National Estimates of Emergency Department Visits for Antibiotic Adverse Events Among Adults—United States, 2011–2015

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Abstract

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.

BACKGROUND

Antibiotics are one of the most commonly prescribed medications in the USA.1 In 2014, almost 200 million antibiotic prescriptions were written for adult outpatients aged ≥ 20 years, approximately five prescriptions for every six Americans.2,3 Increased use of antibiotics is correlated with development of antibiotic resistance,4,5 and the outpatient setting, which accounts for the majority of antibiotic expenditures,6 has been identified as a target for interventions to improve quality of care.7 Approximately one in ten adult outpatient visits results in an antibiotic prescription,8 of which an estimated one third are unnecessary,9 and even more may be inappropriate in antibiotic selection, dosing or duration.8,9,10,11,12 Unnecessary prescribing of antibiotics has been attributed to both demand-side factors (e.g., patient expectations) and supply-side factors (e.g., clinician concerns about patient satisfaction and/or time constraints).12,13,14,15,16,17,18,19,20

In addition to long-term antibiotic resistance, the use of antibiotics causes acute adverse drug events.21 Systemically administered antibiotics are the second most common cause of estimated emergency department (ED) visits for adverse drug events, accounting for one sixth of all estimated adverse drug event ED visits in the USA.22,23 We assessed the frequency, rates, and clinical characteristics of adult ED visits for adverse events (AEs) from antibiotics in the USA to help inform efforts to encourage appropriate prescribing. Pediatric antibiotic AEs were assessed in a separate analysis.

METHODS

Data Source and Collection Methods

National estimates of ED visits for antibiotic AEs by adults (aged ≥ 20 years) were obtained using 5 years of data (January 1, 2011 through December 31, 2015) from hospitals participating in the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance (NEISS-CADES) project. NEISS-CADES is a nationally representative, size-stratified probability sample of hospitals with at least six beds and 24-h EDs (excluding psychiatric and penal institutions) in the USA and its territories. From 2011 through 2015, 55 to 62 hospitals participated in NEISS-CADES each year. As described previously,24 trained abstractors at each participating hospital review clinical records of ED visits to identify clinician-diagnosed adverse drug events, reporting up to two implicated drugs and ten concomitant drugs. Abstractors also record narrative descriptions of the event, including preceding circumstances, clinician diagnoses, testing, treatments administered in the ED or by emergency medical services, and disposition. Narrative data are coded using the Medical Dictionary for Regulatory Activities (MedDRA) version 9.1. Data collection is considered a public health surveillance activity and does not require human subjects review or institutional review board approval.25

To contextualize ED visit numbers relative to antibiotic exposure, national estimates of antibiotic prescriptions dispensed at outpatient retail and long-term care pharmacies were obtained from the 2011–2015 QuintilesIMS National Prescription Audit (NPA). NPA tracks national prescription trends and activity for pharmaceutical products; NPA aggregates prescription data from participating US pharmacies and uses a proprietary algorithm to project national-level estimates of dispensed outpatient prescriptions.1 NPA data have previously been used to provide outpatient dispensed prescription estimates on a national level.26 The NPA sample included pharmacy records from nearly 48,000 retail pharmacies across the USA, representing approximately 80% of all retail prescription activity from independent and chain pharmacies and pharmacies in food and mass merchandise stores, and an additional 1800 pharmacies serving long-term care facilities.1

Definitions

Antibiotic AE cases were defined as visits for problems the treating ED clinician explicitly attributed to the use of systemically administered antibiotics (excluding antitubercular agents). ED visits for AEs involving all other systemically administered medications (prescription and over-the-counter medications, dietary supplements, homeopathic products, and vaccines) were used as a comparison group. Systemically administered antibiotics and other medications were defined as medications administered by oral, injectable, rectal, sublingual, or transdermal routes.

