Use By Utah Physicians: A Brief Survey
the objectives of our Epidemiology and Laboratory Capacity grant is to assess antibiotic
use among Utah physicians. There are obviously many ways to address this objective! To get
started, we conducted a survey of outpatient physicians asking about their prescribing
patterns for five common medical conditions.
Methods. In September 1998, a
survey asking about outpatient antibiotic use was mailed to 300 physicians selected from
the Utah Department of Healths Epidemiology Newsletter mailing list: 100
pediatricians, 100 internists, and 100 family practice physicians. We targeted physicians
with non-hospital addresses to maximize the likelihood of finding physicians
with primarily outpatient practices. The surveys were mailed with a letter that explained
the survey and asked the physician to please return their completed survey in an enclosed
The survey asked physicians to name the antibiotic they would be most likely to prescribe
in an outpatient setting for patients suffering from five conditions: pharyngitis (sore
throat), urinary tract infections (UTIs), pneumonia, acute otitis media (AOM), and
sinusitis. Physicians were also asked how frequently they tended to prescribe antibiotics
for patients with these conditions.
Results. We received 120 completed surveys, and 17 surveys that were
undeliverable. Our return rate was 40% for completed surveys, and 46% overall. A
preliminary analysis of the responses in December 1998 demonstrated relatively consistent
responses, and a decision was made to not send out a second mailing to non-responders.
The 120 respondents included 48 pediatricians, 36 internists, and 36 family practice
physicians. The majority of respondents graduated from medical school in the 1970s or
1980s (78 of 120 or 65%). The earliest graduate had completed medical school in 1941, and
the most recent in 1997. Most respondents (85 of 115 respondents or 74%) had practices
with more than a thousand patients, versus smaller practices, and most reported seeing an
average of 20 to 40 patients per day (71 of 120 or 59%). Most responding physicians were
from larger communities. Sixty-seven physicians (56%) reported that they served
communities of greater than 100,000 people, and 31 (26%) reported that they served
communities of between 25,000 and 100,000 people.
The most popular antibiotic prescribed for pharyngitis by physicians in our survey was
amoxicillin, with 57 physicians listing it as their first choice and 16 listing it as a
possible choice. The second most popular antibiotic was penicillin (in several different
forms), with 29 physicians listing it as their first choice and 14 listing it as a
possible choice. There was no significant difference between pediatricians, internists,
and family practice physicians as to the likelihood of their choosing a particular
antibiotic for pharyngitis. Most physicians indicated that they prescribed antibiotics for
pharyngitis between 25% and 75% of the time. While the survey did not ask about diagnostic
practices, 17 respondents noted that they prescribed antibiotics only when a positive
strep test or culture was available.
The most popular antibiotic prescribed for UTIs was the
combination trimethoprim/sulfamethoxazole (TMP/SMX), with 81 physicians listing it as
their first choice and one listing it as a possible choice. The second most popular was
nitrofurantoin, with 11 physicians listing it as their first choice and three listing it
as a possible choice. While all three types of physicians were likely to list TMP/SMX as
their first choice antibiotic, 10 of the 11 physicians who chose nitrofurantoin as their
first choice were family practice physicians. Nearly all physicians prescribed antibiotics
for patients with UTIs all or nearly all of the time. Twelve respondents noted that they
performed cultures on patients with suspected UTIs to confirm the diagnosis or to identify
bacterial susceptibility patterns.
Macrolide antibiotics were the most popular antibiotics for treating outpatient pneumonia,
with 29 physicians listing azithromycin as their first choice, 16 listing erythromycin,
and 13 listing clarithromycin. An additional six physicians listed azithromycin as a
possible choice, three listed erythromycin and four listed clarithromycin. The combination
of amoxicillin and clavulanic acid was the second most popular choice, with 15 physicians
listing it as their first choice. Internists and family practice physicians preferred
macrolide antibiotics to amoxicillin/clavulanic acid or to amoxicillin alone. The
pediatricians were more evenly divided between preferring macrolides versus
amoxicillin/clavulanic acid or amoxicillin alone (Table 1).
Amoxicillin/Clavulanic Acid or
Table 1. Preference of respondents for antibiotics to
prescribe for outpatient pneumonia (as either first or second choice) by physician
Most physicians prescribed
antibiotics for all or nearly all patients with outpatient pneumonia. There was a
difference in opinion between the specialties, with pediatricians being less likely to
prescribe antibiotics for outpatient pneumonia than internists or family practice
physicians (70% of pediatricians said they usually or always prescribed antibiotics for
patients with outpatient pneumonia, versus 97% of the internists and 94% of the family
practitioners). Two respondents noted they only prescribed antibiotics for pneumonia when
culture results were available.
