Comparative Safety and Attributable Healthcare Expenditures Following Inappropriate Versus Appropriate Outpatient Antibiotic Prescriptions Among Adults With Upper Respiratory Infections.

Background: Little is known about the clinical and financial consequences of inappropriate antibiotics. We aimed to estimate the comparative risk of adverse drug events and attributable healthcare expenditures associated with inappropriate versus appropriate antibiotic prescriptions for common respiratory infections.
Methods: We established a cohort of adults aged 18 to 64 years with an outpatient diagnosis of a bacterial (pharyngitis, sinusitis) or viral respiratory infection (influenza, viral upper respiratory infection, nonsuppurative otitis media, bronchitis) from 1 April 2016 to 30 September 2018 using Merative MarketScan Commercial Database. The exposure was an inappropriate versus appropriate oral antibiotic (ie, non-guideline-recommended vs guideline-recommended antibiotic for bacterial infections; any vs no antibiotic for viral infections). Propensity score-weighted Cox proportional hazards models were used to estimate the association between inappropriate antibiotics and adverse drug events. Two-part models were used to calculate 30-day all-cause attributable healthcare expenditures by infection type.
Results: Among 3 294 598 eligible adults, 43% to 56% received inappropriate antibiotics for bacterial and 7% to 66% for viral infections. Inappropriate antibiotics were associated with increased risk of several adverse drug events, including Clostridioides difficile infection and nausea/vomiting/abdominal pain (hazard ratio, 2.90; 95% confidence interval, 1.31-6.41 and hazard ratio, 1.10; 95% confidence interval, 1.03-1.18, respectively, for pharyngitis). Thirty-day attributable healthcare expenditures were higher among adults who received inappropriate antibiotics for bacterial infections ($18-$67) and variable (-$53 to $49) for viral infections.
Conclusions: Inappropriate antibiotic prescriptions for respiratory infections were associated with increased risks of patient harm and higher healthcare expenditures, justifying a further call to action to implement outpatient antibiotic stewardship programs.
Competing Interests: Potential conflicts of interest. A. M. B. received investigator-initiated research funds from Merck outside the submitted work. D. S. B. reported receiving investigator-initiated research funds from Pfizer outside the submitted work. J. G. N. received investigator-initiated research funds from Merck and Pfizer and has grants from NIH and AHRQ. M. A. O. reported receiving investigator-initiated research funds and consulting fees from Pfizer outside the submitted work. M. J. D. reported receiving grants from The National Institute of Dental and Craniofacial Research, the National Institute on Drug Abuse, and the US Centers for Disease Control and Prevention Epicenters, and grants or contracts from the Barnes-Jewish Hospital Foundation, The Washington University Center for Health Economics and Policy (to institution), payment or honoraria for lecturing for the American Hospital Association on collaboration between antimicrobial stewardship and hospital epidemiology, and travel support from Pew Charitable Trusts for Harnessing Health Systems to Expand and Enhance Antibiotic Stewardship in Outpatient Settings Conference. 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.
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