For the purposes of this analysis, AEs were categorized as allergic reactions (immunologically mediated effects, including severe hypersensitivity reactions such as Stevens-Johnson syndrome), non-allergic adverse effects (undesirable pharmacologic or idiosyncratic effects at recommended doses), supratherapeutic effects of dose or intake of excess dose, or other effects (including those secondary to drug administration [e.g., choking on pill] or vaccination reactions). The MedDRA-coded narrative terms for each case were used to assign a single AE manifestation in a mutually exclusive and hierarchical manner based on severity; for example, a case involving anaphylactic respiratory distress and dyspepsia would be classified as a moderate-to-severe allergic reaction based on the anaphylaxis. Cases involving death in or prior to arrival in the ED and visits involving intentional self-harm, drug abuse, therapeutic failure, non-adherence, medication withdrawal, occupational exposure, and AEs from treatments received in the ED were not included. Cases usually diagnosed as antibiotic AEs only after the patient departs the ED (e.g., most Clostridium difficile infections) were not included.

Statistical Analysis

Cases were weighted based on inverse probability of selection, adjusted for non-response and hospital non-participation, and post-stratified to account for changes in the number of US ED visits each year.27 Nationally estimated (projected) numbers and proportions, with corresponding 95% confidence intervals (CIs), were calculated using the SURVEYMEANS procedure in SAS 9.4 (SAS Institute, Cary, NC). Cumulative 5-year (2011–2015) estimates and corresponding CIs were divided by 5 to calculate average annual estimates and CIs, accounting for weighting and complex sample design. Cumulative estimates less than 1200, based on fewer than 20 cases, or with coefficients of variation greater than 30% were considered statistically unreliable and are noted.

Population rates of ED visits for antibiotic AEs were calculated by dividing the ED visit estimate (from NEISS-CADES) in each age group by the corresponding US Census Bureau bridged-race population estimates from the National Center for Health Statistics, Centers for Disease Control and Prevention.28 Prescription-based rates of ED visits for antibiotic AEs were calculated by dividing the ED visit estimate (from NEISS-CADES) by the corresponding dispensed prescription estimate for retail and long-term care pharmacies (from NPA). Prescription-based rates were also calculated for specific drug products and patient demographics (age group, sex) for oral antibiotic classes with statistically reliable estimates. Accompanying 95% CIs for rate estimates were calculated incorporating the variance of the numerator (NEISS-CADES) estimates of ED visits for antibiotic AEs. Because of the large sample size (approximately 3.8 billion dispensed prescriptions annually), the variance of NPA estimates was considered negligible.

RESULTS

Based on 10,225 NEISS-CADES cases, US adults aged ≥ 20 years made an estimated 145,490 (95% CI, 115,279–175,701) ED visits for AEs from antibiotics each year in 2011–2015, causing 13.7% (95% CI, 12.3–15.2%) of estimated adult ED visits for AEs from all systemically administered medications (Table 1). One third (33.0%) of estimated ED visits for antibiotic AEs involved adults 20 to 34 years of age, representing 27.1% (95% CI, 25.1–29.1%) of estimated ED visits for AEs from all systemically administered medications in young adults. Adults younger than 50 years of age were involved in over one half (56.6%) of estimated ED visits for AEs from antibiotics (95% CI, 54.8–58.4%), but less than a third (31.0%) of estimated ED visits for AEs from all other systemically administered medications (95% CI, 27.7–34.3%).

Table 1 US Emergency Department (ED) Visits Among Adults for Adverse Events (AEs) from Systemically Administered Medications, by Case Characteristics, 2011–2015

The population rate of estimated ED visits for AEs from antibiotics was similar for younger and older age groups (7.3 per 10,000 individuals aged 20–34 years [95% CI, 5.8–8.9] versus 6.7 per 10,000 individuals aged ≥ 65 years [95% CI, 5.1–8.3]). In contrast, the population rate of estimated ED visits for AEs from non-antibiotic, systemically administered medications increased significantly with age, from 19.7 per 10,000 individuals aged 20–34 years (95% CI, 16.0–23.4) to 90.0 per 10,000 individuals aged ≥ 65 years (95% CI, 61.2–118.9).

