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Importance: Acute respiratory infections (ARIs) are the syndrome for which antibiotics are most commonly prescribed; viruses for which antibiotics are ineffective cause most ARIs., Objectives: To characterize antibiotic prescribing among outpatients with ARI during influenza season and to identify targets for reducing inappropriate antibiotic prescribing for common ARI diagnoses, including among outpatients with laboratory-confirmed influenza., Design, Setting, and Participants: Cohort study enrolling outpatients aged 6 months or older with ARI evaluated at outpatient clinics associated with 5 US Influenza Vaccine Effectiveness Network sites during the 2013-2014 and 2014-2015 influenza seasons. All patients received influenza testing by real-time reverse transcriptase-polymerase chain reaction for research purposes only. Antibiotic prescriptions, medical history, and International Classification of Diseases, Ninth Revision diagnosis codes were collected from medical and pharmacy records, as were group A streptococcal (GAS) testing results in a patient subset., Exposure: Visit for ARI, defined by a new cough of 7 days' duration or less., Main Outcomes and Measures: Antibiotic prescription within 7 days of enrollment. Appropriateness of antibiotic prescribing was based on diagnosis codes, clinical information, and influenza and GAS testing results., Results: Of 14 987 patients with ARI (mean [SD] age, 32 [24] years; 8638 [58%] women; 11 892 [80%] white), 6136 (41%) were prescribed an antibiotic. Among these 6136 patients, 2522 (41%) had diagnoses for which antibiotics are not indicated; 2106 (84%) of these patients were diagnosed as having a viral upper respiratory tract infection or bronchitis (acute or not otherwise specified). Among the 3306 patients (22%) not diagnosed as having pneumonia and who had laboratory-confirmed influenza, 945 (29%) were prescribed an antibiotic, accounting for 17% of all antibiotic prescriptions among patients with nonpneumonia ARI. Among 1248 patients with pharyngitis, 1137 (91%) had GAS testing; 440 of the 1248 patients (35%) were prescribed antibiotics, among whom 168 (38%) had negative results on GAS testing. Of 1200 patients with sinusitis and no other indication for antibiotic treatment who received an antibiotic, 454 (38%) had symptoms for 3 days or less prior to the outpatient visit, suggesting acute viral sinusitis not requiring antibiotics., Conclusions and Relevance: Antibiotic overuse remains widespread in the treatment of outpatient ARIs, including among patients with laboratory-confirmed influenza, although study sites may not be representative of other outpatient settings. Identified targets for improved outpatient antibiotic stewardship include eliminating antibiotic treatment of viral upper respiratory tract infections and bronchitis and improving adherence to prescribing guidelines for pharyngitis and sinusitis. Increased access to sensitive and timely virus diagnostic tests, particularly for influenza, may reduce unnecessary antibiotic use for these syndromes.

To determine whether poultry contact/consumption predicts colonization with antimicrobial-resistant Escherichia coli, 567 newly hospitalized patients and 100 vegetarians were assessed microbiologically and epidemiologically. Multivariable analysis showed that poultry contact/consumption, other dietary habits, and antimicrobial use did not significantly predict resistance. In contrast, foreign travel significantly predicted both trimethoprim-sulfamethoxazole resistance (prevalence ratio, 2.7 [95% confidence interval, 1.3-5.6]) and "any resistance" (total population), whereas intensive-care-unit exposure predicted any resistance (hospital patients). Thus, most of the individual-level exposures-including poultry contact/consumption-that had been expected to be significant risk factors for infection with antimicrobial-resistant E. coli did not prove to be such. Other exposures, including household-, community-, and population-level effects, may be more important.

