A Better Prescription Is Needed

THE PROBLEM OF ANTIMICROBIAL RESISTANCE HAS BEEN evident almost from the time antimicrobial drugs entered the pharmacopoeia. However, the clinical impact of resistance has been difficult to measure for a variety of reasons, including separating out the effect of underlying illness and the availability of at least 1 effective drug for most infections. Antimicrobial resistance also has economic consequences, but even those have been difficult to quantify. Nevertheless, the decrease in new drug development and increasing resistance to multiple drug classes among various infections require effective interventions now to mitigate the inevitable increase in morbidity and mortality. Recognizing the potential for serious consequences of resistance to antimicrobial drugs, medical societies, health plans, and insurers, as well as local, state, and federal government agencies, have conducted education and media campaigns to improve use of antimicrobials, with the intent of reducing the evolutionary pressure toward proliferation of resistant pathogens and transfer of resistance mechanisms. Many of these activities have focused on reducing the prescribing of outpatient antimicrobial drugs for viral infections in pediatrics, an area of antimicrobial use that has had the potential for dramatic decreases, given the evidence for vast overuse and the viral etiology of the common diagnoses for which prescriptions are being written. Prescribing of antimicrobial drugs has declined in the face of these educational efforts, but there is still room for improvement. In this issue of JAMA, 2 articles address the prescribing of antimicrobial drugs. Linder et al present the results of an analysis of data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) on prescription of antimicrobials for the diagnosis of sore throat and the impact on prescribing of testing for group A -hemolytic streptococci (GABHS). Samore et al describe a randomized trial to test the effectiveness of a clinical decision support system (CDSS) to reduce inappropriate prescribing of antimicrobials for acute respiratory infections in rural settings, measuring prescriptions through retail pharmacy data and chart review. Linder et al measured rates of prescribing antimicrobial drugs and the effect on prescribing of the use of a GABHS test among children presenting with a sore throat. The findings are at once encouraging and discouraging. Because there has been demonstrated overuse of antimicrobials in this situation, the decline in prescribing observed, from 66% of visits in 1995 to 54% of visits in 2003, is welcome news. Unfortunately, this decline was limited to antimicrobials that are recommended for GABHS (penicillin, amoxicillin, and erythromycin; first-generation cephalosporins as acceptable alternatives). The use of nonrecommended antimicrobials (eg, amoxicillin/clavulanate, clarithromycin, and azithromycin) remained stable over the 9-year study period but at an unacceptably high level of 27% among those who received antimicrobials. A beneficial effect may be inferred from the data regarding GABHS testing. When a GABHS test was performed, antimicrobials were prescribed in 57% of visits with the diagnosis of pharyngitis, tonsillitis, and streptococcal sore throat, compared with 73% of visits when a test was not documented (either because the test was not performed or the survey form was left incomplete). Since the results of GABHS testing are not available in the data sets analyzed, further interpretation is speculative. Although not highlighted in the article, antimicrobials were prescribed in 94% of visits for the diagnosis of acute bronchitis, a condition caused by viral infection in this age group. In the second report on the prescribing of antimicrobial drugs in this issue, Samore et al designed a cluster randomized trial involving communities divided into 2 groups. One group received a community intervention that included meetings, news releases, distribution of educational materials, a mailing to parents of young children, and news articles about antimicrobial use. The other group received the same community-level intervention as well as a clinical decision support tool given to primary care clinicians, either on paper or