Accounting for prescribing frequency of oral antibiotics, young adults aged 20–34 years had twice the estimated rate of ED visits for AEs from oral antibiotics compared with those aged ≥ 65 years (9.7 visits per 10,000 dispensed prescriptions versus 4.6 visits per 10,000 dispensed prescriptions; 95% CI, 7.6–11.8 versus 3.6–5.7). The estimated rate of ED visits for AEs from oral antibiotics among females was 7.2 per 10,000 dispensed prescriptions (95% CI, 5.8–8.7), compared with 5.0 per 10,000 dispensed prescriptions among males (95% CI, 3.9–6.0) (Online Supplementary Table).

Females accounted for 71.8% of estimated ED visits for AEs from antibiotics, compared with 56.3% of visits due to AEs from non-antibiotics (Table 1). A single medication was almost always implicated in ED visits for antibiotic AEs (86.4%), and nearly all estimated ED visits for antibiotic AEs were attributed to oral preparations (96.9%; 95% CI, 96.2–97.6%). Allergic reactions were more common among ED visits for antibiotic AEs, compared with AEs from non-antibiotics (74.3 versus 15.9%), and ED visits for antibiotic AEs less commonly had documented medication errors (2.4 versus 12.5%) or required hospitalization (9.2 versus 32.4%).

Antibiotic Classes Implicated in Adverse Events

The three most frequently implicated antibiotic classes in ED visits by adults for AEs were oral sulfonamides (23.2%), penicillins (20.8%), and quinolones (15.7%) (Table 2). Oral oxazolidinones (linezolid) accounted for just 0.2% of ED visits for antibiotic AEs but, accounting for dispensed prescriptions from retail and long-term care pharmacies, had the highest estimated rate of ED visits for AEs (19.9 ED visits per 10,000 dispensed prescriptions), followed by oral sulfonamides (19.4 ED visits per 10,000 dispensed prescriptions) and lincomycins (clindamycin) (13.2 ED visits per 10,000 dispensed prescriptions).

Table 2 US Emergency Department (ED) Visits Among Adults for Adverse Events (AEs) from Antibiotics, by Drug Class, 2011–2015

Antibiotic Drug Products Implicated in Adverse Events

Sulfamethoxazole/trimethoprim was the most commonly implicated oral antibiotic product across all age groups, accounting for between one fifth (19.7%) and one quarter (25.8%) of estimated ED visits for oral antibiotic AEs (Table 3). Amoxicillin was the second most commonly implicated oral antibiotic product among adults aged 20–34, 35–49, and 50–64 years, accounting for an estimated 14.6, 10.8, and 11.0% of visits, respectively, while among older adults aged ≥ 65 years, ciprofloxacin was the second most commonly implicated oral antibiotic product (12.2%).

Table 3 US Emergency Department (ED) Visits Among Adults for Adverse Events (AEs) from Oral Antibiotics, by Patient Age and Drug Product, 2011–2015

Prescription-based estimated rates of ED visits for AEs from oral antibiotics generally decreased with increasing patient age group. For example, the estimated rate for oral sulfamethoxazole/trimethoprim was 29.7 (95% CI, 21.9–37.5) ED visits per 10,000 dispensed prescriptions among young adults aged 20–34 years, compared with 11.4 (95% CI, 8.4–14.4) per 10,000 dispensed prescriptions among older adults aged ≥ 65 years.

Moxifloxacin had the highest estimated rate of ED visits for AEs from oral antibiotics across all ages, at 30.1 ED visits per 10,000 dispensed prescriptions (95% CI, 20.2–40.0), a rate five to six times that of the oral fluoroquinolones ciprofloxacin and levofloxacin (5.8 and 5.7 ED visits per 10,000 dispensed prescriptions, respectively; 95% CI, 4.2–7.4 and 4.5–6.9). After moxifloxacin, oral antibiotics with the highest estimated rates were linezolid (19.9 ED visits per 10,000 dispensed prescriptions; 95% CI, 8.2–31.5), sulfamethoxazole/trimethoprim (19.1 ED visits per 10,000 dispensed prescriptions; 95% CI, 14.7–23.5), and clindamycin (13.2 ED visits per 10,000 dispensed prescriptions; 95% CI, 10.4–16.0).

