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Phantom Prescribing: Examining the Frequency of Antimicrobial Prescriptions Without a Patient Visit

  • Benjamin N. Riedle (a1), Linnea A. Polgreen (a2), Joseph E. Cavanaugh (a1), Mary C. Schroeder (a2) and Philip M. Polgreen (a3) (a4)...



To investigate the scale of antimicrobial prescribing without a corresponding visit, and to compare the attributes of patients who received antimicrobials with a corresponding visit with those who did not have a visit.


Retrospective cohort.


We followed up 185,010 Medicare patients for 1 year after an acute myocardial infarction. For each antimicrobial prescribed, we determined whether the patient had an inpatient, outpatient, or provider claim in the 7 days prior to the antimicrobial prescription being filled. We compared the proportions of patient characteristics for those prescriptions associated with a visit and without a visit (ie, phantom prescriptions). We also compared the rates at which different antimicrobials were prescribed without a visit.


We found that of 356,545 antimicrobial prescriptions, 14.75% had no evidence of a visit in the week prior to the prescription being filled. A higher percentage of patients without a visit were identified as white (P<.001) and female (P<.001). Patients without a visit had a higher likelihood of survival and fewer additional cardiac events (acute myocardial infarction, cardiac arrest, stroke, all P<.001). Among the antimicrobials considered, amoxicillin, penicillin, and agents containing trimethoprim and methenamine were much more likely to be prescribed without a visit. In contrast, levofloxacin, metronidazole, moxifloxacin, vancomycin, and cefdinir were much less likely to be prescribed without a visit.


Among this cohort of patients with chronic conditions, phantom prescriptions of antimicrobials are relatively common and occurred more frequently among those patients who were relatively healthy.

Infect Control Hosp Epidemiol 2017;38:273–280


Corresponding author

Address correspondence to Philip M. Polgreen, MD, MPH, University of Iowa, Departments of Internal Medicine and Epidemiology, UIHC SW34-Q GH, Iowa City, IA 52242 (


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Previous presentation: American Pharmacists’ Association Meeting; Baltimore, Maryland; March 5, 2016.



