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Background: In 2022-2023, 15- and 20-valent pneumococcal conjugate vaccines (PCV15/PCV20) were recommended for infants. We aimed to estimate the incidence of outpatient visits and antibiotic prescriptions in US children (≤17 years) from 2016-2019 for acute otitis media, pneumonia, and sinusitis associated with PCV15- and PCV20-additional (non-PCV13) serotypes to quantify PCV15/20 potential impacts., Methods: We estimated the incidence of PCV15/20-additional serotype-attributable visits and antibiotic prescriptions as the product of all-cause incidence rates, derived from national health care surveys and MarketScan databases, and PCV15/20-additional serotype-attributable fractions. We estimated serotype-specific attributable fractions using modified vaccine-probe approaches incorporating incidence changes post-PCV13 and ratios of PCV13 versus PCV15/20 serotype frequencies, estimated through meta-analyses., Results: Per 1000 children annually, PCV15-additional serotypes accounted for an estimated 2.7 (95% confidence interval, 1.8-3.9) visits and 2.4 (95% CI, 1.6-3.4) antibiotic prescriptions. PCV20-additional serotypes resulted in 15.0 (95% CI, 11.2-20.4) visits and 13.2 (95% CI, 9.9-18.0) antibiotic prescriptions annually per 1000 children. PCV15/20-additional serotypes account for 0.4% (95% CI, 0.2%-0.6%) and 2.1% (95% CI, 1.5%-3.0%) of pediatric outpatient antibiotic use., Conclusions: Compared with PCV15-additional serotypes, PCV20-additional serotypes account for > 5 times the burden of visits and antibiotic prescriptions. Higher-valency PCVs, especially PCV20, may contribute to preventing pediatric pneumococcal respiratory infections and antibiotic use., Competing Interests: Potential conflicts of interest. L. M. K. reports consulting fees from Merck Sharpe & Dohme and Vaxcyte for unrelated work. J. A. L. reports research grants from Pfizer and Merck Sharpe & Dohme; and consulting fees from Pfizer, Merck, Sharpe & Dohme, and Vaxcyte for unrelated work. S. Y. T. reports research grants from Pfizer for unrelated work. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (Published by Oxford University Press on behalf of Infectious Diseases Society of America 2024.)

Objective: The 2014 US National Strategy for Combating Antibiotic-Resistant Bacteria (CARB) aimed to reduce inappropriate inpatient antibiotic use by 20% for monitored conditions, such as community-acquired pneumonia (CAP), by 2020. We evaluated annual trends in length of therapy (LOT) in adults hospitalized with uncomplicated CAP from 2013 through 2020., Methods: We conducted a retrospective cohort study among adults with a primary diagnosis of bacterial or unspecified pneumonia using International Classification of Diseases Ninth and Tenth Revision codes in MarketScan and the Centers for Medicare & Medicaid Services databases. We included patients with length of stay (LOS) of 2-10 days, discharged home with self-care, and not rehospitalized in the 3 days following discharge. We estimated inpatient LOT based on LOS from the PINC AI Healthcare Database. The total LOT was calculated by summing estimated inpatient LOT and actual postdischarge LOT. We examined trends from 2013 to 2020 in patients with total LOT >7 days, which was considered an indicator of likely excessive LOT., Results: There were 44,976 and 400,928 uncomplicated CAP hospitalizations among patients aged 18-64 years and ≥65 years, respectively. From 2013 to 2020, the proportion of patients with total LOT >7 days decreased by 25% (68% to 51%) among patients aged 18-64 years and by 27% (68%-50%) among patients aged ≥65 years., Conclusions: Although likely excessive LOT for uncomplicated CAP patients decreased since 2013, the proportion of patients treated with LOT >7 days still exceeded 50% in 2020. Antibiotic stewardship programs should continue to pursue interventions to reduce likely excessive LOT for common infections.

