Association between Physician Intensity of Antibiotic Prescribing and the Prescription of Benzodiazepines, Opioids and Proton-Pump Inhibitors to Nursing Home Residents: a Population-Based Observational Study

J Gen Intern Med. 2019 Dec;34(12):2763-2771. doi: 10.1007/s11606-019-05333-8. Epub 2019 Oct 1.


Background: Prescribing patterns for episodic medications, such as antibiotics, might make useful surrogate measures of a physician's overall prescribing practice because use is common, and variation exists across prescribers. However, the extent to which a physician's current antibiotic prescribing practices are associated with the rate of prescription of other potentially harmful medications remains unknown.

Objective: To examine the association between a physician's rate of antibiotic prescribing and their prescribing rate of benzodiazepines, opioids and proton-pump inhibitors in older adults.

Design: Population-based cohort study in nursing homes in Ontario, Canada, which provides comprehensive clinical, behavioural and functional information on all patients.

Participants: 1926 physicians who provided care among 128,979 physician-patient pairs in 2015.

Main measures: Likelihood of prescribing a benzodiazepine, opioid or proton-pump inhibitor between low-, average- and high-intensity antibiotic prescribers, adjusted for patient characteristics.

Key results: Compared with average-intensity antibiotic prescribers, high-intensity prescribers had an increased likelihood of prescribing a benzodiazepine (odds ratio 1.21 [95% CI, 1.11-1.32]), an opioid (odds ratio 1.28 [95% CI, 1.17-1.39]) or a proton-pump inhibitor (odds ratio 1.38 [95% CI, 1.27-1.51]]. High-intensity antibiotic prescribers were more likely to be high prescribers of all three medications (odds ratio 6.24 [95% CI, 2.90-13.39]) and also more likely to initiate all three medications, compared with average-intensity prescribers.

Conclusions: The intensity of a physician's episodic antibiotic prescribing was significantly associated with the likelihood of new and continued prescribing of opioids, benzodiazepines and proton-pump inhibitors in nursing homes. Patterns of episodic prescribing may be a useful mechanism to target physician-level interventions to optimize general prescribing behaviors, instead of prescribing behaviors for single medications.

Keywords: anti-bacterial agents; drug prescriptions; inappropriate prescribing; nursing home; physicians practice patterns.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Analgesics, Opioid / administration & dosage*
  • Anti-Bacterial Agents / administration & dosage*
  • Benzodiazepines / administration & dosage*
  • Drug Prescriptions* / statistics & numerical data
  • Female
  • Humans
  • Long-Term Care / statistics & numerical data
  • Long-Term Care / trends
  • Male
  • Nursing Homes / statistics & numerical data
  • Nursing Homes / trends*
  • Ontario / epidemiology
  • Population Surveillance
  • Practice Patterns, Physicians' / statistics & numerical data
  • Practice Patterns, Physicians' / trends*
  • Proton Pump Inhibitors / administration & dosage*


  • Analgesics, Opioid
  • Anti-Bacterial Agents
  • Proton Pump Inhibitors
  • Benzodiazepines