Journal of General Internal Medicine

, Volume 17, Issue 2, pp 87–94 | Cite as

Tensions in antibiotic prescribing

Pitting social concerns against the interests of individual patients
  • Joshua P. MetlayEmail author
  • Judy A. Shea
  • Linda B. Crossette
  • David A. Asch
Original Articles


BACKGROUND: To reduce the prevalence of antibioticresistant bacteria in the community, physicians must optimize their use of antibiotics. However, optimal use from the perspective of the community (reserving newer agents for future use) is not always consistent with optimal use from the perspective of the individual patient (prescribing newer, broader agents).

OBJECTIVES: To identify preferred patterns of antibiotic prescribing for patients with community-acquired pneumonia (CAP), measure explicit attitudes toward antibiotics and antibiotic resistance, and determine the relationship between these prescribing patterns and attitudes.

DESIGN: Cross-sectional anonymous mail survey.

PARTICIPANTS: National random sample of 400 generalist physicians (general internal medicine and family practice) and 429 infectious diseases specialists.

MEASUREMENTS: Rank ordering of antibiotic preferences for a hypothetical outpatient with CAP and reasons for antibiotic selection. Endorsement of attitudes regarding antibiotic prescribing decisions and resistance.

RESULTS: Both generalists and infectious diseases specialists were more likely to prefer newer, broader drugs for the treatment of CAP compared to older agents still recommended by national guidelines. Physicians rated the issue of contributing to antibiotic resistance lowest among 7 determinants of their choices.

CONCLUSIONS: Despite national guidelines and increasing public awareness, the public health concern of contributing to the problem of antibiotic resistance does not exert a strong impact on physician prescribing decisions for CAP. Future efforts to optimize antibiotic prescribing decisions will need to consider options for increasing the impact of public health issues on the patient-oriented decisions of individual physicians.