Antimicrobial resistance remains a significant global public health threat. Although development of novel antibiotics can be challenging, several new antibiotics with improved activity against multidrug-resistant Gram-negative organisms have recently been commercialised. Expanding access to these antibiotics is a global public health priority that should be coupled with improving access to quality diagnostics, health care with adequately trained professionals, and functional antimicrobial stewardship programmes. This comprehensive approach is essential to ensure responsible use of these new antibiotics., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 World Health Organization. Published by Elsevier Ltd. All rights reserved. This is an Open Access article published under the CC BY NC ND 3.0 IGO license which permits users to download and share the article for non-commercial purposes, so long as the article is reproduced in the whole without changes, and provided the original source is properly cited. This article shall not be used or reproduced in association with the promotion of commercial products, services or any entity. There should be no suggestion that WHO endorses any specific organisation, products or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.)

Using a machine-learning model, we examined drivers of antibiotic prescribing for antibiotic-inappropriate acute respiratory illnesses in a large US claims data set. Antibiotics were prescribed in 11% of the 42 million visits in our sample. The model identified outpatient setting type, patient age mix, and state as top drivers of prescribing.

Time constraints have been suggested as a potential driver of antibiotic overuse for acute respiratory tract infections. In this cross-sectional analysis of national data from visits to offices and emergency departments, we identified no statistically significant association between antibiotic prescribing and the duration of visits for acute respiratory tract infections.

Antibiotic prescribing can lead to adverse drug events and antibiotic resistance, which pose ongoing urgent public health threats (1). Adults aged ≥65 years (older adults) are recipients of the highest rates of outpatient antibiotic prescribing and are at increased risk for antibiotic-related adverse events, including Clostridioides difficile and antibiotic-resistant infections and related deaths (1). Variation in antibiotic prescribing quality is primarily driven by prescribing patterns of individual health care providers, independent of patients' underlying comorbidities and diagnoses (2). Engaging higher-volume prescribers (the top 10% of prescribers by antibiotic volume) in antibiotic stewardship interventions, such as peer comparison audit and feedback in which health care providers receive data on their prescribing performance compared with that of other health care providers, has been effective in reducing antibiotic prescribing in outpatient settings and can be implemented on a large scale (3-5). This study analyzed data from the Centers for Medicare & Medicaid Services (CMS) Part D Prescriber Public Use Files (PUFs)* to describe higher-volume antibiotic prescribers in outpatient settings compared with lower-volume prescribers (the lower 90% of prescribers by antibiotic volume). Among the 59.4 million antibiotic prescriptions during 2019, 41% (24.4 million) were prescribed by the top 10% of prescribers (69,835). The antibiotic prescribing rate of these higher-volume prescribers (680 prescriptions per 1,000 beneficiaries) was 60% higher than that of lower-volume prescribers (426 prescriptions per 1,000 beneficiaries). Identifying health care providers responsible for a higher volume of antibiotic prescribing could provide a basis for additional assessment of appropriateness and outreach. Public health organizations and health care systems can use publicly available data to guide focused interventions to optimize antibiotic prescribing to limit the emergence of antibiotic resistance and improve patient outcomes., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Lauri A. Hicks reports being an unpaid elected board member of the Society for Healthcare Epidemiology of America and an unpaid member of the American College of Physicians Clinical Guidelines Committee. No other potential conflicts of interest were disclosed.