Adverse Event Manifestations

Mild allergic reactions (e.g., rash, pruritus) were the most commonly documented adverse event manifestation across all oral antibiotic classes (Table 4), and accounted for over two thirds of estimated visits involving sulfonamides (69.3%). Moderate-to-severe allergic reactions (e.g., anaphylaxis, angioedema) occurred in approximately one quarter of estimated ED visits for AEs involving oral quinolones (26.2%), and allergic reactions of any severity accounted for 87.2% (95% CI, 84.7–89.7%) of estimated ED visits for AEs involving oral sulfonamides. Gastrointestinal disturbance (e.g., nausea, diarrhea, abdominal pain) was documented in approximately one quarter of estimated visits involving oral nitroimidazoles (metronidazole) (28.3%), macrolides (27.0%), and tetracyclines (25.4%).

Table 4 US Emergency Department (ED) Visits Among Adults for Adverse Events (AEs) from Oral Antibiotics, by Drug Class and AE Manifestation, 2011–2015

Oral sulfonamides had the highest estimated rates of ED visits for mild allergic reactions (13.4 visits per 10,000 dispensed prescriptions; 95% CI, 10.0–16.8) and moderate-to-severe allergic reactions (3.5 visits per 10,000 dispensed prescriptions; 95% CI, 2.6–4.3). While the overall rate of ED visits for moderate-to-severe allergic reactions to oral quinolones (1.7 visits per 10,000 dispensed prescriptions; 95% CI, 1.3–2.1) was lower than that for sulfonamides, moxifloxacin had significantly higher estimated rates of ED visits for moderate-to-severe allergic reactions (9.7 visits per 10,000 dispensed prescriptions; 95% CI, 5.9–13.4) compared with sulfonamides. The estimated rate of ED visits for moderate-to-severe allergic reactions to moxifloxacin was significantly higher than rates for the other oral quinolones levofloxacin (1.7 per 10,000 dispensed prescriptions; 95% CI, 1.3–2.2) and ciprofloxacin (1.3 per 10,000 dispensed prescriptions; 95% CI, 1.0–1.6).

DISCUSSION

Using nationally representative public health surveillance data, an estimated 145,490 ED visits were made by adults for antibiotic AEs annually from 2011 through 2015, making antibiotics a leading cause of AEs, accounting for approximately 14% of all ED visits by adults for AEs from systemically administered medications. These findings are similar to those from a decade ago,21 highlighting the need for continued emphasis on avoiding acute adverse effects of antibiotics, in addition to the individual and community risks from antimicrobial resistance. Specific findings from this study include updated national estimates of the numbers and rates of ED visits for AEs from specific antibiotics stratified by patient age, which can be used by clinicians to optimize the risk-benefit assessment for patients.

The key to reducing the number of antibiotic AEs is avoiding unnecessarily prescribing antibiotics. Allergic reactions were the most common cause (74.3%) of ED visits by adults for antibiotic AEs, while supratherapeutic effects or excessive doses were the most common cause of AEs from other medications. Unlike supratherapeutic effects and overdoses which can be prevented by laboratory monitoring and appropriate dosing, most allergic reactions can only be prevented by avoiding exposure altogether.

Antibiotic adverse events are a particularly important issue for young adults. Young adults were involved in one third of antibiotic AE visits and had double the per-prescription rate of ED visits for antibiotic AEs compared with older adults (aged ≥ 65 years). Higher rates of antibiotic AEs among younger compared to older adults may be related to immune senescence decreasing the likelihood of allergic reactions as patients age.29 Lower proportions of antibiotic ED visits among older adults are likely due to higher use of other medications with high rates of ED visits for AEs such as anticoagulants, diabetes drugs, and chemotherapeutic agents,22 and drug-drug interactions potentiated by antibiotics may be attributed solely to the higher risk non-antibiotic agent. For example, overanticoagulation from interaction of sulfamethoxazole/trimethoprim and warfarin may be attributed only to warfarin in the ED setting.

