Steinman Michael A, Landefeld C Seth, Gonzales Ralph
Division of Geriatrics, San Francisco VA Medical Center, 4150 Clement St, Box 181-G, San Francisco, CA 94121, USA.
JAMA. 2003 Feb 12;289(6):719-25. doi: 10.1001/jama.289.6.719.
Broad-spectrum antibiotics are commonly prescribed, but little is known about the physicians who prescribe and the patients who take these agents.
To identify factors associated with prescribing of broad-spectrum antibiotics by physicians caring for patients with nonpneumonic acute respiratory tract infections (ARTIs).
DESIGN, SETTING, AND PATIENTS: Cross-sectional study using data from the National Ambulatory Medical Care Survey between 1997 and 1999. Information was collected on a national sample of 1981 adults seen by physicians for the common cold and nonspecific upper respiratory tract infections (URTIs) (24%), acute sinusitis (24%), acute bronchitis (23%), otitis media (5%), pharyngitis, laryngitis, and tracheitis (11%), or more than 1 of the above diagnoses (13%).
Prescription of broad-spectrum antibiotics, defined for this study as quinolones, amoxicillin/clavulanate, second- and third-generation cephalosporins, and azithromycin and clarithromycin.
Antibiotics were prescribed to 63% of patients with an ARTI, ranging from 46% of patients with the common cold or nonspecific URTIs to 69% of patients with acute sinusitis. Broad-spectrum agents were chosen in 54% of patients prescribed an antibiotic, including 51% of patients with the common cold and nonspecific URTIs, 53% with acute sinusitis, 62% with acute bronchitis, and 65% with otitis media. Multivariable analysis identified several clinical and nonclinical factors associated with choice of a broad-spectrum agent. After adjusting for diagnosis and chronic comorbid illnesses, the strongest independent predictors of broad-spectrum antibiotic prescribing were physician specialty (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.5 for internal medicine physicians compared with general and family physicians) and geographic region (OR, 2.6; 95% CI, 1.4-4.8 for Northeast and OR, 2.4; 95% CI, 1.4-4.2 for South [both compared with West]). Other independent predictors of choosing a broad-spectrum agent included black race, lack of health insurance, and health maintenance organization membership, each of which was associated with lower rates of broad-spectrum prescribing. Patient age, sex, and urban vs rural location were not significantly associated with prescribing choice.
Broad-spectrum antibiotics are commonly prescribed for the treatment of ARTIs, especially by internists and physicians in the Northeast and South. These high rates of prescribing, wide variations in practice patterns, and the strong association of nonclinical factors with antibiotic choice suggest opportunities to improve prescribing patterns.
广谱抗生素的处方很常见，但对于开具这些药物的医生以及服用这些药物的患者了解甚少。
确定在诊治非肺炎性急性呼吸道感染（ARTIs）患者时医生开具广谱抗生素的相关因素。
设计、地点和患者：采用1997年至1999年美国国家门诊医疗调查数据进行的横断面研究。收集了全国范围内1981名成年人的信息，这些成年人因普通感冒和非特异性上呼吸道感染（URTIs）（24%）、急性鼻窦炎（24%）、急性支气管炎（23%）、中耳炎（5%）、咽炎、喉炎和气管炎（11%）或上述多种诊断（13%）而就诊于医生。
本研究将广谱抗生素定义为喹诺酮类、阿莫西林/克拉维酸、第二代和第三代头孢菌素以及阿奇霉素和克拉霉素的处方情况。
63%的ARTIs患者接受了抗生素治疗，范围从普通感冒或非特异性URTIs患者中的46%到急性鼻窦炎患者中的69%。在接受抗生素治疗的患者中，54%选择了广谱药物，包括普通感冒和非特异性URTIs患者中的51%、急性鼻窦炎患者中的53%、急性支气管炎患者中的62%以及中耳炎患者中的65%。多变量分析确定了与选择广谱药物相关的几个临床和非临床因素。在调整诊断和慢性合并症后，开具广谱抗生素的最强独立预测因素是医生专业（与普通内科和家庭医生相比，内科医生的优势比[OR]为2.4；95%置信区间[CI]为1.6 - 3.5）和地理区域（与西部相比，东北部的OR为2.6；95%CI为1.4 - 4.8，南部的OR为2.4；95%CI为1.4 - 4.2）。选择广谱药物的其他独立预测因素包括黑人种族、缺乏医疗保险和健康维护组织成员身份，每一项都与较低的广谱药物处方率相关。患者年龄、性别以及城市与农村地区与处方选择无显著关联。
广谱抗生素常用于治疗ARTIs，尤其是内科医生以及东北部和南部的医生。这些高处方率、实践模式的广泛差异以及非临床因素与抗生素选择的强烈关联表明有机会改善处方模式。
