Paper Information

Among 838,929 encounters, antibiotic overuse occurred in 38.5%. In the primary model, estimated 12-month changes were -5.0 percentage points (95% CI, -7.1 to -3.0; P <.001) around the CDC milestone and -15.7 percentage points (95% CI, -31.3 to -0.1; P =.049) around TJC. Estimates around COVID-19 and CMS were less stable.

Declines were most consistent around the CDC milestone; later estimates were limited by closely spaced interruptions and pandemic disruption.

Antibiotic overuse for acute respiratory tract infections (ARTIs) remains common in emergency departments (EDs), but national trends among older adults are not well described.

ED-focused outpatient stewardship remains needed for older adults with never-appropriate ARTIs.

We conducted a retrospective cohort study of US ED encounters in Epic Cosmos (January 2013-December 2025) among adults aged 65 years or older with never-appropriate ARTI diagnoses. Monthly antibiotic overuse (ED administration and/or discharge prescription) was evaluated with segmented regression around Centers for Disease Control and Prevention (CDC) Core Elements (November 2016), The Joint Commission (TJC) ambulatory stewardship standard (January 2020), COVID-19 onset (March 2020), and Centers for Medicare & Medicaid Services (CMS) interpretive guidance (July 2022).