Patient expectations for antibiotics, particularly expectations of young adults, might be tempered with specific information on antibiotic AEs. In a focus group evaluating knowledge and attitudes towards antibiotic AEs, most younger adults (age range, 23–53) reported that AEs were “not a significant issue” but also reported never having discussed the potential for AEs with their provider.30 When provided information about AEs, however, messages about AEs were found to resonate with younger parents, particularly mothers of young children.30 If specific data about acute harms from antibiotics can modify antibiotic safety assumptions of younger patients, targeting educational campaigns to these patients, who are more likely than older adults to be treated in the ED for antibiotic AEs and less likely to develop complications from infections,31,32 may be an efficient strategy to improve antibiotic prescribing and reduce AEs.

ED visits for antibiotic AEs were disproportionately made by women (71.8%); however, this finding is consistent with higher ED utilization in general by women33 and higher ED utilization by women for other types of adverse drug events,22 so it is uncertain if targeting antibiotic safety messages to women would be an effective approach to reducing antibiotic AEs.34,35,36,37

Estimates of the number needed to harm (NNH) for individual antibiotics by patient age can also inform clinician decision-making when selecting among agents with similar activity. Among young adults, for example, the NNH for ED visits for AEs from oral antibiotics ranged more than 12-fold, from an estimated 1 in 200 moxifloxacin prescriptions to 1 in 2541 azithromycin prescriptions. Although the overall rates of ED visits for AEs from oral antibiotics were lower for older adults, the range in rates was greater, with more than 15-fold difference in rates between moxifloxacin and azithromycin.38,39

Efforts to improve antibiotic prescribing such as the Centers for Disease Control and Prevention’s Be Antibiotics Aware: Smart Use, Best Care educational program seek to bridge the communication and education gap with patients and clinicians.3 Engaging patients with data on rates of acute harms can help reinforce that there are downsides of antibiotic prescription, particularly for patients who may be unaware of or not understand the distinction between a viral and bacterial illness. However, for all patients, education on antibiotic use should include communicating the side effects and frequency of potential harms from antibiotic use.40 Providing clinicians with information on acute harms from antibiotics is also important, as clinicians are more likely to prescribe appropriately if they understand that the antibiotics can cause harm.41

Public health surveillance data have limitations. First, these data likely underestimate the total burden of antibiotic AEs because such events often can be managed outside the ED setting. ED-based surveillance is not the best method to detect antibiotic AEs with subacute onset, such as fluoroquinolone-associated disability syndromes, medication interactions, or indirect and long-term harms such as those resulting from antibiotic resistance. Second, adverse events were identified according to the data available at the time of the ED visit. Thus, Clostridium difficile infections were rarely identified since this diagnosis is not typically confirmed during the course of the ED visit. Third, because medical history and prior treatment information is limited in the ED medical record, the contribution of inappropriate prescribing (e.g., guideline-discordant prescription of antibiotics for acute bronchitis) could not be directly assessed. Fourth, specific types of reactions to specific antibiotics (e.g., admissions for moderate-to-severe allergic reactions to moxifloxacin) were not frequent enough to calculate reliable estimates. Fifth, these national data could not be stratified at the regional or state level, owing to surveillance system sampling design. Sixth, rate calculations were based on QuintilesIMS dispensed prescription data obtained from retail and long-term care pharmacies only and did not include mail order prescriptions; however, mail order was not likely a major source of systemically administered antibiotic prescriptions.

