Antibiotic Use for Emergency Department Patients With Upper Respiratory Infections: Prescribing Practices, Patient Expectations, and Patient Satisfaction

doi:10.1016/j.annemergmed.2007.03.026

Annals of Emergency Medicine

Volume 50, Issue 3, September 2007, Pages 213-220

https://doi.org/10.1016/j.annemergmed.2007.03.026 Get rights and content

Study objective

Physicians often prescribe antibiotics to patients even when there is no clear indication for their use. Previous studies examining antibiotic use in acute bronchitis and upper respiratory infections have been conducted in primary care settings. We evaluate the factors that physicians in the emergency department (ED) consider when prescribing antibiotics (eg, patient expectations) and the factors associated with patient satisfaction.

Methods

Ten academic EDs enrolled adults and children presenting with symptoms consistent with upper respiratory infection. Enrolled patients were interviewed before their physician encounter and were reinterviewed before discharge and 2 weeks later. Physicians were interviewed about factors that influenced their management decisions, including their perceptions of patients’ expectations. Patients with a single diagnosis of uncomplicated acute bronchitis or upper respiratory infection were included for analysis.

Results

Of 272 patients enrolled, 68% of bronchitis patients and 9% of upper respiratory infection patients received antibiotics. Physicians were more likely to prescribe antibiotics when they believed that patients expected them (odds ratio [OR] 5.3; 95% confidence interval [CI] 2.9 to 9.6), although they were able to correctly identify only 27% of the patients who expected antibiotics. Satisfaction with the ED visit was reported by 87% of patients who received antibiotics and 89% of those not receiving antibiotics. Satisfaction with the visit was reported by 92% of patients who believed they had a better understanding of their illness but only by 72% of those who thought they had no better understanding (OR 4.4; 95% CI 2.0 to 8.4).

Conclusion

Physicians in our academic EDs prescribed antibiotics to 68% of acute bronchitis patients and to fewer than 10% of upper respiratory infection patients. Physicians were more likely to prescribe antibiotics to patients who they believed expected them, although they correctly identified only about 1 in 4 of those patients. Patient satisfaction was not related to receipt of antibiotics but was related to the belief they had a better understanding of their illness.

Introduction

Increases in antimicrobial resistance, related to antibiotic use and overuse, have been a growing concern.1, 2, 3, 4, 5, 6 Because upper respiratory infections and acute bronchitis are among the most frequent source of antibiotic prescriptions and because antibiotics provide little if any benefit for these conditions, the Centers for Disease Control and Prevention (CDC) and others have published guidelines for appropriate antibiotic use.5, 7, 8, 9, 10, 11 The guidelines have focused on medical appropriateness, but other factors may also affect the decision to prescribe antibiotics.

Physicians may prescribe antibiotics because the patient insists on them or because they believe the patient expects them.12, 13 Patients with upper respiratory infection or bronchitis may insist on antibiotics because they believe that they are necessary for treatment, a perception that could be the result of previous experiences with similar illnesses or the misconception that antibiotics have a beneficial effect in viral illnesses.14, 15, 16 Physicians may believe that patient satisfaction depends on the receipt of an antibiotic prescription, but correction of patient misconceptions may be of value as well.

Previously published studies on antibiotic use in respiratory infections have been predominantly based in primary care settings,13, 14, 16, 17, 18, 19 and so their findings may not necessarily apply to the emergency department (ED). Patients in the ED may be more ill, be less likely to have insurance, and lack access to good medical follow-up.

This study was designed to examine the antibiotic prescribing practices of physicians for ED patients and the effect of those practices on patient satisfaction. Surveys of patients and treating physicians were used to assess some of the clinical and nonclinical factors associated with the decision to prescribe antibiotics, such as patients’ expectations. Other factors contributing to patient satisfaction such as patient education and waiting times were also examined.