Background: The microbiologic etiologies, clinical manifestations, and antimicrobial treatment of neonatal infections differ substantially from infections in adult and pediatric patient populations. In 2019, the Centers for Disease Control and Prevention developed neonatal-specific (Standardized Antimicrobial Administration Ratios SAARs), a set of risk-adjusted antimicrobial use metrics that hospitals participating in the National Healthcare Safety Network's (NHSN's) antimicrobial use surveillance can use in their antibiotic stewardship programs (ASPs)., Methods: The Centers for Disease Control and Prevention, in collaboration with the Vermont Oxford Network, identified eligible patient care locations, defined SAAR agent categories, and implemented neonatal-specific NHSN Annual Hospital Survey questions to gather hospital-level data necessary for risk adjustment. SAAR predictive models were developed using 2018 data reported to NHSN from eligible neonatal units., Results: The 2018 baseline neonatal SAAR models were developed for 7 SAAR antimicrobial agent categories using data reported from 324 neonatal units in 304 unique hospitals. Final models were used to calculate predicted antimicrobial days, the SAAR denominator, for level II neonatal special care nurseries and level II/III, III, and IV NICUs., Conclusions: NHSN's initial set of neonatal SAARs provides a way for hospital ASPs to assess whether antimicrobial agents in their facility are used at significantly higher or lower rates compared with a national baseline or whether an individual SAAR value is above or below a specific percentile on a given SAAR distribution, which can prompt investigations into prescribing practices and inform ASP interventions., Competing Interests: CONFLICTS OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Background: Antimicrobial stewardship programs (ASPs) promote the principle of de-escalation: moving from broad- to narrow-spectrum agents and stopping antibiotics when no longer indicated. A standard, objective definition of de-escalation applied to electronic data could be useful for ASP assessments., Methods: We derived an electronic definition of antibiotic de-escalation and performed a retrospective study among 5 hospitals. Antibiotics were ranked into 4 categories: narrow-spectrum, broad-spectrum, extended-spectrum, and agents targeted for protection. Eligible adult patients were cared for on inpatient units, had antibiotic therapy for at least 2 days, and were hospitalized for at least 3 days after starting antibiotics. Number of antibiotics and rank were assessed at 2 time points: day of antibiotic initiation and either day of discharge or day 5. De-escalation was defined as reduction in either the number of antibiotics or rank. Escalation was an increase in either number or rank. Unchanged was either no change or discordant directions of change. We summarized outcomes among hospitals, units, and diagnoses., Results: Among 39 226 eligible admissions, de-escalation occurred in 14 138 (36%), escalation in 5129 (13%), and antibiotics were unchanged in 19 959 (51%). De-escalation varied among hospitals (median, 37%; range, 31-39%, P < .001). Diagnoses with lower de-escalation rates included intra-abdominal (23%) and skin and soft tissue (28%) infections. Critical care had higher rates of both de-escalation and escalation compared with wards., Conclusions: Our electronic de-escalation metric demonstrated variation among hospitals, units, and diagnoses. This metric may be useful for assessing stewardship opportunities and impact., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Antibiotic use is necessary in the outpatient hemodialysis setting because patients receiving hemodialysis are at increased risk for infections and sepsis. However, inappropriate antibiotic use can lead to adverse drug events, including adverse drug reactions and infections with Clostridioides difficile and antibiotic-resistant bacteria. Optimizing antibiotic use can decrease adverse events and improve infection cure rates and patient outcomes. The American Society of Nephrology and the US Centers for Disease Control and Prevention created the Antibiotic Stewardship in Hemodialysis White Paper Writing Group, comprising experts in antibiotic stewardship, infectious diseases, nephrology, and public health, to highlight strategies that can improve antibiotic prescribing for patients receiving maintenance hemodialysis. Based on existing evidence and the unique patient and clinical setting characteristics, the following strategies for improving antibiotic use are reviewed: expanding infection and sepsis prevention activities, standardizing blood culture collection processes, treating methicillin-susceptible Staphylococcus aureus infections with β-lactams, optimizing communication between nurses and prescribing providers, and improving data sharing across transitions of care. Collaboration among the Centers for Disease Control and Prevention; American Society of Nephrology; other professional societies such as infectious diseases, hospital medicine, and vascular surgery societies; and dialysis provider organizations can improve antibiotic use and the quality of care for patients receiving maintenance hemodialysis., (Copyright © 2020 National Kidney Foundation, Inc. All rights reserved.)

