What are examples of inappropriate antibiotic use?

Examples of Inappropriate Antibiotic Use

Inappropriate antibiotic use falls into three major categories: overuse for conditions that do not require antibiotics (especially viral infections), misuse through incorrect selection or dosing, and underuse when antibiotics are genuinely indicated. 1

Overuse: Prescribing Antibiotics When Not Needed

Viral Upper Respiratory Tract Infections

• Prescribing antibiotics for the common cold, acute bronchitis, or viral pharyngitis represents the most common form of inappropriate use, accounting for 41% of all antibiotic prescriptions in the United States despite these conditions being predominantly viral. 2
• Acute uncomplicated bronchitis does not benefit from antibiotic therapy because it resolves spontaneously within 7-10 days regardless of treatment. 1
• Acute laryngitis with dysphonia should not be treated with antibiotics as the underlying cause is viral in over 90% of cases. 1
• Rhinosinusitis in its acute phase (less than 10 days of symptoms) rarely requires antibiotics, yet 67% of non-prescription antibiotics dispensed in European pharmacies are for upper respiratory tract infections. 2, 1

Other Common Scenarios of Overuse

• Treating asymptomatic bacteriuria in non-pregnant women is inappropriate because this represents colonization rather than infection and does not require treatment. 1
• At least 30-50% of all outpatient antibiotic prescriptions in the United States are unnecessary, representing a massive burden of inappropriate exposure. 2, 1
• Globally, 62% of antibiotics are obtained without prescription, with 78% supplied after direct patient request, particularly in low- and middle-income countries where regulatory enforcement is weak. 2, 1

Misuse: Wrong Drug, Wrong Dose, Wrong Duration

Inappropriate Antibiotic Selection

• Using broad-spectrum antibiotics (fluoroquinolones, extended-spectrum cephalosporins, macrolides) when narrow-spectrum agents would suffice accelerates antimicrobial resistance and has been linked to higher rates of multidrug-resistant pneumococcal disease. 2, 1
• Prescribing higher-generation antibiotics for conditions treatable with first-line agents is a common pattern observed across multiple countries. 3
• In Senegal, cefixime (a third-generation cephalosporin) was the most frequently prescribed antibiotic for pediatric outpatients, often for conditions not requiring such broad coverage. 4

Incorrect Dosing and Duration

• Incomplete antibiotic courses or subtherapeutic dosing creates selective pressure for resistance by allowing bacteria to survive at drug levels insufficient to kill them. 1
• Only 31.5% of prescribed antibiotics and 24.6% of non-prescription antibiotics dispensed in Jordan had appropriate dosage and duration, demonstrating widespread dosing errors. 3
• At hospital discharge, 70% of prescribed antibiotics were inappropriate in drug choice, dose, or duration, highlighting a critical gap at care transitions. 5

Self-Medication and Non-Prescription Use

• Using leftover antibiotics from previous prescriptions or sharing antibiotics with family members leads to incomplete courses and inappropriate selection. 2
• Self-medication with antibiotics is particularly common in low- and middle-income countries, where patients bypass healthcare providers entirely. 2

Underuse: Failing to Prescribe When Indicated

• Withholding prophylactic antibiotics before high-risk procedures (such as pyloric stent placement) represents a missed indication and increases postoperative infection risk. 1
• Failing to treat confirmed bacterial infections in immunocompromised patients is inappropriate because timely therapy is essential to prevent severe outcomes and mortality. 1

Common Pitfalls and Clinical Contexts

Patient and Provider Factors

• Children older than 3 months are at significantly higher risk of receiving inappropriate antibiotics (adjusted odds ratio 1.91-5.25 across countries) compared to younger infants. 4
• Rural settings have substantially higher rates of inappropriate prescribing (adjusted odds ratio 1.83-4.40) compared to urban areas, likely reflecting limited access to diagnostic resources. 4
• Higher perceived illness severity increases inappropriate prescribing even when antibiotics are not indicated (adjusted odds ratio 2.00 for moderately severe, 3.10 for most severe presentations). 4

Consequences of Inappropriate Use

• One in five patients receiving antibiotics experiences an adverse event requiring medical attention, ranging from mild diarrhea to life-threatening anaphylaxis or Stevens-Johnson syndrome. 2, 1, 6
• Clostridioides difficile infection causes approximately 29,300 deaths annually in the United States, predominantly as a consequence of antibiotic exposure. 2, 1
• Antimicrobial resistance was responsible for an estimated 1.3 million deaths worldwide in 2019, driven primarily by inappropriate antibiotic use. 1, 6
• Antibiotic-resistant infections cost the U.S. economy at least $30 billion annually, with direct prescription costs of unnecessary antibiotics exceeding $3 billion. 2

Specific High-Risk Prescribing Patterns

• Amoxicillin and amoxicillin-clavulanate are the most commonly dispensed antibiotics for viral upper respiratory infections, followed by azithromycin, despite lack of indication. 2, 1
• Prescriptions for broad-spectrum antibiotics (fluoroquinolones and macrolides) have increased 4-fold over the past decade even as overall antibiotic prescribing has decreased by 18%. 2
• In pediatric outpatients across Madagascar, Senegal, and Cambodia, 76.5% of antibiotic prescriptions were for conditions determined not to require antibiotics, with rhinopharyngitis and uncomplicated gastroenteritis being the most common inappropriate indications. 4