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Antibiotic Use for Viral Acute Respiratory Tract Infections Remains Common
Mark H. Ebell, MD, MS; and Taylor Radke, MPH
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Antibiotic Use for Viral Acute Respiratory Tract Infections Remains Common

Mark H. Ebell, MD, MS; and Taylor Radke, MPH
Antibiotic use for acute respiratory tract infections that are largely viral remains common. Macrolide use has increased since 2007, and 9% of patients received a second antibiotic within 30 days.
Our primary finding is that clinicians in typical community practice continue to prescribe antibiotics at high levels for ARTIs that are exclusively or predominantly caused by viruses. Rates are especially high when the clinical diagnosis is acute bronchitis, when patients are seen by a clinician in an urgent care setting, or when they are seen by a nurse practitioner or physician assistant. Although antibiotic use is more common in older patients (pediatricians had the lowest rates of prescribing antibiotics), use of anti-influenza drugs is highest among individuals aged 5 to 17 years.

Of particular note is the fact that 8.9% of patients received a second antibiotic and 0.7% received a third during the 28 days following the index encounter. Examination of Figure 1, a graph of when the second prescriptions were filled in relation to the first, reveals that there are 2 peaks around 3 and 7 days. We hypothesize that the first may represent patients who did not tolerate the initial medication, while the second peak around 7 days may represent patients requesting a second prescription because of lack of efficacy with the first.

Although we used a regional sample, our findings for the years 2000 to 2006 are very similar to those of Grijalva and colleagues, who used the National Ambulatory Medical Care Survey.3 Their definition of ARTI was similar to ours, although they reported prescriptions written and we reported prescriptions actually filled. From 2000 to 2006, they reported that prescriptions written for antibiotics for an ARTI declined from 63% in 1995/1996 to 54% in 2005/2006, while we found that antibiotic prescriptions filled for an ARTI declined from 54% in 2000 to 40.5% in 2006. This is shown in Figure 2, with use of antibiotics declining until 2007. However, we found that use began to rise again in 2007. This trend was driven largely by an increase in the use of macrolides and coincides with the year that azithromycin became available as a generic medication. Specifically, the use of macrolides declined from 26.5% of prescriptions for presumed viral ARTI in 2000 to only 19.7% in 2007, then jumped to 25.3% in 2008 and is now at 30.2%. This is despite a lack of evidence that macrolides have a clinically meaningful benefit for patients with acute bronchitis or any of the other presumed viral ARTIs studied.6,12,13

Strengths and Limitations

This study has several strengths compared with previous studies.2,3,5 First, it uses a contemporary sample of patients in private practice settings and reports prescriptions filled, rather than prescriptions written, by the physician. Thus, it provides a more accurate assessment of the impact of inappropriate antibiotic prescribing in the community. It is also the first study to determine the number of patients with second or third antibiotic prescriptions shortly following the initial encounter, and the first to describe increasing use of antibiotics since azithromycin became available as a generic drug.

Limitations include the small number of patients 65 years or older and the fact that all of the patients had health insurance, largely through an employer. This may make them less price-sensitive than uninsured patients, but should not differ from patients with Medicaid or Medicare Part D, which also provide prescription coverage. Race or socioeconomic status were not directly captured, but the plan’s members came from a community that is very diverse based on census data and has a high poverty rate of 33.5%.

The relatively high number of patients receiving a second or third prescription is a novel finding and may be driven by a mismatch between patient expectations and reality. In a previous study, we surveyed residents of Georgia to determine how long they felt that an episode of acute bronchitis typically lasts. The mean was approximately 8 days—much lower than the mean of 17.8 days that we found in a systematic review of placebo groups in randomized controlled trials.14


Our study has several important implications for medical and public health practice. First, the rise in antibiotic use for largely viral ARTIs from 2007 to 2012 is of great concern. Public health messaging to the community, continuing education for physicians, and patient education by physicians should continue to emphasize that antibiotics are not effective for acute bronchitis and other presumed viral ARTIs. Second, a substantial proportion of patients receive a second prescription for an antibiotic or anti-influenza medication after filling the first prescription, presumably because the first one did not “work.” By setting appropriate expectations for the duration of an illness, we may be able to reduce patient demands for a first (or second) antibiotic. Previous research has found that calling the episode a “chest cold” rather than “acute bronchitis” reduces expectations for an antibiotic.15 Thus, the message to patients should be, “You have a chest cold that is caused by a virus and will probably last about 2 weeks. Antibiotics are unlikely to help and may hurt you.” Third, although improvement was seen in antibiotic prescribing rates until 2007, once azithromycin became available as a generic medication (at much lower cost), a significant barrier to its use was removed and prescribing rates increased dramatically. Thus, physicians and patients appear to be at least somewhat sensitive to price, and reducing price may have unintended adverse consequences in terms of inappropriate antibiotic prescribing.

In terms of future research, there have been relatively few adequately powered studies in US populations comparing treatments for ARTIs such as acute bronchitis. Pelargonium sidoides16-18 and anti-inflammatory drugs8,19 have shown promise in previous studies. However, studies of pelargonium have largely been manufacturer-sponsored, with concern about publication bias.20 Studies of anti-inflammatories have had mixed results and have generally been underpowered or used artificially induced respiratory infections.8,19 A large, pragmatically designed randomized controlled trial comparing these interventions, including azithromycin because it is so widely prescribed, is badly needed in the United States. Finally, development and validation of clinical decision rules and point-of-care tests such as c-reactive protein could help physicians to better identify patients who are very likely to have a viral cause of their infection.


The authors wish to thank Geoffrey Cole, MD, and Fred Young, MD, for facilitating access to the data set.

Author Affiliations: Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia (MHE, TR), Athens.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MHE); acquisition of data (MHE); analysis and interpretation of data (MHE, TR); drafting of the manuscript (MHE); critical revision of the manuscript for important intellectual content (MHE, TR); statistical analysis (MHE, TR); and supervision (MHE).

Address correspondence to: Mark H. Ebell, MD, MS, 233 Miller Hall, UGA Health Sciences Campus, Athens, GA 30602. E-mail:
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19. Sperber SJ, Hendley JO, Hayden FG, Riker DK, Sorrentino JV, Gwaltney JM Jr. Effects of naproxen on experimental rhinovirus colds: a randomized, double-blind, controlled trial. Ann Intern Med. 1992;117(1):37-41.

20. Timmer A, Günther J, Rücker G, Motschall E, Antes G, Kern WV. Pelargonium sidoides extract for acute respiratory tract infections. Cochrane Database Syst Rev. 2008;(3):CD006323. 
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