Variability in Antibiotic Prescribing: An Inconvenient Truth

The rising tide of antibiotic-resistant infections has led to calls to action by public health professionals, professional medical organizations, scientists, and policy makers. Most of us working on the front lines to address this problem agree that we must stop the rampant misuse of antibiotics to preserve antibiotic resources. Understanding variability in the patterns of antibiotic prescribing may help to identify where inappropriate use is most common and inform efforts to improve practices. Antibiotic prescribing rates vary 3-fold among 29 countries in Europe (highest in Greece and lowest in The Netherlands) [1]. In the United States, states in the Appalachian region have antibiotic prescribing rates that more than double those of states in the Pacific Northwest [2]. Ultimately, we need to better understand why providers practice differently, how much variability in prescribing exists at the local level, and whether practice-level data can provide useful information to guide antibiotic stewardship efforts at the health system level. In this issue of the Journal of the Pediatric Infectious Diseases Society, Gerber et al [3] assessed variation in prescribing rates across a pediatric primary care network that included 25 practices. After adjusting for patient demographics, prior antibiotic use, allergies, and comorbid conditions, antibiotic prescribing for acute respiratory tract infections ranged from 18% to 36% of visits, and variability in using broad-spectrum antibiotics ranged from 15% to 58% of visits during which antibiotics were prescribed [3]. Identifying practice differences may signal the places where inappropriate antibiotic prescribing is most common. Because of their perceived low toxicity, antibiotics are seen as ultrasafe “miracle drugs” by physicians and patients alike. Healthcare providers dispense antibiotics, often reflexively; however, from the earliest days, it became clear that antibiotic use leads to resistance. Because resistance to antibiotics is limiting the treatment options for many infections, including important pathogens such as Staphylococcus aureus, pneumococcus, and enterobacteriaceae, the problem is getting worse. The dilemma is that resistance is a long-term problem, and it affects the community as much as the individual. For both parents and providers, resistance may be a small risk compared with the potential benefits antibiotics can give to the child in front of them suffering from an infection. The substantial variation identified by Gerber et al [3] indicates that as practitioners weigh risks and benefits, they are drawing their lines in different places; however, parents routinely opt for what they believe is best for their child more than an abstract concern for the community, and it is hard to blame them for this reaction. The game-changer is that it’s increasingly evident that the consequences of antibiotic use are not limited to resistance. For example, there are the immediate complications such as acute toxicity, rashes, and gastrointestinal upset. Fortunately, the most severe complications are uncommon, and the common complications are generally mild. However, antibiotic exposure, especially in early life, may have long-term consequences, including increased risk for obesity, type 1 diabetes, asthma, and inflammatory bowel disease [4–7].Results from both epidemiologic studies in humans and experimental models in animals [8–9] lead to a similar conclusion: a possible biological cost from early life antibiotic exposures [10]. If these observations are substantiated, then Editorial Commentary