Article Figures & Data
Figures
- Figure 1
Area plot of frequency of antibiotic prescribing for acute nonspecific respiratory infections for each of 326 practices, by practice.
Tables
Generic Name No. of Visits Penicillins 685,265 Macrolides 126,934 Cephalosporins, cephamycins, and other β-lactams 71,646 Tetracyclines 70,554 Sulphonamides and trimethoprim 34,629 Quinolones 12,203 Othera 819 Total visits with antibiotics 1,002,050 -
↵a Metronidazole, methenamine, nitrofuratoin, fosfomycin, amoxicillin/clarithromycin/lansoprazole, clindamycin, colistin, chloramphenicol, and fusidic acid.
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- Table 2
Characteristics of Patients With Antibiotic-Exposed vs Antibiotic-Unexposed Visits for Acute Respiratory Infections
Characteristic Visits With Antibiotics Visits Without Antibiotics Total visits (N = 1,531,019), No. (%) 1,002,050 (65.4) 528,969 (34.6) Male, No. (%) 385,712 (38.5) 184,720 (35) Age, median (mean) y 46 (47.91) 40 (43.98) Comorbidities Any comorbidity, No. (%) 350,078 (34.94) 161,607 (30.55) Number of comorbidities, mean 0.48 0.41 Number of different classes of drugs used in previous year, mean 5.98 4.25 Number of visits made in previous year, mean 8.94 8.87 With Antibiotics 1,002,050 Visits Without Antibiotics 528,969 Visits Time After Index Visit No. ofEvent Events Ratea No. of Event Events Ratea Risk Differencea P Value 15 days 85 8.48 41 7.75 0 .73 .63 30 days 148 14.77 80 15.12 −0.35 .86 Note: The following events occurred at 15 days: hypersensitivity 44, diarrhea 18, liver toxicity 13, renal toxicity 21, arrhythmia 6, seizure 23; at 30 days, hypersensitivity 79, diarrhea 25, liver toxicity 28, renal toxicity 39, arrhythmia 11, seizure 46.
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↵a Per 100,000 visits.
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Risk Difference for Antibiotic Use Grouped Visits Point Estimate 95% CI P Value All antibiotic use vs none −1.07 −4.52 to 2.38 .54 Specific antibiotic class vs none β-Lactams −1.62 −5.19 to 1.96 .37 Macrolides 2.40 −3.26 to 8.07 .40 Flouroquinolones 1.06 −17.02 to 19.14 .91
Supplemental Appendix & Tables
Supplemental Appendix. Additional Analyses; Table A1. Acute Respiratory Infection Diagnostic Codes; Table A2. Adverse Event Diagnostic Codes; Table A3. Community-Acquired Pneumonia Diagnostic Codes; Table A4. Severe Adverse Events Per 100,000 Visits by Propensity Score Quintile; Table A5. Severe Adverse Events Per 100,00 Visits: Specific vs Other Antibiotic Class
Files in this Data Supplement:
- Supplemental data: Appendix & Tables A1-A5 - PDF file, 11 pages, 254 KB
The Article in Brief
Risks and Benefits Associated With Antibiotic Use for Acute Respiratory Infections: A Cohort Study
Sharon B. Meropol , and colleagues
Background Antibiotics are frequently prescribed for acute respiratory infections (ARIs), although research has failed to demonstrate a clear benefit from antibiotics for these conditions. This study uses outpatient ARI visits to estimate the risks of serious adverse drug events and community-acquired pneumonia among patients who have and have not received antibiotics.
What This Study Found In this study, there is a small reduction in subsequent hospitalization for pneumonia and no increase in severe adverse drug reactions for patients prescribed antibiotics. Analyzing data on more than 1.5 million patient visits, researchers found antibiotics were prescribed in 65 percent of cases. The adjusted risk difference for treated vs untreated patients per 100,000 visits was 1.07 fewer adverse events and 8.16 fewer pneumonia hospitalizations within 15 days following the visit. The number needed to treat was 12,255 patients to prevent 1 hospitalization.
Implications
- The authors conclude this small benefit from antibiotics for a common diagnosis creates a persistent tension; at the societal level, physicians are compelled to reduce antibiotic prescribing, thus minimizing future resistance, whereas at the visit level, they are compelled to optimize the benefit-risk balance for that patient.
Annals Journal Club
Mar/Apr 2013: The Big Picture on Antibiotics for Respiratory Infections
The Annals of Family Medicine encourages readers to develop a learning community of those seeking to improve health care and health through enhanced primary care. You can participate by conducting a RADICAL journal club and sharing the results of your discussions in the Annals online discussion for the featured articles. RADICAL is an acronym for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. The word radical also indicates the need to engage diverse participants in thinking critically about important issues affecting primary care and then acting on those discussions.1
HOW IT WORKS
In each issue, the Annals selects an article or articles and provides discussion tips and questions. We encourage you to take a RADICAL approach to these materials and to post a summary of your conversation in our online discussion. (Open the article online and click on "TRACK Comments: Submit a response.") You can find discussion questions and more information online at: http://www.AnnFamMed.org/site/AJC/.
CURRENT SELECTION
Article for Discussion
- Meropol SB, Localio AR, Metlay JP. Risks and benefits associated with antibiotic use for acute respiratory infections: a cohort study. Ann Fam Med. 2013;11(2):165-172.
Discussion Tips
This large cohort study provides an opportunity to wear both our personal clinician and public health hats in balancing the risks of antibiotic resistance and side effects against the benefit of antibiotics for selected people with respiratory tract infections. The introduction and discussion of this article do a nice job of laying out the relevant issues.
Discussion Questions
- What are the study's research questions and hypotheses, and why do they matter?
- How does this study advance beyond previous research and clinical practice on this topic?
- How strong is the study design for answering the question?
- To what degree can the findings be accounted for by:
- How patients were selected, excluded, or lost to follow-up?
- How the main variables were measured?
- Confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a 3rd factor)?
- Chance?
- How the findings were interpreted?
- How were possible biases controlled for in analyses? How do the sensitivity analyses affect your confidence in the findings?
- What are the main study findings? What (if anything) surprised you?
- How comparable is the study sample to similar patients in your practice? What is your judgment about the transportability of the findings?
- In applying the findings to patient care, how do you weigh the different risks and benefits examined in this study? How about the societal and individual risks of antibiotic resistance (that were not examined by this study)?
- How might this study change your practice? Policy? Education? Research?
- Who are the constituencies for the findings, and how might they be engaged in interpreting or using the findings?
- What are the next steps in interpreting or applying the findings?
- What researchable questions remain?
References
- Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: It's time to get RADICAL. Ann Fam Med. 2006;4(3):196-197.
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