The proportion of antibiotic prescriptions prescribed in US physician offices and emergency departments that were unnecessary decreased slightly, from 30% in 2010-2011 to 28% in 2014-2015. However, a greater decrease occurred in children: 32% in 2010-2011 to 19% in 2014-2015. Unnecessary prescribing in adults did not change during this period., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Improving antibiotic prescribing in outpatient settings is a public health priority. In the United States, urgent care (UC) encounters are increasing and have high rates of inappropriate antibiotic prescribing. Our objective was to characterize antibiotic prescribing practices during UC encounters, with a focus on respiratory tract conditions. This was a retrospective cohort study of UC encounters in the Intermountain Healthcare network. Among 1.16 million UC encounters, antibiotics were prescribed during 34% of UC encounters and respiratory conditions accounted for 61% of all antibiotics prescribed. Of respiratory encounters, 50% resulted in antibiotic prescriptions, yet the variability at the level of the provider ranged from 3% to 94%. Similar variability between providers was observed for respiratory conditions where antibiotics were not indicated and in first-line antibiotic selection for sinusitis, otitis media, and pharyngitis. These findings support the importance of developing antibiotic stewardship interventions specifically targeting UC settings., (Published by Oxford University Press for the Infectious Diseases Society of America 2019. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Patients visiting the emergency department (ED) for nontraumatic dental conditions usually receive nondefinitive health care and are referred to treatment elsewhere. This may lead to potentially avoidable antibiotic and opioid use., Methods: A retrospective study was conducted in IBM MarketScan Research Databases in Treatment Pathways from 2012 through 2014. This study included patients with commercial insurance or enrolled in Medicaid. Patients receiving a diagnosis of a dental condition in the ED with no secondary diagnosis warranting an antibiotic prescription were included. Patients were stratified on the basis of the primary payer and available demographics, as well as on the basis of repeat visits to the ED., Results: A higher proportion of Medicaid beneficiaries (280,410, 4.9%) had dental-related visits compared with the commercially insured (159,066, 1.3%). The most common diagnoses were similar for both groups and included caries. In both cohorts, the 18- through 34-year age group had the highest rate of dental-related ED visits. Within 7 days of a dental-related ED visit, 54.9% of Medicaid beneficiaries and 55.0% of commercially insured beneficiaries filled a prescription for an antibiotic and 39.6% of Medicaid patients and 42.0% of commercially insured patients filled an opioid prescription., Conclusions: Antibiotics and opioids are frequently prescribed during ED visits for dental conditions. Access to preventive and acute oral health care for routine dental symptoms, such as caries, may reduce unnecessary prescriptions in both the commercially insured and Medicaid beneficiary populations., Practical Implications: Treatment of dental conditions in the ED often indicates a lack of access to preventive or acute oral health care. Data-driven solutions, such as guideline implementation, could improve oral health access, reduce medication-related harms, and avert health care expenditures., (Copyright © 2020 American Dental Association. Published by Elsevier Inc. All rights reserved.)

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., (Published by Oxford University Press for the Infectious Diseases Society of America 2019.)

Using the 2014 IBM MarketScan commercial database, we compared antibiotic selection for pharyngitis, sinusitis, and acute otitis media in retail clinics, emergency departments, urgent care centers, and offices. Only 50% of visits for these conditions received recommended first-line antibiotics. Improving antibiotic selection for common outpatient conditions is an important stewardship target.

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.

Unnecessary and inappropriate use of antibiotics in human healthcare is a major driver for the development and spread of antimicrobial resistance; many countries are implementing measures to limit the overuse and misuse of antibiotics e.g. through the establishment of antimicrobial use reduction targets. We performed a review of antimicrobial use reduction goals in human medicine in Transatlantic Taskforce on Antimicrobial Resistance partner countries. On 31 March 2017, the European Centre for Disease Prevention and Control sent a questionnaire to National Focal Points for Antimicrobial Consumption and the National Focal Points for Antimicrobial Resistance in 28 European Union countries, Iceland and Norway. The same questionnaire was sent to the TATFAR implementers in Canada and the United States. Thirty of 32 countries replied. Only nine countries indicated that they have established targets to reduce antimicrobial use in humans. Twenty-one countries replied that no target had been established. However, 17 of these 21 countries indicated that work to establish such targets is currently underway, often in the context of developing a national action plan against antimicrobial resistance. The reported targets varied greatly between countries and can be a useful resource for countries willing to engage in the reduction of antibiotic use in humans.