Section snippets

Study Design

This was a multicenter, prospective, observational cohort study. Study sites were 10 members of a collaboration of geographically diverse EDs whose participation in the study was supported by the CDC. A detailed description of the structure and administration of the study group has been published previously.²⁰ Patients were interviewed twice during the ED visit and received a telephone follow-up interview 2 weeks later. Treating physicians (residents or attending physicians) were interviewed as

Results

During the study periods, 875 patients were approached for participation in the study. Twenty-one patients were excluded because of incomplete previsit interviews, 107 because of incomplete postvisit interviews, and 17 because of incomplete physician interviews. Patients with asthma (111), pneumonia (85), sinusitis (78), otitis media (48), chronic obstructive pulmonary disease (19), or multiple diagnoses were excluded from further analyses. Patients with other diagnoses necessitating antibiotic

Limitations

We performed simple univariate analyses without performing multivariate adjustments. Because we did not adjust for confounding or interaction, we may have overestimated or underestimated some associations. Some sites used convenience samples, which may have subjected the results to some selection bias. Our study was based in urban, academic EDs so that prescribing practices in other ED settings may differ. We did perform a pilot study of the survey instrument but did not perform any formal

Discussion

Inappropriate antibiotic use by physicians is ubiquitous and has far-reaching consequences. The emergence of drug resistance has been closely linked to antibiotic use.1, 3, 4, 6, 21, 22 The significant incidence of adverse effects in patients given antibiotics inappropriately is also an important consideration.19, 23 Financial considerations are a further concern as more expensive, broad-spectrum agents are used and because overuse may also result in future unnecessary medical visits.14, 24, 25

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Cited by (135)

