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Antibiotic use in the United States: where do we stand?

Posted on by CDC's Safe Healthcare Blog
Ramanan Laxminarayan, PhD.
Ramanan Laxminarayan, PhD

Author – Ramanan Laxminarayan, Ph.D.,
director of Extending the Cure (ETC)

Patients in the United States are among the most intensive users of antibiotics in the world, but you may be surprised to learn that overall per capita outpatient antibiotic prescribing in the United States has decreased in recent years. In fact, between 1999 and 2007, the number of dispensed antibiotic prescriptions per thousand inhabitants dropped from 975 to 858 – a 12% decline.

Extending the Cure’s ResistanceMap shows new visualizations documenting this downward trend in prescribing. But enthusiasm should be tempered by some troubling patterns of antibiotic use.

For example, while penicillins still account for one out of every three antibiotic prescriptions filled, the use of more powerful, broad-spectrum antibiotics is increasingly rapidly. Dispensing of one powerful class of antibiotics, fluoroquinolones, increased by 49% over the time period.

To a certain extent, the increase is warranted by the emergence of drug resistance to other antibiotic therapies. However, doctors often indiscriminately turn to fluoroquinolone antibiotics because they are broad-spectrum and therefore effective against a range of bacterial infections.

But it is precisely because quinolones are powerful and widely effective that we should be using them prudently. Their effectiveness is much like a shared resource that we all benefit from. Already, resistance to fluoroquinolones among E. coli samples in the United States has risen from just 3.3% in 1999 to 21.74% in 2010.

The situation with fluoroquinolones demonstrates the perils of antibiotic resistance. As dangerous resistant organisms like carbapenem-resistant Klebsiella pneumoniae (CRKP) and multidrug-resistant Acinetobacter baumannii continue to spread globally, we need to ensure that we don’t lose our effective antibiotics to resistance.

The first step is to stop using antibiotics when they are not indicated, such as for treatment of viral illnesses including cold and flu. But ResistanceMap also shows how stewardship messages will need to be tailored to different classes of antibiotics, as well as to geographical regions. The maps highlight vast regional variations in use – in some areas of the Southeast, antibiotic dispensing levels are twice those in the Pacific states. Experience from Europe has shown how targeting these high-consumption regions with information campaigns can aid conservation efforts.

Research remains to be done to determine how and why variations in prescribing patterns emerge. “Get Smart Week” is an important reminder to think twice before using antibiotics and preserve these life-saving therapies for future generations.

Posted on by CDC's Safe Healthcare Blog

6 comments on “Antibiotic use in the United States: where do we stand?”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy ».

    In response to your comment Sharon– that drug manufacturers should formulate new antibiotics that are incapable of inducing antibiotic resistance– I have to disagree with this. The concept of antibiotic resistance does not have to do with the effectiveness of the antibiotics themselves, rather, antibiotic resistance develops due to the overuse of the antibiotics, regardless of their effectiveness. By taking antibiotics, the more resistant bacteria remain after the treatment. This allows them to grow in the host and when future antibiotics are used, the bacteria present are already resistant. Again, this leads to the prescription of stronger antibiotics which can further the process and produce multi-drug resistant bacteria. Therefore, as Dr. Laxminarayan addresses, it is important that the distribution of these drugs are regulated! The way of prevention of resistance is to return to the root of the problem. The antibiotics themselves are doing their job; it is the nature of the bacteria in response to these antibiotics that allow them to evolve. In regulating the use of antibiotics, the goal is to reduce the overuse of antibiotics when they are unnecessary so as to prevent these resistant bacteria from dominating.

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    Obviously, antibiotic resistance is an ever-growing problem. However, the difficulty in obtaining antibiotics under necessary circumstances; e.g., bacterial sinus infections, bacterial pneumonia; and for an appropriate length of duration, so as to completely resolve infections, also must be taken into consideration in the clinical desicision-making process. Otherwise, infectious bacterial infections may be only partially resolved, thereby potentially strengthening the organisms of concern; and thusly defeating efforts to curtail antibiotic resistance.

    In addition, requiring patients to wait 10 or more days, before accepting that an infection is indeed bacterial, frequently results in unnecesary lost work, sick and vacation days.

    Finally, through recent studies, it is becoming more and more clear that much of the antibiotic resistance that is occurring is a result of the meat and poultry industry practices of using equivalent antibiotics to those used for prophylactic infection prevention in livestock are the very same as those used to treat human infections.

    Rather than taking such a heavy-handed approach by refusing to prescribe antibiotics to when necessary, I strongly recommend that government agencies and the AMA lobby to immediately stop the use of the same antibiotics for preventive purposes in livestock as those used for infection-treatment purposes in humans. In adddition, government agencies and physicians should work with drug manufacturers to formulate new antibiotics which are incapable of inducing antibiotic resistance.

    The overuse of powerful broad-spectrum antibiotics is often a fallback for diagnostic uncertainty. As Dr. Laxminarayan points out, a physician will often prescribe the most broad-spectrum antibiotic available when it is unclear what type of bacterial infection the patient is suffering from. Knowing that the drug will be effective against a range of different pathogens, the hope is that the one infecting the patient will fall within that range.

    This misguided “better safe than sorry” approach to antibiotic prescription highlights the need for development and utilization of better diagnostic methods and technologies that are ASSURED – Affordable, Sensitive, Specific, User-friendly, Rapid/Robust, Equipment-free, and Deliverable (from “Divining Without Seeds” by Dr. Iruka Okeke). As these technologies advance and health systems provide incentives to use them, physicians can then utilize powerful narrow-spectrum antibiotics to match the actual need rather than squandering critical (and rapidly diminishing) medicinal resources such as ampicillin and the fluoroquinolones.

    More insights into recent diagnostic innovations from experts in the field can be found in the APUA Clinical Newsletter Vol.29 No.2 (Diagnostic Innovation to Contain Resistance) at

    I have warned people about this. Very thing. We seem to give antibiotics for everything from a cold to a non strep sore throat! I think it will take a lot or re- educating the public and yes even some of us who give in to the constant patient who just knows they NEED an antibiotic!

    It is not a good use of antibiotics to use them to treat the flu or common cold. What is needed to reduce antibiotic overuse is a new flu vaccine that would be multi-year and cover all strains. This is a major step to limiting antibiotics use and also to unnecessary hospitalizations and doctors’ office visits.

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