Key words

antibiotics drug utilization physician’s practice patterns drug resistance microbial pneumonia 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Levy SB. Confronting multidrug resistance. A role for each of us. JAMA. 1993;269:1840–2.PubMedCrossRefGoogle Scholar
  2. 2.
    Cohen ML. Epidemiology of drug resistance: implications for a post-antimicrobial era. Science. 1992;257:1050–5.PubMedCrossRefGoogle Scholar
  3. 3.
    Bartlett JG, Dowell SF, Mandell LA, File TM Jr, Musher DM, Fine MJ. Practice guidelines for the management of communityacquired pneumonia in adults. Infectious Diseases Society of America. Clin Infect Dis. 2000;31:347–82.PubMedCrossRefGoogle Scholar
  4. 4.
    Warren JW, Abrutyn E, Hebel JR, Johnson JR, Schaeffer AJ, Stamm WE. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America (IDSA). Clin Infect Dis. 1999;29:745–58.PubMedGoogle Scholar
  5. 5.
    Schwartz B, Bell DM, Hughes JM. Preventing the emergence of antimicrobial resistance. A call for action by clinicians, public health officials, and patients. JAMA. 1997;278:944–5.PubMedCrossRefGoogle Scholar
  6. 6.
    Schwartz B. Preventing the spread of antimicrobial resistance among bacterial respiratory pathogens in industrialized countries: the case for judicious antimicrobial use. Clin Infect Dis. 1999;28:211–3.PubMedGoogle Scholar
  7. 7.
    Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for treatment of acute respiratory tract infections in adults: background, specific aims, and methods. Ann Intern Med. 2001;134:479–86.PubMedGoogle Scholar
  8. 8.
    Low DE, Scheld WM. Strategies for stemming the tide of antimicrobial resistance. [editorial; comment]. JAMA. 1998:279:394–5.PubMedCrossRefGoogle Scholar
  9. 9.
    Seppala H, Klaukka T, Vuopio-Varkila J, et al. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. Finnish Study Group for Antimicrobial Resistance. N Engl J Med. 1997;337:441–6.PubMedCrossRefGoogle Scholar
  10. 10.
    Arason VA, Kristinsson KG, Sigurdsson JA, Stefansdottir G, Molstad S, Gudmundsson S. Do antimicrobials increase the carriage rate of penicillin-resistant pneumococci in children? Cross sectional prevalence study. BMJ. 1996;313:387–91.PubMedGoogle Scholar
  11. 11.
    Chen DK, McGeer A, de Azavedo JC, Low DE. Decreased susceptibility of Streptococcus pneumoniae to fluoroquinolones in Canada. Canadian Bacterial Surveillance Network. N Engl J Med. 1999;341:233–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Niederman MS, Mandell LA, Anzueto A, et al. Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med. 2001;163:1730–54.PubMedGoogle Scholar
  13. 13.
    Hooper DC. Expanding uses of fluoroquinolones: opportunities and challenges. Ann Intern Med. 1998;129:908–10.PubMedGoogle Scholar
  14. 14.
    Heffelfinger JD, Dowell SF, Jorgensen JH, et al. Management of community-acquired pneumonia in the era of pneumococcal resistance: a report from the Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group. Arch Intern Med. 2000;160:1399–408.PubMedCrossRefGoogle Scholar
  15. 15.
    Whitney CG, Farley MM, Hadler J, et al. Increasing prevalence of multidrug-resistant Streptococcus pneumoniae in the United States. N Engl J Med. 2000;343:1917–24.PubMedCrossRefGoogle Scholar
  16. 16.
    Bartlett JG, Breiman RF, Mandell LA, File TM Jr. Community-acquired pneumonia in adults: guidelines for management. The Infectious Diseases Society of America. Clin Infect Dis. 1998;26:811–38.PubMedGoogle Scholar
  17. 17.
    Niederman MS, Bass JB Jr., Campbell GD, et al. Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. American Thoracic Society. Medical Section of the American Lung Association. Am Rev Respir Dis. 1993;148:1418–26.PubMedGoogle Scholar
  18. 18.
    Christakis NA, Asch DA. Medical specialists prefer to withdraw familiar technologies when discontinuing life support. J Gen Intern Med. 1995;10:491–4.PubMedCrossRefGoogle Scholar
  19. 19.
    Asch DA, Christakis NA, Ubel PA. Conducting physician mail surveys on a limited budget. A randomized trial comparing $2 bill versus $5 bill incentives. Med Care. 1998;36:95–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Allison P, Christakis N. Logit models for sets of ranked items. Sociology Methodol. 1994;24:199–228.CrossRefGoogle Scholar
  21. 21.
    Asch DA, Christakis NA. Why do physicians prefer to withdraw some forms of life support over others? Intrinsic attributes of life-sustaining treatments are associated with physicians’ preferences. Med Care. 1996;34:103–11.PubMedCrossRefGoogle Scholar
  22. 22.
    Baquero F. Evolving resistance patterns of Streptococcus pneumoniae: a link with long-acting macrolide consumption? J Chemother. 1999;11:35S-43S.Google Scholar
  23. 23.
    Gilbert K, Gleason PP, Singer DE. et al. Variation in antimicrobial use and cost in more than 2,000 patients with community-acquired pneumonia. Am J Med. 1998;104:17–27.PubMedCrossRefGoogle Scholar
  24. 24.
    Gleason PP, Kapoor WN, Stone RA, et al. Medical outcomes and antimicrobial costs with the use of the American Thoracic Society guidelines for outpatients with community-acquired pneumonia. JAMA. 1997;278:32–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol. 1997;50:1129–36.PubMedCrossRefGoogle Scholar
  26. 26.
    Cummings SM, Savitz LA, Konrad TR. Reported response rates to mailed physician questionnaires. Health Serv Res. 2001;35:1347–55.PubMedGoogle Scholar
  27. 27.
    Mandell LA, Marrie TJ, Grossman RF, Chow AW, Hyland RH. Canadian guidelines for the initial management of community-acquired pneumonia: an evidence-based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society. The Canadian Community-Acquired Pneumonia Working Group. Clin Infect Dis. 2000;31:383–421.PubMedCrossRefGoogle Scholar
  28. 28.
    Shlaes DM, Gerding DN, John JF Jr., et al. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Clin Infect Dis. 1997;25:584–99.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2002

Authors and Affiliations

  • Joshua P. Metlay
    • 1
    • 2
    • 3
    • 4
    • 5
    Email author
  • Judy A. Shea
    • 2
    • 3
    • 5
  • Linda B. Crossette
    • 3
  • David A. Asch
    • 1
    • 2
    • 3
    • 4
    • 5
  1. 1.the Philadelphia Veterans Affairs Medical CenterUniversity of PennsylvaniaPhiladelphia
  2. 2.the Division of General Internal Medicine, Department of MedicineUniversity of PennsylvaniaPhiladelphia
  3. 3.the Center for Clinical Epidemiology and BiostatisticsUniversity of PennsylvaniaPhiladelphia
  4. 4.the Center for Education and Research on TherapeuticsUniversity of PennsylvaniaPhiladelphia
  5. 5.the Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphia

Personalised recommendations