Background: Parent education is an integral component to promoting judicious antibiotic use. Opportunities to educate parents directly are limited. Child care providers are in a position to relay information to parents., Methods: A group-randomized trial assessed the impact of a child care center staff intervention on parental knowledge and attitudes regarding appropriate antibiotic use. A 9-point knowledge score and 3 attitude items were measured., Results: Surveys were returned by 151 (51%) of 298 intervention center parents and 150 (42%) of 361 control center parents. Intervention center respondents were significantly more likely than control center respondents to be college graduates, non-Hispanic white, and insured. Among college graduates, the median knowledge score was 7.0 at intervention centers and 6.5 at control centers (P<0.01). No significant differences were found in knowledge scores among noncollege educated parents (P=0.11). After adjusting for clustering within child care centers, multivariate analysis demonstrated high knowledge score was associated with white race (P=0.02), being a college graduate (P=0.02), and being in the intervention group (P=0.06)., Conclusion: An appropriate antibiotic use program for child care providers promotes better knowledge among parents of children aged <5 years, particularly among highly educated parents.

In 1999, Wisconsin initiated an educational campaign for primary care clinicians and the public to promote judicious antimicrobial drug use. We evaluated its impact on clinician knowledge and beliefs; Minnesota served as a control state. Results of pre- (1999) and post- (2002) campaign questionnaires indicated that Wisconsin clinicians perceived a significant decline in the proportion of patients requesting antimicrobial drugs (50% in 1999 to 30% in 2002; p<0.001) and in antimicrobial drug requests from parents for children (25% in 1999 to 20% in 2002; p = 0.004). Wisconsin clinicians were less influenced by nonpredictive clinical findings (purulent nasal discharge [p = 0.044], productive cough [p = 0.010]) in terms of antimicrobial drug prescribing. In 2002, clinicians from both states were less likely to recommend antimicrobial agent treatment for the adult case scenarios of viral respiratory illness. For the comparable pediatric case scenarios, only Wisconsin clinicians improved significantly from 1999 to 2002. Although clinicians in both states improved on several survey responses, greater overall improvement occurred in Wisconsin.

The Wisconsin Antibiotic Resistance Network (WARN) was launched in 1999 to educate physicians and the public about judicious antimicrobial drug use. Public education included radio and television advertisements, posters, pamphlets, and presentations at childcare centers. Physician education included mailings, susceptibility reports, practice guidelines, satellite conferences, and presentations. We analyzed antimicrobial prescribing data for primary care physicians in Wisconsin and Minnesota (control state). Antimicrobial prescribing declined 19.8% in Minnesota and 20.4% in Wisconsin from 1998 to 2003. Prescribing by internists declined significantly more in Wisconsin than Minnesota, but the opposite was true for pediatricians. We conclude that the secular trend of declining antimicrobial drug use continued through 2003, but a large-scale educational program did not generate greater reductions in Wisconsin despite improved knowledge. State and local organizations should consider a balanced approach that includes limited statewide educational activities with increasing emphasis on local, provider-level interventions and policy development to promote careful antimicrobial drug use.

Media reports suggested increased public demand for anthrax prophylaxis after the intentional anthrax cases in 2001, but the magnitude of anthrax-related prescribing in unaffected regions was not assessed. We surveyed a random sample of 400 primary care clinicians in Minnesota and Wisconsin to assess requests for and provision of anthrax-related antimicrobial agents. The survey was returned by 239 (60%) of clinicians, including 210 in outpatient practice. Fifty-eight (28%) of those in outpatient practice received requests for anthrax-related antimicrobial agents, and 9 (4%) dispensed them. Outpatient fluoroquinolone use in both states was also analyzed with regression models to compare predicted and actual use in October and November 2001. Fluoroquinolone use as a proportion of total antimicrobial use was not elevated, and anthrax concerns accounted for an estimated 0.3% of all fluoroquinolone prescriptions. Most physicians in Minnesota and Wisconsin managed anthrax-related requests without dispensing antimicrobial agents.