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1. Schwartz, B, Bell, DM, Hughes, JM. Preventing the emergence of antimicrobial resistance: a call for action by clinicians, public health officials, and patients. JAMA 1997;278:944945.
2. Spellberg, B, Guidos, R, Gilbert, D, et al. The epidemic of antibiotic-resistant infections: a call to action for the medical community from the Infectious Diseases Society of America. Clin Infect Dis 2008;46:155164.
3. French, GL. The continuing crisis in antibiotic resistance. Intl J Antimicrob Agents 2010;36:S3S7.
4. World Health Organization (WHO). Antimicrobial Resistance: Global Report on Surveillance 2014. Geneva, Switzerland: WHO, 2014.
5. File, TM Jr, Srinivasan, A, Bartlett, JG. Antimicrobial stewardship: importance for patient and public health. Clin Infect Dis 2014;59:S93S96.
6. Huttner, B, Harbarth, S, Nathwani, D. Success stories of implementation of antimicrobial stewardship: a narrative review. Clin Microbiol Infect 2014;20:954962.
7. Fleming-Dutra, KE, Hersh, AL, Shapiro, DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA 2016;315:18641873.
8. Costelloe, C, Metcalfe, C, Lovering, A, Mant, D, Hay, AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010;340:c2096.
9. Wagner, B, Filice, GA, Drekonja, D, et al. Antimicrobial stewardship programs in inpatient hospital settings: a systematic review. Infect Control Hosp Epidemiol 2014;35:12091228.
10. Drekonja, DM, Filice, GA, Greer, N, et al. Antimicrobial stewardship in outpatient settings: a systematic review. Infect Control Hosp Epidemiol 2015;36:142152.
11. Rohde, JM, Jacobsen, D, Rosenberg, DJ. Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative. Clin Ther 2013;35:751757.
12. Johannsson, B, Beekmann, SE, Srinivasan, A, Hersh, AL, Laxminarayan, R, Polgreen, PM. Improving antimicrobial stewardship: the evolution of programmatic strategies and barriers. Infect Control Hosp Epidemiol 2011;32:367374.
13. Hersh, AL, Beekmann, SE, Polgreen, PM, Zaoutis, TE, Newland, JG. Antimicrobial stewardship programs in pediatrics. Infect Control Hosp Epidemiol 2009;30:12111217.
14. Tabah, A, Cotta, MO, Garnacho-Montero, J, et al. A systematic review of the definitions, determinants, and clinical outcomes of antimicrobial de-escalation in the intensive care unit. Clin Infect Dis 2016;62:10091017.
15. Luyt, CE, Brechot, N, Trouillet, JL, Chastre, J. Antibiotic stewardship in the intensive care unit. Crit Care 2014;18:480.
16. Society for Healthcare Epidemiology of America; Infectious Diseases Society of America; Pediatric Infectious Diseases Society. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol 2012;33:322327.
17. Elligsen, M, Walker, SA, Pinto, R, et al. Audit and feedback to reduce broad-spectrum antibiotic use among intensive care unit patients: a controlled interrupted time series analysis. Infect Control Hosp Epidemiol 2012;33:354361.
18. Kaki, R, Elligsen, M, Walker, S, Simor, A, Palmay, L, Daneman, N. Impact of antimicrobial stewardship in critical care: a systematic review. J Antimicrob Chemother 2011;66:12231230.
19. Finkelstein, JA, Davis, RL, Dowell, SF, et al. Reducing antibiotic use in children: a randomized trial in 12 practices. Pediatrics 2001;108:17.
20. Andrews, T, Thompson, M, Buckley, DI, et al. Interventions to influence consulting and antibiotic use for acute respiratory tract infections in children: a systematic review and meta-analysis. PLOS ONE 2012;7:e30334.
21. Gerber, JS, Prasad, PA, Fiks, AG, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial. JAMA 2013;309:23452352.
22. Hallsworth, M, Chadborn, T, Sallis, A, et al. Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial. Lancet 2016;387:17431752.
23. Nyquist, AC, Gonzales, R, Steiner, JF, Sande, MA. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 1998;279:875877.
24. Mangione-Smith, R, McGlynn, EA, Elliott, MN, Krogstad, P, Brook, RH. The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. Pediatrics 1999;103:711718.
25. Bauchner, H, Pelton, SI, Klein, JO. Parents, physicians, and antibiotic use. Pediatrics 1999;103:395401.
26. Research Data Assistance Center (ResDAC). Carrier RIF, overview. ResDAC website. Published 2016. Accessed May 8, 2016.
27. Polgreen, PM, Yang, M, Laxminarayan, R, Cavanaugh, JE. Respiratory fluoroquinolone use and influenza. Infect Control Hosp Epidemiol 2011;32:706709.
28. Hicks LA, Bartoces MG, Roberts RM, et al. US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis 2015;60:13081316.
29. Mehrotra A, Paone S, Martich GD, Albert SM, Shevchik GJ. A comparison of care at e-visits and physician office visits for sinusitis and urinary tract infection. JAMA Intern Med 2013;173:7274.
30. Uscher-Pines L, Mulcahy A, Cowling D, Hunter G, Burns R, Mehrotra A. Antibiotic prescribing for acute respiratory infections in direct-to-consumer telemedicine visits. JAMA Intern Med 2015;175:12341235.
31. Uscher-Pines L, Mulcahy A, Cowling D, Hunter G, Burns R, Mehrotra A. Access and quality of care in direct-to-consumer telemedicine. Telemedicine J E Health 2016;22:282287.
32. Klein EY, Makowsky M, Orlando M, Hatna E, Braykov NP, Laxminarayan R. Influence of provider and urgent care density across different socioeconomic strata on outpatient antibiotic prescribing in the USA. J Antimicrob Chemother 2015;70:15801587.
33. Masiero G, Filippini M, Ferech M, Goossens H. Socioeconomic determinants of outpatient antibiotic use in Europe. Int J Public Health 2010;55:469478.
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