Background: Antibiotic overuse is the most important modifiable factor contributing to antibiotic resistance. We conducted an educational campaign in Minya, Egypt targeting prescribers and the public through communications focused on appropriate antibiotic use for acute respiratory infections (ARIs)., Methods: The entire population of Minya was targeted by the campaign. Physicians and pharmacists were invited to participate in the pre-intervention assessments. Acute care hospitals and a sample of primary healthcare centers in Minya were randomly selected for a pre-intervention survey and all patients exiting outpatient clinics on the day of the survey were invited to participate. The same survey methodology was conducted for the post-intervention assessments. Descriptive comparisons were made through three assessments conducted pre- and post-intervention. We quantitated antibiotic prescribing through a survey administered to patients with an ARI exiting outpatient clinics. Additionally, physicians, pharmacists, and patients were interviewed regarding their attitudes and beliefs towards antibiotic prescribing. Finally, physicians were tested on three clinical scenarios (cold, bronchitis, and sinusitis) to measure their knowledge on antibiotic use., Results: Post-intervention patient exit surveys revealed a 23.1% decrease in antibiotic prescribing for ARIs in this population (83.7 to 64.4%) and physicians and pharmacists self-reported less frequently prescribing antibiotics for ARIs on their follow-up surveys. We also found an increase in correct responses to the clinical scenarios and in attitude and belief scores for physicians, pharmacists, and patients regarding antibiotic use in the post-intervention sample., Conclusions: Overall, the samples surveyed after the community-based educational campaign reported a lower frequency of antibiotic prescribing and improved knowledge and attitudes regarding antibiotic misuse compared to the samples surveyed before the campaign. Ongoing interventions educating providers and patients are needed to decrease antibiotic misuse and reduce the spread of antibiotic resistance in Egypt.

: media-1vid110.1542/5972296744001PEDS-VA&#95;2018-1056 Video Abstract 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%, P < .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%, P < .0001) and a lower frequency of first-line, guideline-concordant prescribing for the respiratory conditions studied (77% vs 87%, P < .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., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

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.

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 Core Elements of Outpatient Antibiotic Stewardship , 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., Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

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., (© 2018, Copyright the Author Journal compilation © 2018, The American Geriatrics Society.)

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.

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.

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.

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., (Published by Oxford University Press for the Infectious Diseases Society of America 2017. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

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.

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.

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.

Background: Dentists prescribe approximately 10% of outpatient antibiotics, but little is known about dentists' antibiotic prescribing patterns. The authors conducted a study to characterize prescribing by dentists according to antibiotic agent and category, patient demographic characteristics, and geographic region in the United States., Methods: The authors identified oral antibiotic prescriptions dispensed during 2013 in the Xponent (QuintilesIMS) database. The authors used the total number of prescriptions and county-level census population denominators to calculate prescribing rates. In addition, the authors analyzed prescribing according to individual agent, drug category, and patient demographic characteristics and the total number of prescriptions calculated for general dentists overall., Results: Dentists prescribed 24.5 million courses of antibiotics in 2013, a prescribing rate of 77.5 prescriptions per 1,000 people. Penicillins were the most commonly prescribed antibiotic category. Dentists prescribed most antibiotics for adults older than 19 years. The Northeast census region had the highest prescribing rate per 1,000 people. The District of Columbia had the highest prescribing rate of 99.5 per 1,000 people, and Delaware had the lowest prescribing rate of 50.7 per 1,000 people., Conclusions: Dentists prescribe large quantities of antibiotics in outpatient settings, and there is considerable geographic variability. Additional study is needed to better understand the reasons for this variability and identify areas of possible intervention and improvement., Practical Implications: Continued efforts to combat antibiotic resistance will require all prescribers, including dentists, to examine prescribing behaviors for appropriateness and the effectiveness of guidelines to identify opportunities to optimize antibiotic use., (Published by Elsevier Inc.)