Background: Public attitudes and expectations contribute to inappropriate antibiotic prescribing and antibiotic resistance. This study assessed knowledge, attitudes, and experiences regarding antibiotic use for respiratory infection or illness., Methods: Random-digit-dialing telephone surveys of adults and parents of children <5 years old were conducted in Wisconsin and Minnesota during 1999., Results: The survey was completed by 405 adults and 275 parents of children <5 years old. The median age was 32 years for parents and 50 years for adults. Seven percent of parents and 17% of adults believed that antibiotics are never or almost never necessary for bronchitis. More than 70% in each group believed that antibiotics are needed for green or yellow nasal drainage, and nearly half of respondents believed that they knew whether an antibiotic was needed before seeing a physician. Exposure to multiple information sources on antibiotic resistance in the past 6 months was independently associated with a knowledge score greater than or equal to the median for nine questions., Conclusions: The general public has misconceptions regarding indications for antibiotic use, and this may contribute to inappropriate prescribing. Providing multiple and varied antibiotic-related informational messages may increase knowledge of appropriate antibiotic prescribing and decrease patient demand for antibiotics., ((C)2002 American Health Foundation and Elsevier Science (USA).)

Objective: Inappropriate use of antibiotics is common in primary care, and effective interventions are needed to promote judicious antibiotic use and reduce antibiotic resistance. The objective of this study was to assess the impact of parent and clinician education on pediatric antibiotic prescribing and carriage of penicillin-nonsusceptible Streptococcus pneumoniae in child care facilities., Methods: A nonrandomized, controlled, community intervention trial was conducted in northern Wisconsin Clinicians. Clinic staff received educational materials and small-group presentations; materials were distributed to parents through clinics, child care facilities, and community organizations. Prescribing data were analyzed for 151 clinicians who provided primary pediatric care; nasopharyngeal carriage of penicillin-nonsusceptible S pneumoniae was assessed for 664 children in the baseline period (January-June 1997) and for 472 children in the postintervention period (January-June 1998)., Results: The median number of solid antibiotic prescriptions per clinician declined 19% in the intervention region and 8% in the control region. The median number of liquid antibiotic prescriptions per clinician declined 11% in the intervention region, compared with an increase of 12% in the control region. Retail antibiotic sales declined in the intervention region but not in the control region. Among participating children in child care facilities, there were no significant differences in antibiotic use or penicillin-nonsusceptible S pneumoniae colonization between the intervention and control regions., Conclusions: A multifaceted educational program for clinicians and parents led to community-wide reductions in antibiotic prescribing, but in child care facilities, there was no apparent impact on judicious antibiotic use or colonization with drug-resistant S pneumoniae. Longer follow-up time or greater reductions in antibiotic use may be required to identify changes in the pneumococcal susceptibility.

Background: Overuse of antibiotics for children's upper respiratory infections is widespread and contributes to the emergence of antibiotic-resistant bacteria., Objective: To assess changes in knowledge and awareness regarding antibiotic resistance and appropriate antibiotic use after community-wide educational interventions to reduce inappropriate antibiotic use., Design: Baseline survey conducted during June through July 1997 and postintervention survey of baseline participants during June through August 1998., Setting: Communities in northern Wisconsin., Participants: Parents of 729 randomly selected children <4 years of age were called until 215 in each of the intervention and control areas were reached. Of the 430 baseline participants, 365 (85%) participated in the postintervention survey., Intervention: Parent-oriented activities included distribution of materials and presentations. Physician-oriented activities included formal presentations and small group meetings., Outcome Measure: Change in awareness about antibiotic resistance and knowledge about antibiotic indications., Results: A higher proportion of parents in the intervention area (53%) were exposed to 2 or more local educational messages, compared with the control area (23%). From the baseline to the postintervention survey, the percentage of parents with a high degree of antibiotic resistance awareness increased more in the intervention area (58% to 73%) than in the control area (60% to 65%). In the intervention area, there was also a larger increase in knowledge regarding appropriate indications for antibiotic use, compared with the control area. The proportion of parents who expected an antibiotic for their child and did not receive one declined in the intervention area (14% to 9%), while it increased in the control area (7% to 10%). In addition, the percentage of parents in the intervention area who brought their child to another physician because they did not receive an antibiotic decreased (5% to 2%), while it increased in the control area (2% to 4%)., Conclusion: Parental knowledge and awareness about antibiotic indications and antibiotic resistance can be changed with educational interventions directed at parents and clinicians.