摘要：Objectives. This study examined antimicrobial prescribing patterns for adults and children with bronchitis or upper respiratory infections (URIs) before and after release of nationally disseminated pediatric practice recommendations. Methods. Data from the 1993, 1995, 1997, and 1999 National Ambulatory Medical Care Survey were used to evaluate prescriptions for antimicrobials for URIs and bronchitis. Results. From 1993 to 1999, the proportion of children receiving antimicrobials after visits for URIs and bronchitis decreased. However, the use of broad-spectrum antimicrobials rose from 10.6% of bronchitis visits to 40.5%. Prescriptions of antimicrobials for adults with URIs or bronchitis showed a decrease between 1993 and 1999. Conclusions. Although antimicrobial prescribing for URIs and bronchitis has decreased for both children and adults, the prescribing of broad-spectrum antibiotics among children has shown a proportional rise. Since the mid-1990s, a number of studies have documented the widespread use of antimicrobials in outpatient settings for viral upper respiratory infections (URIs). 1– 6 These studies, using administrative data from Medicaid populations (1993–1994), data from the 1992 National Ambulatory Medical Care Survey (NAMCS; a national survey of visits to office-based physicians), and chart reviews of primary care physicians, found rates of prescribing of antimicrobials for the common cold and uncomplicated URIs of 40% to 60%. 1– 3, 5– 7 Other studies examining the use of antibiotics for acute bronchitis, another predominantly viral respiratory illness, show even higher antimicrobial prescribing rates. Moreover, evidence from the NAMCS showed an increasing trend toward the use of broad-spectrum antimicrobials and decreasing rates of narrower-spectrum drugs over the decade from 1980 to 1992. 1 A recent study using data from the NAMCS showed that the rate of antimicrobial prescribing overall and for respiratory infections for children and adolescents younger than 15 years decreased between 1989–1990 and 1999–2000. 8 This information on the widespread use and potential overuse of antimicrobials for primarily viral URIs carries particular significance, because not only is there little evidence to support their effectiveness as treatments, but the inappropriate use of antimicrobial agents creates an environment for the development of resistance, placing both populations and individual patients at risk. Reducing the use of antimicrobial agents can decrease the spread of resistance. Therefore, judicious use of antimicrobials, especially for respiratory illnesses, has been advocated as a key strategy for reducing rising drug resistance. 9– 12 In an effort to change antibiotic prescribing practices, a variety of guidelines have been developed and implemented. 13 Although the Centers for Disease Control and Prevention (CDC) began its campaign against overuse of antibiotics in 1995, the first of the nationally disseminated recommendations on judicious use of antimicrobials was produced by the CDC and the American Academy of Pediatrics and disseminated in 1998. 14 These recommendations were distributed to all members of the American Academy of Pediatrics and were also disseminated through articles sent to all members of the American Academy of Family Physicians. 15, 16 In response to this set of recommendations, several strategies focusing on limited groups of providers were implemented with the use of some form of “academic detailing,” a process whereby physicians or other health professionals discuss with practicing physicians appropriate indications and use of medications in an effort to change prescribing practices, and presentations to small groups of providers. 17, 18 These interventions had varied degrees of success in changing prescribing practices. Although most of the effort to date has been expended in curtailing the use of antibiotics for pediatric respiratory diseases, most studies have shown that antibiotics are prescribed more often for adults with colds than for children. 2 Other observations show that physicians who treat both adults and children are more likely to prescribe antibiotics for children than are physicians who treat only children. 19 These results suggest that antibiotic overuse is not simply a pediatric problem but may be even more widespread among adults. Guidelines for reducing antibiotic use in adults were published by the American College of Physicians in 2001, 20 3 years after recommendations were disseminated for children. Although the creation and dissemination of clinical practice guidelines is a popular method for educating physicians in an effort to change practices, it has not been particularly successful. 21 It is not clear what effect the delay in issuing guidelines for antibiotic use in adults has had on the use of antimicrobials in this age group. The purpose of this study was to examine the impact of the principles of judicious use of antimicrobial agents for pediatric URIs on antimicrobial prescribing for children and adults with colds, uncomplicated URIs, and bronchitis.
