One of 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 Health’s 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 postage-paid envelope.

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).

Table 1. Preference of respondents for antibiotics to prescribe for outpatient pneumonia (as either first or second choice) by physician specialty.

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.

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.

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.

It’s Time Again For Summer Food Safety!

Every 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 summer’s 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.

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.

Remember 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.

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.