No abstract

Broad-spectrum antibiotic prescribing in ambulatory pediatrics is extremely common and frequently inappropriate. These findings can inform the development and implementation of antibiotic stewardship efforts in ambulatory care toward the most important geographic regions, diagnostic conditions, and patient populations.

Background: Community-acquired methicillinresistant Staphylococcus aureus (CA-MRSA) has emerged as a common cause of skin and soft-tissue infections (SSTIs) in the United States. It is unknown whether this development has affected the national rate of visits to primary care practices and emergency departments (EDs) and whether changes in antibiotic prescribing have occurred.Methods: We examined visits by patients with SSTIs to physician offices, hospital outpatient departments, and EDs using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1997 to 2005. We estimated annual visit rates for all SSTIs and a subset classified as abscess/cellulitis. For abscess/cellulitis visits, we examined trends in characteristics of patients and clinical settings and in antibiotic prescribing.Results: Overall rate of visits for SSTIs increased from 32.1 to 48.1 visits per 1000 population (50%; P=.003 for trend), reaching 14.2 million by 2005. More than 95% of this change was attributable to visits for abscess/ cellulitis, which increased from 17.3 to 32.5 visits per 1000 population (88% increase; P Ͻ .001 for trend). The largest relative increases occurred in EDs (especially in high safety-net-status EDs and in the South), among black patients, and among patients younger than 18 years. Use of antibiotics recommended for CA-MRSA increased from 7% to 28% of visits (P Ͻ .001) during the study period. Independent predictors of treatment with these antibiotics included being younger than 45 years, living in the South, and an ED setting. Conclusions:The incidence of SSTIs has rapidly increased nationwide in the CA-MRSA era and appears to disproportionately affect certain populations. Although physicians are beginning to modify antibiotic prescribing practices, opportunities for improvement exist, targeting physicians caring for patients who are at high risk.

Broad-spectrum agents constitute the majority of antibiotics in ambulatory care. More than 25% of prescriptions are for conditions for which antibiotics are rarely indicated. Antibiotic stewardship interventions targeting respiratory and non-respiratory conditions are needed in ambulatory care.

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2004 clinical practice guideline on outpatient parenteral antimicrobial therapy (OPAT) [1]. This guideline is intended to provide insight for healthcare professionals who prescribe and oversee the provision of OPAT. It considers various patient features, infusion catheter issues, monitoring questions, and antimicrobial stewardship concerns. It does not offer recommendations on the treatment of specific infections. The reader is referred to disease- or organism-specific guidelines for such support.

No abstract

Most upper respiratory tract infections are caused by viruses and require no antibiotics. This clinical report focuses on antibiotic prescribing strategies for bacterial upper respiratory tract infections, including acute otitis media, acute bacterial sinusitis, and streptococcal pharyngitis. The principles for judicious antibiotic prescribing that are outlined focus on applying stringent diagnostic criteria, weighing the benefits and harms of antibiotic therapy, and understanding situations when antibiotics may not be indicated. The principles can be used to amplify messages from recent clinical guidelines for local guideline development and for patient communication; they are broadly applicable to antibiotic prescribing in general.

ATTERNS OF HORMONE THERAPYuse among postmenopausal women in the United States ideally should reflect known risks and benefits. However, definitive information on these risks and benefits was lacking until recently. The Heart and Estrogen/Progestin Replacement Study (HERS) 1 and HERS follow-up (HERS II) 2 concluded that postmenopausal hormone therapy with combination oral estrogen/progestin offered no cardiovascular disease benefit among women with established disease. The estrogen plus progestin trial of the Women's Health Initiative (WHI) 3 demonstrated that hormone therapy with an estrogen/ progestin combination caused increased risk of breast cancer and cardiovascular disease in postmenopausal women. These findings from randomized trials contrast with prior observational studies that suggested cardiovascular benefits. [4][5][6] Based on the quality of recent data, new guidelines recommend against routine hormone therapy use for chronic conditions, 7 and current users have been advised to taper doses toward discontinuation. 8,9 Prior studies from nationally representative databases showed that in 1975, hormone therapy prescriptions peaked at 30 million. [10][11][12] Prescriptions subsequently declined to approximately 15 million in the early 1980s as evidence emerged showing an increased risk of endometrial cancer with unopposed estrogen use. [10][11][12] Prescription growth resumed as progestins were prescribed in combination with estrogen, and prescriptions for hormone therapy reached 36 million in 1992, representing approximately 6 million women and 17% of women older than 50 years. 10 More re-