Optimizing Antimicrobial Stewardship in the Emergency Department
2024, Emergency Medicine Clinics of North America
Antibiotic expectation, behaviour, and receipt among patients presenting to emergency departments with uncomplicated upper respiratory tract infection during the COVID-19 pandemic
2023, Journal of Global Antimicrobial Resistance
Pre-COVID-19 pandemic, patients who attended the emergency department (ED) for upper respiratory tract infection (URTI) were more likely to receive antibiotics if they expected them. These expectations could have changed with the change in health-seeking behaviour during the pandemic. We assessed the factors associated with antibiotics expectation and receipt for uncomplicated URTI patients in four Singapore EDs during the COVID-19 pandemic.
We conducted a cross-sectional study on adult patients with URTI from March 2021 to March 2022 in four Singapore EDs and assessed the determinants of antibiotics expectation and receipt using multivariable logistic regression models. We also assessed the reasons patients expect antibiotics during their ED visit.
Among 681 patients, 31.0% expected antibiotics while 8.7% received antibiotics during their ED visit. Factors (adjusted odds ratio [95% confidence interval]) that significantly influenced expectation for antibiotics include: 1) prior consultation for current illness with (6.56 [3.30–13.11]) or without (1.50 [1.01–2.23]) antibiotics prescribed; 2) anticipation for COVID-19 test (1.56 [1.01–2.41]); and 3) poor (2.16 [1.26–3.68]) to moderate (2.26 [1.33–3.84]) knowledge on antibiotics use and resistance. Patients expecting antibiotics were 10.6 times (10.64 [5.34–21.17]) more likely to receive antibiotics. Those with tertiary education were twice (2.20 [1.09–4.43]) as likely to receive antibiotics.
In conclusion, patients with URTI who expected antibiotics to be prescribed remained more likely to receive it during the COVID-19 pandemic. This highlights the need for more public education on the non-necessity for antibiotics for URTI and COVID-19 to address the problem of antibiotic resistance.
Providers’ shared decision-making as a predictor of healthcare outcomes for college-aged adults managing upper respiratory tract infections
2023, Patient Education and Counseling
Strategies that assist patients with upper respiratory tract infections (URTIs) to endorse non-antibiotic treatments are vital to curbing antibiotic resistance. This study examines the potential of shared decision-making (SDM) for improving stewardship-relevant outcomes and investigates patient affect as a mechanism that explains the beneficial impact of perceived SDM.
Patients (N = 433) seeking care for URTIs at a university student health center and not prescribed antibiotics completed a pre-visit questionnaire and two surveys one day and 14 days post-visit. The day-one survey assessed perceived SDM, affect, and immediate stewardship-relevant outcomes, and the day-14 survey assessed long-term stewardship-relevant outcomes.
Perceived SDM was negatively associated with negative affect and positively associated with positive affect, favorable perceptions of non-antibiotic treatments and providers, and self-efficacy to manage symptoms and obtain follow-up care. Patient affect and day-one outcomes were mediators between perceived SDM and retrospective self-efficacy two weeks post-visit.
The study illustrated the beneficial influence of patient perceived SDM on antibiotic stewardship in both short and long terms and elucidated the mechanisms through which the influence occurs.
SDM can be an effective strategy for primary care providers to improve patients’ outcomes with URTI visits without prescribing unwarranted antibiotics.
Antibiotic assemblages and their implications for the prevention of antimicrobial resistance
2022, Social Science and Medicine
Individual antibiotic use for common infections is a focus for public health efforts seeking to prevent antimicrobial resistance (AMR). These approaches employ a binary opposition of responsible and irresponsible antibiotic use with a focus on the knowledge, behaviours and intentions of the individual. To overcome these unhelpful tendencies and reveal new entry points for AMR prevention, we adopted assemblage theory to analyse personal experience narratives on individual antibiotic use in community settings. Antibiotic use was irregular, situationally diverse and shaped by factors not always under personal control. Individuals were focussed on preventing, moderating and treating infections that threatened their health. Our analysis shows that antibiotic assemblages are both cause and effect of individual efforts to manage infections. We suggest that AMR prevention needs to look beyond the antibiotic as object and the (ir)responsible use binary to engage with the antibiotic effects individuals seek in order to manage infectious diseases. This antibiotic assemblage orientation is likely to be more meaningful for individuals seeking out methods for promoting their health in the face of common infections.
Treatment of Acute Bronchitis and its Impact on Return Emergency Department Visits
2022, Journal of Emergency Medicine
Citation Excerpt :
However, Pulia et al. studied patients in the ED who received nonindicated antibiotic prescriptions for respiratory tract conditions, including bronchitis, and found no difference in Press Ganey patient satisfaction scores compared with those who do not receive antibiotics (26). Instead, research suggests that patient satisfaction is connected to believing they have a better understanding of their infection, and providing education about acute bronchitis and setting expectations decreased the number of patients who believed that antibiotics are effective against viruses by 43% (20). Education could help avoid prescribing antibiotics that most likely will not benefit and could cause harm to the patient.
Antibiotics are not recommended in healthy, uncomplicated adults for the treatment of acute bronchitis, yet are still often prescribed. No randomized studies have examined whether prescribing antibiotics in the emergency department (ED) impacts hospital return rates.
Our aim was to compare hospital return rates between those who were prescribed an antibiotic vs. those who were not prescribed an antibiotic for the treatment of acute bronchitis.
A retrospective cohort study was completed evaluating patients aged 18–64 years who presented to a community teaching hospital ED with acute bronchitis between January 2017 and December 2019. The primary outcomes were 30-day ED return and hospital admissions from initial ED visit. The rates of ED return or readmitted were compared for patients prescribed an antibiotic for treatment of acute bronchitis vs. those patients who were not prescribed an antibiotic.
Of the 752 patients included, 311 (41%) were prescribed antibiotics. Baseline demographics were similar between both groups. Of those prescribed an antibiotic, 26 of 311 (8.4%) returned to the hospital within 30 days compared with 33 of 441 patients (7.5%) who were not prescribed an antibiotic (odds ratio 1.13; 95% confidence interval 0.66–1.92).
There was no association found between antibiotic therapy for treatment of acute bronchitis and return to the hospital.
Antibiotic expectations of patients attending an emergency department with upper respiratory tract infections: clinical and behavioural determinants of antibiotic use
2022, International Journal of Antimicrobial Agents
Antibiotics are often prescribed for upper respiratory tract infections (URTIs) in emergency departments (EDs) due to patient requests and expectations perceived by physicians. This study aimed to identify clinical and behavioural factors associated with patient antibiotic expectations.
A cross-sectional study was undertaken of 717 patients attending the ED at Tan Tock Seng Hospital for URTIs between June 2016 and November 2018. A questionnaire was administered and electronic medical records were accessed. Principal component analysis was used to derive latent behavioural factors associated with antibiotic use, and these were applied in multi-variable multi-nomial logistic regression analyses. Independent factors associated with patient antibiotic expectations and requests were identified.
Patients were predominantly young [mean age 40.5 (standard deviation 14.7) years], had no comorbidities (66.5%, 477/717), presented within <7 days of symptom onset (62.9%, 451/717), and did not fulfil the US Centers for Disease Control and Prevention's influenza-like illness (ILI) criteria (79.1%, 567/717). Behavioural factors identified were: (1) non-compliance with prescribed antibiotic regimen; (2) self-administration of antibiotics that were not prescribed for the illness episode; and (3) self-discontinuation of antibiotics upon experiencing adverse effects or allergies. After adjusting for age, gender, ethnicity, comorbidities, influenza vaccination history, and illness duration, patients with ILI [adjusted odds ratio (OR) 1.73, 95% confidence interval (CI) 1.15–2.59; P=0.008] or who self-administered antibiotics that were not prescribed for an illness episode (adjusted OR 1.28, 95% CI 1.04–1.57; P=0.021) were more likely to expect antibiotics at the ED visit.
Patients with ILI or who previously self-administered antibiotics were more likely to expect antibiotics at ED visits. Public education on appropriate antibiotic use is imperative to ensure optimal antibiotic use.

