The distribution of antibiotic use and its association with antibiotic resistance

Elife. 2018 Dec 18:7:e39435. doi: 10.7554/eLife.39435.


Antibiotic use is a primary driver of antibiotic resistance. However, antibiotic use can be distributed in different ways in a population, and the association between the distribution of use and antibiotic resistance has not been explored. Here, we tested the hypothesis that repeated use of antibiotics has a stronger association with population-wide antibiotic resistance than broadly-distributed, low-intensity use. First, we characterized the distribution of outpatient antibiotic use across US states, finding that antibiotic use is uneven and that repeated use of antibiotics makes up a minority of antibiotic use. Second, we compared antibiotic use with resistance for 72 pathogen-antibiotic combinations across states. Finally, having partitioned total use into extensive and intensive margins, we found that intense use had a weaker association with resistance than extensive use. If the use-resistance relationship is causal, these results suggest that reducing total use and selection intensity will require reducing broadly distributed, low-intensity use.

Keywords: E. coli; S. pyogenes; antibiotic resistance; antimicrobial; epidemiology; global health; infectious disease; microbiology; public health.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Anti-Bacterial Agents / classification
  • Anti-Bacterial Agents / therapeutic use*
  • Bacterial Infections / drug therapy*
  • Drug Prescriptions / statistics & numerical data
  • Drug Resistance, Microbial*
  • Humans
  • Insurance / statistics & numerical data
  • Risk Assessment / methods
  • Risk Assessment / standards*
  • Risk Factors
  • United States


  • Anti-Bacterial Agents