CONCLUSION

Antibiotic AEs are a common cause of ED visits by adults for adverse drug events and represent an important safety issue. Quantification of acute harms associated with taking specific antibiotics for specific patient populations, such as younger adults, can provide additional information to help clinicians weigh the risks versus benefits when making the decision to prescribe or not prescribe antibiotics. Quantification of AE rates is also important for facilitating clinician communication about the risks and benefits with patients and may modify patient preferences and expectations for antibiotics as well. Efforts to improve antibiotic prescribing are central to patient safety, to both avoid unnecessary adverse events and optimize treatment of infections.

References

  1. 1.

    QuintilesIMS Institute. Medicines Use and Spending in the U.S. A Review of 2016 and Outlook to 2021. 2016. https://www.iqvia.com/en/institute/reports/medicines-use-and-spending-in-the-us-a-review-of-2016. Accessed February 22, 2018.

  2. 2.

    US Department of Health and Human Services, Centers for Disease Control and Prevention. Outpatient antibiotic prescriptions—United States, 2014. 2016. https://www.cdc.gov/antibiotic-use/community/pdfs/Annual-ReportSummary_2014.pdf. Accessed February 22, 2018.

  3. 3.

    US Department of Health and Human Services, Centers for Disease Control and Prevention. Be Antibiotics Aware: Smart Use, Best Care. https://www.cdc.gov/antibiotic-use/. Accessed February 22, 2018.

  4. 4.

    Harris AM, Hicks LA, Qaseem A. Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults. Ann Intern Med. 2016;165(9):674.

    Article  Google Scholar 

  5. 5.

    Hicks LA, Chien YW, Taylor TH, Jr, et al. Outpatient antibiotic prescribing and nonsusceptible Streptococcus pneumoniae in the United States, 1996-2003. Clin Infect Dis. 2011;53(7):631–9.

    Article  Google Scholar 

  6. 6.

    Suda KJ, Hicks LA, Roberts RM, Hunkler RJ, Danziger LH. A national evaluation of antibiotic expenditures by healthcare setting in the United States, 2009. J Antimicrob Chemother. 2013;68(3):715–8.

    CAS  Article  Google Scholar 

  7. 7.

    US Department of Health and Human Services, Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. 2013. https://www.cdc.gov/drugresistance/threat-report-2013/. Accessed February 22, 2018.

  8. 8.

    Shapiro DJ, Hicks LA, Pavia AT, Hersh AL. Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09. J Antimicrob Chemother 2014;69(1):234–40.

    CAS  Article  Google Scholar 

  9. 9.

    Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. JAMA. 2016;315(17):1864–73.

    CAS  Article  Google Scholar 

  10. 10.

    US Department of Health and Human Services, Centers for Disease Control and Prevention. Office-related antibiotic prescribing for persons aged ≤14 years--United States, 1993-1994 to 2007-2008. MMWR Morb Mortal Wkly Rep. 2011;60(34):1153–6.

    Google Scholar 

  11. 11.

    Gonzales R, Malone DC, Maselli JH, Sande MA. Excessive antibiotic use for acute respiratory infections in the United States. Clin Infect Dis 2001;33(6):757–62.

    CAS  Article  Google Scholar 

  12. 12.

    Sanchez GV, Roberts RM, Albert AP, Johnson DD, Hicks LA. Effects of knowledge, attitudes, and practices of primary care providers on antibiotic selection, United States. Emerg Infect Dis. 2014;20(12):2041–7.

    CAS  Article  Google Scholar 

  13. 13.

    Dempsey PP, Businger AC, Whaley LE, Gagne JJ, Linder JA. Primary care clinicians’ perceptions about antibiotic prescribing for acute bronchitis: a qualitative study. BMC Fam Pract. 2014;15(194):1–10.

    Google Scholar 

  14. 14.

    Stearns CR, Gonzales R, Camargo CA, Jr, Maselli J, Metlay JP. Antibiotic prescriptions are associated with increased patient satisfaction with emergency department visits for acute respiratory tract infections. Acad Emerg Med. 2009;16(10):934–41.

  15. 15.