View all citing articles on Scopus

Supervising editors: Kathy J. Rinnert, MD, MPH; E. John Gallagher, MD

Author contributions: SO, GJM, MJK, and DAT conceived and designed the study. DAT obtained funding. SO and JN handled data management and statistical analysis. DAT served as group study chair. SO and DJK drafted the article, which was reviewed by all of the authors. SO takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that may create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. The Centers for Disease Control and Prevention Cooperative agreement U50/CCU912342 funded the study.

Available online April 30, 2007.

^⁎: All members are listed in the Appendix.

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Infectious disease/original researchAntibiotic Use for Emergency Department Patients With Upper Respiratory Infections: Prescribing Practices, Patient Expectations, and Patient Satisfaction

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Study Design

Results

Limitations

Discussion

Ann Emerg Med

Lancet

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Resp Med

The relationship between the volume of antimicrobial consumption in human communities and the frequency of resistance

Proc Natl Acad Sci U S A

Pneumococcal resistance to antibiotics

Clin Microbiol Rev

The crisis in antibiotic resistance

Science

Resistance to antimicrobial drugs—a worldwide calamity

Ann Intern Med

Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections

Pediatrics

Cough illness/bronchitis-Principles of judicious use of antimicrobial agents

Pediatrics

The common cold to principles of judicious use of antimicrobial agents

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Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis

JAMA

The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior

Pediatrics

Misconceptions about colds and predictors of health service utilization

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Patient beliefs about the characteristics, causes, and care of the common cold: an update

J Fam Pract

Antibiotics and respiratory infections: do antibiotic prescriptions improve outcomes?

J Okla State Med Assoc

Factors associated with antibiotic use for acute bronchitis

J Gen Intern Med

Antibiotics and respiratory infections: are patients more satisfied when expectations are met?

J Fam Pract

Antibiotics for acute bronchitis

Cochrane Database Syst Rev

Infectious disease/original research
Antibiotic Use for Emergency Department Patients With Upper Respiratory Infections: Prescribing Practices, Patient Expectations, and Patient Satisfaction