Infection Control & Hospital Epidemiology
infections.2 Previous studies of inappropriate antibiotic prescribing in outpatient acute respiratory infections (ARIs) have focused on oral, rather than parenteral, antibiotics.3,4 Our objective was to describe ceftriaxone use in adult outpatient ARI visits.
Methods
We identified adult (aged 18–64 years) visits to urgent care, retail health, and physician office settings that occurred between January 1, 2014, and December 31, 2014, in the IBM® MarketScan® Commercial Database (IBM® Watson Health™, Ann Arbor, MI). This database contains insurance claims from a convenience sample of several million individuals aged <65 years with private, employer-sponsored insurance from >260 employers.5 We identi- fied unique visits by date, enrollee number, and place of service. We excluded records without enrollee numbers or International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. We excluded enrollees without coverage in MarketScan for ≥30 days prior to the outpatient visit. To exclude higher-acuity patients potentially warranting empiric ceftriaxone therapy, we excluded visits with previous (≤30 days) hospital discharges or same-day admissions. We aggregated all claims for each visit to identify all diagno-
ses and ceftriaxone injections. We used a previously described tiered-diagnosis system3 modified for ceftriaxone indications (Supplementary Table online) to assign a single diagnosis to each visit. We identified ceftriaxone injections using Healthcare Common Procedure Coding System code J0696. We excluded visits with concurrent diagnoses for conditions where ceftriaxone could be permissible (sexually transmitted infections and related diagnoses [eg, cervicitis], pneumonia, uri- nary tract infection, sickle cell disease, and acute suppurative otitis media). We defined ceftriaxone-inappropriate ARIs as sinusitis, pharyngitis, bronchitis, viral upper respiratory infec- tion, and influenza. We calculated per-visit ceftriaxone rates by dividing the number of outpatient visits with ceftriaxone by total outpatient visits for ceftriaxone-inappropriate ARIs. We estimated confidence intervals using a binomial distribu- tion. The National Center for Emerging and Zoonotic Infectious Diseases human subjects advisor determined this study to be nonhuman subjects research not requiring institu- tional review board review. Analyses were conducted using DataProbe 5.0 software (IBM® Watson Health™)and SAS version 9.4 software (SAS Institute, Cary, NC). Statistical tests were conducted at α=0.05.
Results
In 2014, there were 9,653,688 adult outpatient visits for ceftriaxone- inappropriate ARIs. Ceftriaxone injections were given in 3.5% (95%CI, 3.5%–3.5%) of these visits (Table 1). The per-visit ceftriax- one rate in the South was 6.9% (95% CI, 6.9%–7.0%), the highest of all regions, and the South accounted for 84.3% of all ceftriaxone injections. In the South, the highest ceftriaxone rate occurred in physician offices (7.3%; 95% CI, 7.3%–7.3%).
Discussion
Despite being an inappropriate treatment, ceftriaxone injec- tions occurred in 3.5% of adult outpatient ARI visits in this study. More than 80% of inappropriate ceftriaxone injections occurred in the South. In our study, we excluded visits with
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ceftriaxone-permissible diagnoses and individuals potentially warranting empiric ceftriaxone therapy; therefore, regional differ- ences are likely due to differences in provider behavior rather than clinical factors. Previous studies of oral antibiotics demonstrate higher rates of unnecessary3,6 and broad-spectrum7,8 prescribing in the South. Although underlying health may be worse in the South,9 there may also be a tendency among clinicians in this region to prescribe and/or administer medications, even when not clinically appropriate. Further research on regional differences in clinician behavior is needed. Our study has limitations. These data were obtained from a
convenience sample of privately insured individuals <65 and may not be generalizable to other populations; we were not able to evaluate the representativeness of this sample. Additionally, because claims data were used, we made assumptions to assign a single diagnosis to a visit and were unable to evaluate the dose of ceftriaxone given. A strength of this study is its examination of parenteral antibiotic use in multiple outpatient settings in a large sample.
Although ceftriaxone was used in only 3.5% of adult visits for ceftriaxone-inappropriate ARIs, this translates to 338,394 likely unnecessary exposures in this sample alone. Inappropriate cef- triaxone use in outpatient ARI management puts patients at risk for adverse events, C. difficile, and antibiotic-resistant infections. Stewardship of this important antibiotic is urgently needed, espe- cially in the South.
Supplementary materials. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2019.21
Author ORCIDs. Laura M. King, 0000-0002-7785-4712
Acknowledgments. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
IBM Watson Health and MarketScan are registered trademarks of IBM Corporation in the United States, other countries, or both.
Financial support. This work was supported by the Centers for Disease Control and Prevention. M.A.K. receives salary support from the Tennessee Department of Health.
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
References
1. Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015;64:1–137.
2. Baxter R, Ray GT, Fireman BH. Case-control study of antibiotic use and sub- sequent Clostridium difficile-associated diarrhea in hospitalized patients. Infect Control Hosp Epidemiol 2008;29:44–50.
3. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA 2016;315:1864–1873.
4. Hersh AL, Shapiro DJ, Pavia AT, Fleming-Dutra KE, Hicks LA. Geographic variability in diagnosis and antibiotic prescribing for acute respiratory tract infections. Infect Dis Ther 2018;7:171–174.
5. Hansen L. IBM MarketScan Research Databases for life sciences researchers. IBM MarketScan Research Databases website.
https://www-01.ibm.com/ common/ssi/cgi-bin/ssialias?htmlfid=HLW03049USEN&. Published 2018. Accessed January 8, 2019.
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