The Core Elements of Outpatient Antibiotic Stewardship provides a framework for antibiotic stewardship for outpatient clinicians and facilities that routinely provide antibiotic treatment. This report augments existing guidance for other clinical settings. In 2014 and 2015, respectively, CDC released the Core Elements of Hospital Antibiotic Stewardship Programs and the Core Elements of Antibiotic Stewardship for Nursing Homes. Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing involves implementing effective strategies to modify prescribing practices to align them with evidence-based recommendations for diagnosis and management. The four core elements of outpatient antibiotic stewardship are commitment, action for policy and practice, tracking and reporting, and education and expertise. Outpatient clinicians and facility leaders can commit to improving antibiotic prescribing and take action by implementing at least one policy or practice aimed at improving antibiotic prescribing practices. Clinicians and leaders of outpatient clinics and health care systems can track antibiotic prescribing practices and regularly report these data back to clinicians. Clinicians can provide educational resources to patients and families on appropriate antibiotic use. Finally, leaders of outpatient clinics and health systems can provide clinicians with education aimed at improving antibiotic prescribing and with access to persons with expertise in antibiotic stewardship. Establishing effective antibiotic stewardship interventions can protect patients and improve clinical outcomes in outpatient health care settings.

Objectives: Antibiotic prescribing has become increasingly viewed as an issue related to patient safety and quality of care. The objective of this study was to better understand the differences between health plan reporting and the geographic variation seen in quality measures related to antibiotic use., Study Design: We focused on 3 measures from the Healthcare Effectiveness Data and Information Set (HEDIS) related to antibiotic prescribing and testing to guide antibiotic prescribing., Methods: We analyzed data for 3 relevant measures for the years 2008 to 2012, including only commercial health plans. We analyzed the following 3 HEDIS measures: 1) "Appropriate Testing for Children With Pharyngitis," 2) "Appropriate Treatment for Children With Upper Respiratory Infections," and 3) "Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis.", Results: Out of these 3 measures, health plans consistently performed poorly on the adult bronchitis measure. Performance was better on the 2 measures focused on the pediatric population. We also saw geographic variation between measures when looking at Census divisions across all years., Conclusions: There is wide variation between individual health plan performance on the measures related to antibiotic use. Geographic differences were also observed on these measures, with health plans in the South Central Census division performing worse than other parts of the country. Stakeholders, such as public health, advocacy groups, foundations, and professional societies, interested in improving the quality of care that patients receive related to antibiotic use in the outpatient setting should consider how existing measures and working with health plans could be used to improve prescribing.

Importance: The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotic use by 50% by 2020, but the extent of inappropriate outpatient antibiotic use is unknown., Objective: To estimate the rates of outpatient oral antibiotic prescribing by age and diagnosis, and the estimated portions of antibiotic use that may be inappropriate in adults and children in the United States., Design, Setting, and Participants: Using the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, annual numbers and population-adjusted rates with 95% confidence intervals of ambulatory visits with oral antibiotic prescriptions by age, region, and diagnosis in the United States were estimated., Exposures: Ambulatory care visits., Main Outcomes and Measures: Based on national guidelines and regional variation in prescribing, diagnosis-specific prevalence and rates of total and appropriate antibiotic prescriptions were determined. These rates were combined to calculate an estimate of the appropriate annual rate of antibiotic prescriptions per 1000 population., Results: Of the 184,032 sampled visits, 12.6% of visits (95% CI, 12.0%-13.3%) resulted in antibiotic prescriptions. Sinusitis was the single diagnosis associated with the most antibiotic prescriptions per 1000 population (56 antibiotic prescriptions [95% CI, 48-64]), followed by suppurative otitis media (47 antibiotic prescriptions [95% CI, 41-54]), and pharyngitis (43 antibiotic prescriptions [95% CI, 38-49]). Collectively, acute respiratory conditions per 1000 population led to 221 antibiotic prescriptions (95% CI, 198-245) annually, but only 111 antibiotic prescriptions were estimated to be appropriate for these conditions. Per 1000 population, among all conditions and ages combined in 2010-2011, an estimated 506 antibiotic prescriptions (95% CI, 458-554) were written annually, and, of these, 353 antibiotic prescriptions were estimated to be appropriate antibiotic prescriptions., Conclusions and Relevance: In the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate, supporting the need for establishing a goal for outpatient antibiotic stewardship.

