In addition, although this DUE was not designed to assess the appropriateness of using first line versus second line therapy, it was noted that a relatively high proportion of prescriptions were for second line agents, ie, 24% using the Ontario guidelines and 6% using the Sanford’s Guide. The lower percentage of deviation noted when using the Sanford Guide may be explained by the fact that resistance rates are generally higher in the United States, therefore leading to broad spectrum antibiotics being more frequently recommended. Nonetheless, this trend toward using broader spectrum and more expensive antimicrobial drugs, which generally constitute second line agents in guidelines, was reported by McCaig and Hughes . These authors were warning clinicians about the potential impact of such a trend because it may increase health care costs and lead to the development of antimicrobial resistance. This trend was also recently observed in Canada where the use of scheduled, second line antibiotics on the Manitoba provincial formulary increased between 1995 and 1998 . There is a paucity of published literature on outpatient DUE. One such study, evaluating the use of oral ciprofloxacin in community practice reported a noncompliance rate of 43.8% . Our results compare favourably.
One area of intervention that has been identified in the literature is the fact that a significant number of antibiotics are prescribed for adults for conditions that are generally viral in nature. Indeed, Gonzales and colleagues reported that common colds, upper respiratory tract infections and bronchitis are a group of infections that have a viral etiology in over 90% of cases, but that 50% to 70% of office visits for these conditions result in an antibiotic prescription. In our DUE, bronchitis represented 17.6% of all antibiotic prescriptions.