Factors associated with antibiotic prescribing for acute bronchitis at a university health center

Abstract

Background: Antibiotics are not indicated for treating acute bronchitis cases, yet up to 70% of adult acute bronchitis medical visits in the USA result in an antibiotic prescription. Reducing unnecessary antibiotic prescribing for acute bronchitis is a key antibiotic stewardship goal set forth by the Centers for Disease Control and Prevention. Understanding what factors influence prescribing for bronchitis cases can inform antimicrobial stewardship initiatives. The goal of this study was to identify factors associated with antibiotic prescribing at a high-volume student health center at a large US university. The Pennsylvania State University Health Services offers on-campus medical care to a population of over 40,000 students and receives over 50,000 visits every year. Methods: We conducted a retrospective chart review of acute bronchitis visits for the 2015-2016 academic year and used a multivariate logistic regression analysis to identify variables associated with antibiotic prescribing. Results: Findings during lung exams increased the likelihood of an antibiotic prescription (rales OR 13.95, 95% CI 3.31-80.73; rhonchi OR 5.50, 95% CI 3.08-10.00; percussion abnormality OR 13.02, 95% CI 4.00-50.09). Individual clinicians had dramatically different rates of prescribing (OR range 0.03-12.3). Male patients were more likely than female patients to be prescribed antibiotics (OR 1.68, 95% CI 1.17-2.41). Patients who reported longer duration since the onset of symptoms were slightly more likely to receive prescriptions (OR 1.04 per day, 95% CI 1.03-1.06), as were patients who reported worsening symptoms (OR 1.78, 95% CI 1.03-3.10). Visits with diagnoses or symptoms associated with viral infections or allergies were less likely to result in prescriptions (upper respiratory tract infection (URI) diagnosis OR 0.33, 95% CI 0.18-0.58; sneezing OR 0.39, 95% CI 0.17-0.86; vomiting OR 0.31, 95% CI 0.10-0.83). An exam finding of anterior cervical lymphadenopathy was associated with antibiotic prescribing (tender OR 3.85, 95% CI 1.70-8.83; general OR 2.63, 95% CI 1.25-5.54). Conclusions: Suspicious findings during lung examinations (rales, rhonchi, percussion abnormality) and individual healthcare providers were important factors influencing antibiotic prescribing rates for acute bronchitis visits. Patient gender, worsening symptoms, duration of illness, symptoms associated with viral infections or allergies, and anterior cervical lymphadenopathy also influenced prescribing rates.

Management of Acute Bronchitis in Adults: Recent Trends and Practices

“…In the event of AB due to bacterial pathogens such as Streptococcus pneumoniae, Moraxella Catarrhalis and Hemophilus influenzae, organisms are only isolated in 30% of the cases (4). Commonly prescribed antibiotics for AB are Amoxicillin, erythromycin, doxycycline, and trimethoprim-sulfamethoxazole, however due to ever increasing resistance, physicians are now transitioning to prescribing second and third generation cephalosporins or macrolides (4) Certain patient factors also lead to higher antibiotic prescriptions (11,20). A retrospective chart review by Morley et al reported patients with examination findings such as rales, and rhonchi on auscultation, percussion abnormalities and involvement of cervical lymphadenopathy as these findings raise suspicion of pneumonia.…”

“…A retrospective chart review by Morley et al reported patients with examination findings such as rales, and rhonchi on auscultation, percussion abnormalities and involvement of cervical lymphadenopathy as these findings raise suspicion of pneumonia. Rales and percussion abnormalities raised antibiotic prescriptions to 13-fold whereas rhonchi raised antibiotic prescriptions to 5-fold (20). Furthermore, worsening of symptoms, prolonged duration of illness, male gender, history of smoking are also known to influence higher antibiotic prescriptions (11,19,20).…”

“…Rales and percussion abnormalities raised antibiotic prescriptions to 13-fold whereas rhonchi raised antibiotic prescriptions to 5-fold (20). Furthermore, worsening of symptoms, prolonged duration of illness, male gender, history of smoking are also known to influence higher antibiotic prescriptions (11,19,20). Some of the factors that drive over prescription of antibiotics are diagnostic uncertainty (20), the highly variable symptoms of AB and difficulty in differentiation between uncomplicated bronchitis and pneumonia, societal expectations of patients due to consumer-centric pharmacotherapy thereby undermining physician autonomy and patient dissatisfaction on lack of prescribing antibiotics.…”

“…Furthermore, worsening of symptoms, prolonged duration of illness, male gender, history of smoking are also known to influence higher antibiotic prescriptions (11,19,20). Some of the factors that drive over prescription of antibiotics are diagnostic uncertainty (20), the highly variable symptoms of AB and difficulty in differentiation between uncomplicated bronchitis and pneumonia, societal expectations of patients due to consumer-centric pharmacotherapy thereby undermining physician autonomy and patient dissatisfaction on lack of prescribing antibiotics. When visiting the doctor, patients rely on antibiotics as a last resort after exhausting all pharmacological and nonpharmacological measures, as they are under the false impression that antibiotics are a quick solution to help them recover from their symptoms immediately (1,17).…”

Relationships Between Diagnosis, Bacterial Isolation, and Antibiotic Prescription in Out Patients With Respiratory Tract Infection Symptoms in Rural Anhui, China

“…Several studies have found that symptoms reported by patients, diagnosis given by physicians and the social-demographic background of patients are all linked to antibiotic prescribing patterns (11)(12)(13). Other studies have reported that antibiotic prescribing rates are higher in rural (vs. urban) practices, among patients with longer illness duration or acute bronchitis, and when providers experience greater diagnostic uncertainty (14,15). However, contemporary studies on determinants of antibiotic prescription in rural China suffer from two major shortcomings.…”