Background: Acute respiratory tract infection (ARTI) is the most common reason for antibiotic prescription in adults. Antibiotics are often inappropriately prescribed for patients with ARTI. This article presents best practices for antibiotic use in healthy adults (those without chronic lung disease or immunocompromising conditions) presenting with ARTI., Methods: A narrative literature review of evidence about appropriate antibiotic use for ARTI in adults was conducted. The most recent clinical guidelines from professional societies were complemented by meta-analyses, systematic reviews, and randomized clinical trials. To identify evidence-based articles, the Cochrane Library, PubMed, MEDLINE, and EMBASE were searched through September 2015 using the following Medical Subject Headings terms: "acute bronchitis," "respiratory tract infection," "pharyngitis," "rhinosinusitis," and "the common cold.", High-Value Care Advice 1: Clinicians should not perform testing or initiate antibiotic therapy in patients with bronchitis unless pneumonia is suspected., High-Value Care Advice 2: Clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis (for example, persistent fevers, anterior cervical adenitis, and tonsillopharyngeal exudates or other appropriate combination of symptoms) by rapid antigen detection test and/or culture for group A Streptococcus. Clinicians should treat patients with antibiotics only if they have confirmed streptococcal pharyngitis., High-Value Care Advice 3: Clinicians should reserve antibiotic treatment for acute rhinosinusitis for patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (>39 °C) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or onset of worsening symptoms following a typical viral illness that lasted 5 days that was initially improving (double sickening)., High-Value Care Advice 4: Clinicians should not prescribe antibiotics for patients with the common cold.

Objectives: The objectives of this study were: to examine trends in the use of prescription antibiotics overall and by population subgroups between 1999 and 2012; and to examine trends in the use of categories of antibiotics and individual antibiotics., Methods: Use of antibiotics was examined among 71 444 participants in the nationally representative National Health and Nutrition Examination Survey (NHANES; 1999-2012). Use of an antibiotic in the past 30 days was the main outcome variable. Analyses of trends were conducted overall and separately by population subgroups (i.e. age, sex, race/Hispanic origin, health insurance status and respiratory conditions) across four time periods (1999-2002, 2003-06, 2007-10 and 2011-12)., Results: The percentage of the US population that used a prescription antibiotic in the past 30 days significantly declined from 6.1% in 1999-2002 to 4.1% in 2011-12 (P < 0.001). Declines were also identified for five age groups (0-1 year, 6-11 years, 12-17 years, 18-39 years and 40-59 years), both sexes, non-Hispanic white and non-Hispanic black persons, persons with and without insurance and among those who currently had asthma. Significant declines were also observed for three categories of antibiotics (penicillins, cephalosporins and macrolide derivatives). Of the most common antibiotics prescribed, only amoxicillin use decreased significantly., Conclusions: Overall, there was a significant decline in the use of antibiotics between 1999-2002 and 2011-12. Due to concerns about antimicrobial resistance, it is important to continue monitoring the use of antibiotics., (Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Each year in the United States, approximately two million persons become infected with antibiotic-resistant bacteria, at least 23,000 persons die as a direct result of these infections, and many more die from conditions complicated by a resistant infection. Antibiotic-resistant infections contribute to poor health outcomes, higher health care costs, and use of more toxic treatments. Although emerging resistance mechanisms are being identified and resistant infections are on the rise, new antibiotic development has slowed considerably.