service, Centers for Disease Control and Prevention, ‡Respiratory Diseases Branch, Division of Bacterial Diseases, National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, and §Division of Laboratory Systems, Center for Surveillance, Epidemiology and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia.

Background: Using antibiotics appropriately is critical to slow spread of antibiotic resistance, a major public health problem. Children, especially young children, receive more antibiotics than other age groups. Our objective was to describe antibiotic use in children in the United States and use of azithromycin, which is recommended infrequently for pediatric conditions.

Methods: We used QuintilesIMS Xponent 2013 data to calculate the number and rate of oral antibiotic prescriptions for children by age (0-2, 3-9 and 10-19 years) and agent. We used log-binomial regression to calculate adjusted prevalence ratios and 95% confidence intervals to determine if specialty and patient age were associated with azithromycin selection when an antibiotic was prescribed.

Results: In 2013, 66.8 million antibiotics were prescribed to US children ≤19 years of age (813 antibiotic prescriptions per 1000 children). Amoxicillin and azithromycin were the 2 most commonly prescribed agents (23.1 million courses, 35% of all antibiotics; 12.2 million, 18%, respectively). Most antibiotics for children were prescribed by pediatricians (39%) and family practitioners (15%). Family practitioners were more likely to select azithromycin when an antibiotic was prescribed in all age groups than pediatricians (for children 0-2 years of age: prevalence ratio: 1.79, 95% confidence interval: 1.78-1.80; 3-9 years: 1.40, 1.40-1.40 and 10-19 years: 1.18, 1.18-1.18).

Conclusion: Despite infrequent pediatric recommendations, variations in pediatric azithromycin use may suggest inappropriate antibiotic selection. Public health interventions focused on improving antibiotic selection in children as well as reducing antibiotic overuse are needed.
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http://dx.doi.org/10.1097/INF.0000000000001708DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6622452PMC
January 2018
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