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Overuse of Empirical Antibiotics for Acute Diarrhea

Antimicrobial therapy is rarely indicated for acute diarrhea; current guidelines recommend that stool culture be performed when such therapy is prescribed. In this evaluation of Tennessee Medicaid data, antimicrobials were prescribed for more than 10% of diarrhea episodes, usually without a stool culture. Of 315,828 diarrheal episodes identified, 10.4% were treated with antimicrobials; only 10.6% had a stool culture. Antimicrobials may worsen outcome in some cases infectious diarrheas (E. coli O157:H7, C. diff.) while also raising cost and resistance pressure. Failing to perform a stool culture when antimicrobials are prescribed limits diagnostic information to guide management and increases likelihood of missing outbreaks of public health importance.

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Examination of Medicaid data from Tennessee revealed that antimicrobials were prescribed for more than 10% of diarrhea episodes, usually without a stool culture.

Antimicrobial therapy is rarely indicated for acute diarrhea, and current guidelines recommend that a stool culture be performed when such therapy is prescribed. Investigators recently examined Medicaid data from Tennessee for 1995 through 2004 to determine the frequency of antimicrobial use for acute diarrhea and the extent to which stool cultures accompanied such therapy.

Of 315,828 diarrheal episodes identified, 15,820 (5.0%) were evaluated with stool culture, and 32,949 (10.4%) were treated with antimicrobial therapy. Among the episodes for which antimicrobial therapy was prescribed, only 3504 (10.6%) had a stool culture performed. Multivariable regression revealed that white race, urban residence, antimicrobial prescription, and not receiving a concurrent diagnosis of respiratory tract infection were associated with higher rates of stool culture.

Comment: This study reveals a high rate of antimicrobial use for acute diarrhea and a disconcertingly low rate of stool culture evaluation. Antimicrobial use may worsen outcome in some cases of infectious diarrhea (e.g., those caused by Escherichia coli O157:H7 or Clostridium difficile) while also raising both cost and antimicrobial- resistance pressure. In addition, failing to perform a stool culture when antimicrobials are prescribed limits diagnostic information to guide management and increases the likelihood of missing infections or outbreaks that are of public health importance.

— Daniel J. Diekema, MD, MS

Published in Journal Watch Infectious Diseases May 7, 2008

Citation:

Carpenter LR et al. Stool cultures and antimicrobial prescriptions related to infectious diarrhea. J Infect Dis 2008 Apr 21; [e-pub ahead of print]. [Medline® abstract]

Copyright © 2008, Massachusetts Medical Society. All rights reserved.