    Scott JG, Cohen D, DiCicco-Bloom B, Orzano AJ, Jaen CR, Crabtree BF. Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription. J Fam Pract 2001;50(10):853–8.

    CAS  PubMed  Google Scholar 

  16. 16.

    Gonzales R, Steiner JF, Maselli J, Lum A, Barrett PH, Jr Impact of reducing antibiotic prescribing for acute bronchitis on patient satisfaction. Eff Clin Pract. 2001;4(3):105–11.

  17. 17.

    Butler CC, Rollnick S, Pill R, Maggs-Rapport F, Stott N. Understanding the culture of prescribing: qualitative study of general practitioners’ and patients’ perceptions of antibiotics for sore throats. BMJ. 1998;317(7159):637–42.

    CAS  Article  Google Scholar 

  18. 18.

    Shapiro E. Injudicious antibiotic use: an unforeseen consequence of the emphasis on patient satisfaction? Clin Ther 2002;24(1):197–204.

    Article  Google Scholar 

  19. 19.

    Ong S, Nakase J, Moran GJ, et al. Antibiotic use for emergency department patients with upper respiratory infections: prescribing practices, patient expectations, and patient satisfaction. Ann Emerg Med 2007;50(3):213–20.

    Article  Google Scholar 

  20. 20.

    Lin MP, Nguyen T, Probst MA, Richardson LD, Schuur JD. Emergency Physician Knowledge, Attitudes, and Behavior Regarding ACEP’s Choosing Wisely Recommendations: A Survey Study. Acad Emerg Med. 2017;24(6):668–75.

    Article  Google Scholar 

  21. 21.

    Shehab N, Patel PR, Srinivasan A, Budnitz DS. Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis. 2008;47(6):735–43.

    Article  Google Scholar 

  22. 22.

    Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016;316(20):2115–25.

    Article  Google Scholar 

  23. 23.

    Budnitz DS, Pollock DA, Weidenbach KN, Mendelsohn AB, Schroeder TJ, Annest JL. National surveillance of emergency department visits for outpatient adverse drug events. JAMA. 2006;296(15):1858–66.

    CAS  Article  Google Scholar 

  24. 24.

    Jhung MA, Budnitz DS, Mendelsohn AB, Weidenbach KN, Nelson TD, Pollock DA. Evaluation and overview of the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance Project (NEISS-CADES). Med Care. 2007;45(10 Supl 2):S96–102.

    Article  Google Scholar 

  25. 25.

    US Department of Health and Human Services, Centers for Disease Control and Prevention. Distinguishing public health research and public health nonresearch. 2010. http://www.cdc.gov/od/science/integrity/docs/cdc-policy-distinguishing-public-health-research-nonresearch.pdf. Accessed February 22, 2018.

  26. 26.

    Ritchey M, Tsipas S, Loustalot F, Wozniak G. Use of Pharmacy Sales Data to Assess Changes in Prescription- and Payment-Related Factors that Promote Adherence to Medications Commonly Used to Treat Hypertension, 2009 and 2014. PLoS One. 2016;11(7):e0159366.

    Article  Google Scholar 

  27. 27.

    Schroeder T, Ault K. The NEISS sample (design and implementation) 1997 to present. http://www.cpsc.gov//PageFiles/106617/2001d011-6b6.pdf. Accessed February 22, 2018.

  28. 28.

    US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. CDC WONDER: Bridged-race vintage 2015 postcensal population estimates. 2016. http://wonder.cdc.gov/bridged-race-v2015.html. Accessed February 22, 2018.

  29. 29.

    Montecino-Rodriguez E, Berent-Maoz B, Dorshkind K. Causes, consequences, and reversal of immune system aging. J Clin Invest. 2013;123(3):958–65.

    CAS  Article  Google Scholar 

  30. 30.

    Roberts RM, Albert AP, Johnson DD, Hicks LA. Can Improving Knowledge of Antibiotic-Associated Adverse Drug Events Reduce Parent and Patient Demand for Antibiotics? Health Serv Res Manag Epidemiol 2015;2:1–5.

