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Updated: Dec 29, 2025
Multiplex Therapeutic Drug Monitoring by Isotope-dilution HPLC-MS/MS of Antibiotics in Critical Illnesses
Published on: August 30, 2018
Non-Infection-Related And Non-Visit-Based Antibiotic Prescribing Is Common Among Medicaid Patients
Michael A Fischer1, Mufaddal Mahesri2, Joyce Lii3
1Michael A. Fischer ( mfischer@partners. org ) is an associate professor of medicine at Harvard Medical School and an associate physician in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, both in Boston, Massachusetts.
Abstract:
Ambulatory antibiotic stewardship policies focus on prescribing decisions made when patients present to clinicians with possible infections. They do not capture antibiotics prescribed outside of clinician visits or without clear indications for use. Antibiotic prescribing for vulnerable patients in the US has not been comprehensively measured. We measured the frequency with which all filled antibiotic prescriptions were associated with infections and in-person visits for Medicaid patients in the period 2004-13. We found that among 298 million antibiotic fills (62 percent for children) for 53 million patients, 55 percent were for clinician visits with an infection-related diagnosis, 17 percent were for clinician visits without an infection-related diagnosis, and 28 percent were not associated with a visit. Non-visit-based antibiotic prescriptions were less common for children than for adults and more common in the West than in other US regions. Large fractions of antibiotic prescriptions are filled without evidence of infection-related diagnoses or accompanying clinician visits. Current ambulatory antibiotic stewardship policies miss about half of antibiotic prescribing.
Insights
Current antibiotic stewardship policies miss nearly half of all antibiotic prescriptions. Many fills lack infection diagnoses or clinician visits, indicating gaps in tracking and control for vulnerable populations.
Area of Science:
- Health Services Research
- Infectious Diseases
- Pharmacology
Background:
- Ambulatory antibiotic stewardship policies primarily address prescribing during patient-clinician encounters.
- Existing policies do not account for antibiotics prescribed outside of these visits or without clear infection indications.
- Comprehensive measurement of antibiotic prescribing, especially for vulnerable groups like Medicaid patients, is lacking.
Purpose of the Study:
- To measure the frequency of filled antibiotic prescriptions associated with infections and in-person visits among US Medicaid patients.
- To identify the proportion of antibiotic prescriptions filled without an infection diagnosis or an accompanying clinician visit.
- To evaluate the scope of antibiotic prescribing not captured by current ambulatory stewardship policies.
Main Methods:
- Analysis of filled antibiotic prescriptions for 53 million US Medicaid patients from 2004-2013.
- Categorization of antibiotic fills based on association with clinician visits and infection-related diagnoses.
- Examination of demographic and regional variations in non-visit-based antibiotic prescriptions.
Main Results:
- Out of 298 million antibiotic fills, 55% were linked to visits with infection diagnoses, 17% to visits without infection diagnoses, and 28% were not associated with any visit.
- Non-visit-based prescriptions were less frequent in children than adults.
- Geographically, non-visit-based prescriptions were more common in the Western US compared to other regions.
Conclusions:
- A significant proportion of antibiotic prescriptions, nearly half, are filled without clear evidence of infection or a concurrent clinician visit.
- Current ambulatory antibiotic stewardship strategies likely underestimate total antibiotic use and may miss crucial prescribing patterns.
- There is a need to expand stewardship efforts to encompass antibiotic prescribing outside of traditional clinical encounters to improve antimicrobial use.
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