There was a strong consensus on antibiotic selection for AOM. The most popular antibiotic
for 86 physicians was amoxicillin, with another two listing it as a possible choice. The
second most popular selection was amoxicillin/clavulanic acid, with nine physicians
listing it as their first choice and one listing it as a possible choice. Antibiotic
preference did not differ by physician type, and nearly all respondents prescribed
antibiotics for AOM all or nearly all of the time. One respondent prescribed antibiotics
for AOM only after performing a culture of the middle ear fluid.
The most popular antibiotic selected to treat sinusitis was amoxicillin, with 59
physicians listing it as their first choice and two listing it as a possible choice. The
second most popular was amoxicillin/clavulanic acid, with 20 physicians listing it as
their first choice and two listing it as a possible choice. The likelihood of choosing a
particular antibiotic did not differ by physician type. Physicians treated sinusitis with
antibiotics between 25% and 75% of the time. Four physicians noted that, to make a diagnosis of
sinusitis, the patient needed to present with specific signs and/or symptoms.
Physician respondents used a variety of resources to help them make decisions about which
antibiotics to prescribe. All respondents indicated that they routinely used at least one
external source of information, with Continuing Medical Education courses and journals
(selected by 90% and 80% of respondents, respectively) being the most popular. Eighteen
respondents specifically mentioned the Sanford Guide by name as a resource they use to
make antibiotic decisions.
Discussion. Since the Sanford Guide was named as a resource by
some of our respondents, we decided to compare the antibiotic choices named by our survey
respondents with the suggested antibiotics listed in the Sanford Guide. The purpose of
this comparison was to see how the antibiotic choices of our respondents were either
similar to or different from suggested antibiotics.
For pharyngitis, penicillin V or benzathine penicillin G are suggested
in the Sanford Guide (assuming the etiology is strep). The most popular selection of
physicians in the survey, amoxicillin, although not specifically listed as an acceptable
therapy, is presumably prescribed as a substitute for penicillin. We did not ask
physicians why they chose a particular antibiotic, so we can only surmise why amoxicillin
was preferred. Several qualities of amoxicillin, including that it is an oral medication
(versus injectable benzathine penicillin G) and it must be given three times a day (versus
four times a day for penicillin V), may partially explain the preference.
For acute and
uncomplicated UTIs, the suggested antibiotic is TMP/SMX. TMP/SMX was also the most
popular selection of physicians in our survey. While fluoroquinolones were also suggested
as first choice therapies in the Sanford Guide, only four respondents named one of these
antibiotics. (None of these respondents who chose a fluoroquinolone were pediatricians.)
Nitrofurantoin, the second most popular antibiotic of our respondents, was suggested as an
alternative therapy in the Sanford Guide.
The Sanford Guide suggestions for outpatient pneumonia are
complex. For patients three months to 5 years of age with pneumonia treated on an
outpatient basis, erythromycin or clarithromycin are suggested as primary therapies. For
patients 5 to 18 years of age, erythromycin is suggested as a primary therapy, plus
cefuroxime if Streptococcus pneumoniae is suspected. For patients 18 to 60 years of
age, the Sanford Guide suggests erythromycin, clarithromycin or azithromycin as primary
therapies. For patients over 60 years of age, azithromycin or clarithromycin are suggested
primary therapies. If it is suspected that these patients are infected with
penicillin-resistant Streptococcus pneumoniae, then levofloxacin, sparfloxacin,
trovafloxacin or grepafloxacin are suggested. The macrolides were the most popular choices
of our survey respondents.
Amoxicillin is suggested as a primary therapy to treat AOM. This was
also the most popular selection of our survey respondents. If penicillin-resistant Streptococcus
pneumoniae is suspected or proven, amoxicillin/clavulanic acid or a higher dose of
amoxicillin are suggested. Amoxicillin/clavulanic acid was the second most popular
selection of respondents. Other suggested antibiotics to treat AOM include TMP/SMX, second
and third generation oral cephalosporins, or a single dose of parenteral ceftriaxone.
While amoxicillin was the most popular antibiotic of our survey
respondents, it is not suggested as a primary or alternate therapy for sinusitis in the
Sanford Guide. The second most popular antibiotic, amoxicillin/clavulanic acid, is
suggested as a primary therapy, as are cefuroxime or TMP/SMX. There is a comment about the
treatment of sinusitis that discusses the use of amoxicillin or penicillin V. While there
are conflicting study results, it is believed that amoxicillin or penicillin V are
acceptable if there is little or no antibiotic resistance suspected or confirmed among
bacteria commonly associated with sinusitis.
Conclusions. The antibiotics selected by nearly all of the
survey respondents to treat five outpatient conditions were the same as or comparable to
antibiotics suggested in the Sanford Guide. Some respondents also wrote in comments that,
prior to prescribing antibiotics for these conditions, they required laboratory
confirmation of a bacterial infection. There were few significant differences in
prescribing patterns for these five conditions by physician specialty.