    Google Scholar 

  31. 31.

    Meyer KC. Impact of aging on the lung. Semin Respir Crit Care Med. 2010;31(5):519–20.

    Article  Google Scholar 

  32. 32.

    Viasus D, Nunez-Ramos JA, Viloria SA, Carratala J. Pharmacotherapy for community-acquired pneumonia in the elderly. Expert Opin Pharmacother. 2017;18(10):957–64.

    CAS  Article  Google Scholar 

  33. 33.

    Manuel JI. Racial/Ethnic and Gender Disparities in Health Care Use and Access. Health services research. 2017 May 8 [Epub ahead of print].

  34. 34.

    Barlam TF, Morgan JR, Wetzler LM, Christiansen CL, Drainoni ML. Antibiotics for respiratory tract infections: a comparison of prescribing in an outpatient setting. Infect Control Hosp Epidemiol. 2015;36(2):153–9.

    Article  Google Scholar 

  35. 35.

    Hicks LA, Bartoces MG, Roberts RM, et al. US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis. 2015;60(9):1308–16.

    PubMed  Google Scholar 

  36. 36.

    Roberts RM, Hicks LA, Bartoces M. Variation in US outpatient antibiotic prescribing quality measures according to health plan and geography. Am J Manag Care. 2016;22(8):519–23.

    PubMed  Google Scholar 

  37. 37.

    Schröder W, Sommer H, Gladstone BP, et al. Gender differences in antibiotic prescribing in the community: a systematic review and meta-analysis. J Antimicrob Chemother. 2016;71(7):1800–6.

    Article  Google Scholar 

  38. 38.

    Jones SC, Budnitz DS, Sorbello A, Mehta H. US-based emergency department visits for fluoroquinolone-associated hypersensitivity reactions. Pharmacoepidemiol Drug Saf. 2013;22(10):1099–106.

    CAS  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Leone R, Venegoni M, Motola D, et al. Adverse drug reactions related to the use of fluoroquinolone antimicrobials: an analysis of spontaneous reports and fluoroquinolone consumption data from three italian regions. Drug Saf. 2003;26(2):109–20.

    CAS  Article  Google Scholar 

  40. 40.

    Broniatowski DA, Klein EY, Reyna VF. Germs are germs, and why not take a risk? Patients’ expectations for prescribing antibiotics in an inner-city emergency department. Med Decis Making. 2015;35(1):60–7.

    Article  Google Scholar 

  41. 41.

    Klein EY, Martinez EM, May L, Saheed M, Reyna V, Broniatowski DA. Categorical Risk Perception Drives Variability in Antibiotic Prescribing in the Emergency Department: A Mixed Methods Observational Study. J Gen Intern Med. 2017;32(10):1083–9.

    Article  Google Scholar 

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Funding

This study was funded by the Federal government of the USA.

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Authors

Contributions

The authors thank Dr. Nina Weidle from Eagle Medical Services, LLC (contractor to CDC), Ms. Katie Rose, Ms. Sandra Goring, Ms. Arati Baral, and Mr. Alex Tocitu, from Northrop Grumman (contractor to CDC), for assistance with data coding and programming. The authors also thank Mr. Tom Schroeder, Ms. Elenore Sonski, Mr. Herman Burney, and data abstractors from the US Consumer Product Safety Commission, for their assistance with data acquisition.

Corresponding author

Correspondence to Andrew I. Geller MD.

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The authors declare that they do not have a conflict of interest.

Disclaimer

Federal government employees had a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. However, the findings in and conclusions of this study are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention.

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Geller, A.I., Lovegrove, M.C., Shehab, N. et al. National Estimates of Emergency Department Visits for Antibiotic Adverse Events Among Adults—United States, 2011–2015. J GEN INTERN MED 33, 1060–1068 (2018). https://doi.org/10.1007/s11606-018-4430-x

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KEY WORDS

  • pharmaceutical care
  • patient safety
  • community health
  • primary care
  • evidence-based medicine