Every time I review an article espousing the benefits of a protocol based on the use of procalcitonin to improve antibiotic stewardship, I usually say something along the lines of: “We don’t need this test, it only looks like we need it because our baseline antibiotic prescribing is hysterically shameful.”
Well, here’s another piece of evidence describing the basis for that statement.
This is a secondary analysis of observational data collected from the Influenza Vaccine Effectiveness Network. All patients were eligible for inclusion in the study if they presented with an acute cough of duration fewer than 7 days. Patients all received influenza testing as part of disease surveillance, as well as any other testing indicated.
Of 14,987 patient visits analyzed, 6,136 (41%) were associated with an antibiotic prescription. Of these, 2,494 patients (52%) received diagnoses for “potentially indicated” antibiotics – pharyngitis, sinusitis, and otitis media – while 2,522 (41%) fell into a category of “antibiotics not indicated” – viral upper respiratory infection, bronchitis, allergy or asthma, clinical influenza, or “other”. So, as far as the coded diagnosis is reliable, it is likely half of prescribed antibiotics are simply unnecessary.
Then, of the 14,987 analyzed, 3,381 had laboratory-confirmed influenza. Excluding those receiving a diagnosis of pneumonia, there were 945 who received a prescription for antibiotics. Finally, there were an estimated 860 patients with a diagnosis of pharyngitis and a negative test for Group A Strep, 327 (38%) of whom received antibiotics.
And, let’s not even get into whether patients received an appropriate narrow-spectrum antibiotic (44%).
There are limitations to the precision and clinical context of using diagnosis codes to classify antibiotic prescribing as appropriate or not, but these results are broadly consistent with the prior literature. Before we start deferring our prescribing decisions to something like a PCT assay, there’s a huge opportunity to simply Do The Right Thing, first. Once the low-hanging fruit has been resolved, then we can worry about tweezing out the uncertain cases in a narrow cohort with potential limited application of PCT or other infectious disease differentiation engine.
“Outpatient Antibiotic Prescribing for Acute Respiratory Infections
During Influenza Seasons”
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2683951