The two instances where the most popular antibiotic of our survey
respondents differed from the suggestions of the Sanford Guide were the antibiotics for
pharyngitis and sinusitis. As mentioned earlier, we did not ask why physicians chose a
particular antibiotic, so we can only surmise why they chose it. Amoxicillin may have been
the preferred antibiotic for pharyngitis because it has an antibacterial activity similar
to that of penicillin yet may be easier to administer. The choice of amoxicillin for
sinusitis is supported in the Sanford Guide if the physician is not concerned about
antibiotic resistance in those organisms that are commonly responsible for causing
This survey has limitations. Since the respondents were chosen from the
Epidemiology Newsletter mailing list as opposed to a list of all physicians practicing in
Utah, and since we had a 40% return rate for completed surveys, we cannot be sure that the
responses we received would necessarily be consistent with those of all Utah physicians in
these three specialties. Also, the replies may have been different if we had provided a
more detailed clinical description of the five outpatient conditions.
We are pleased with the response to
this survey. For a survey sent through the mail with no second mailing or reminder, a 40%
return rate was encouraging. Second, the thoughtful comments about diagnostic practices
from many respondents were interesting and provided information above and beyond what we
had hoped to collect. Finally, with the growing concerns about antibiotic resistance, we
were encouraged to see an overwhelming preference of these Utah physicians for so-called
first line antibiotics to treat five common outpatient conditions. Saving
newer or more broad-spectrum antibiotics for those situations where first line
antibiotics have failed (or could be expected to fail) may prolong the development of
resistance to these newer, more powerful antibiotics.
Time Again For Summer Food Safety!
summer, people take advantage of the nice, warm weather by cramming the season with
numerous outdoor activities and stuffing themselves with barbequed hamburgers, potato
salads, chips, and dips. A native Utahn would also add jello salad to the list.
Unfortunately, an increase in some enteric diseases may accompany the summer months due to
improper food handling. By implementing some simple precautions, however, summer cooks can
avoid inflicting others, and themselves, with foodborne illness.
Choose foods carefully
Select foods based on available
resources and facilities. If one is planning on a day hike and taking sandwiches for
lunch, he or she would be better off taking a peanut butter and jelly sandwich rather than
one needing refrigeration. The availability of hand washing facilities should also play a
role in deciding which foods to prepare for summers activities. If no such
facilities are available, one should avoid handling raw chicken or beef.
Prepare food carefully
One of the most effective ways to
prevent summer food hazards includes washing hands thoroughly before any food handling. It
is also wise to prepare as much food as possible at home. Many summer excursions include
spots where food preparation facilities are less than adequate.
To avoid cross-contamination, clean cutting boards and utensils used
for raw meats with hot, soapy water prior to their use with ready-to-eat foods.
Contamination may also be avoided if one washes his or her hands frequently during food
preparation. In addition, always use clean, treated water for washing hands, utensils, or
dishes since lake, river, or stream water may contain harmful pathogens.
Food handlers need to cook meats thoroughly as well. Cook raw hamburger
and chicken until the meat is no longer pink in the middle and the juices run clear.
Store food appropriately
one simple rule: keep hot foods hot and cold foods cold. Keep hot foods on the
grill, fire, coals, or warming pan and keep cold foods in the shade, in a cooler, or
sitting on ice until serving time.
Protect food from insects such as flies, which can spread bacteria, and
store food so that it is inaccessible to animals like rodents. It is not only important to
keep food away from animals, but to keep some items away from each other too. Store
uncooked meats and ready-to-eat foods in separate containers to avoid cross-contamination.
Eat food promptly
Eat food as soon as it is served and
put it away as soon as possible following the meal. Do not allow it to sit for prolonged
periods of time. Avoid eating food that should be refrigerated if it has been sitting at
room temperature for more than two hours. Less time is needed if it is warmer than room
temperature (such as sitting out on a picnic table).
Improper food-handling can ruin the most carefully planned summer
activity. Fortunately, by implementing these simple precautions, summer food hazards can
easily be prevented.
Department of Health, Bureau of Epidemiology
Monthly Morbidity Summary - May 1999 - Provisional Data
The Epidemiology Newsletter is
published monthly by the Utah Department of Health, Division of Epidemiology and
Laboratory Services, Bureau of Epidemiology, to disseminate epidemiologic information to
the health care professional and the general public.
Send comments to:
The Bureau of Epidemiology, Box 142104, Salt Lake City, UT 84114-2104, or call (801)
Approval 8000008:Appropriation 3705
Rod Betit, Executive Director, Utah Department of Health
Charles Brokopp, Dr.P.H., Division of Epidemiology and Laboratory Services
Craig R Nichols, MPA, Editor, State Epidemiologist, Director Bureau of Epidemiology
Cristie Chesler, BA, Managing Editor