Infection Control & Hospital Epidemiology (2018), 39, 991–993 doi:10.1017/ice.2018.117
Concise Communication
Appropriateness of antibiotic prescriptions for acute sinusitis and pharyngitis in an integrated healthcare system
Lakshmi Chauhan MD1, Heather Young MD1,2,3, Bryan C. Knepper MSc, MPH3, Katherine C. Shihadeh PharmD4 and Timothy C. Jenkins MD1,2,3 1Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, 2Division of Infectious Diseases,
Department of Medicine, Denver Health, Denver, Colorado, 3Department of Patient Safety and Quality, Denver Health, Denver, Colorado and 4Department of Pharmacy, Denver Health, Denver, Colorado
Abstract
We evaluated the appropriateness of antibiotic prescriptions for acute sinusitis and pharyngitis. Overall, 81% of antibiotic prescriptions for acute sinusitis were inappropriate and 48% of antibiotic prescriptions for pharyngitis were inappropriate. Types of prescribing errors differed between the 2 infections, including lack of an indication for antibiotics and excessive duration in ~50% of sinusitis cases and incorrect antibiotic dose in ~33% of pharyngitis cases.
(Received 21 February 2018; accepted 28 April 2018; electronically published May 29, 2018)
The National Action Plan for Combating Antibiotic Resistance calls for a 50% reduction in inappropriate antibiotic use in out- patient settings by 2020,1 and the Centers for Disease Control and Prevention (CDC) guidance suggests identifying 1 or more high- priority conditions for initial intervention.2 Acute sinusitis and pharyngitis are 2 of the 3 most common indications for antibiotic prescriptions.3 Numerous studies suggest that a large proportion of these prescriptions may be inappropriate;3–8 however, given the use of administrative data, the appropriateness of prescriptions could not be directly assessed in these studies. The objective of this study was to evaluate the appropriateness of antibiotic pre- scriptions for acute sinusitis and pharyngitis.
Methods Study design and setting
Denver Health is an integrated healthcare system with ambulatory- care sites including an emergency department, 2 urgent care centers, 9 primary care clinics, and 17 school-based health centers.9 This study was a retrospective cross-sectional study of patients diag- nosed with acute sinusitis or pharyngitis between May 1, 2016, and October 31, 2016.
Data collection
Potentially eligible cases were identified from the institutional data warehouse using International Classification of Disease,
Author for correspondence: Timothy Jenkins,MD, Denver Health, 777 Bannock Street,
MC4000, Denver, Colorado, 80204. E-mail:
timothy.jenkins@
dhha.org PREVIOUS PRESENTATION: This work was presented in part at IDWeek on October
5, 2017, in San Diego, California (abstract #675) Cite this article: Chauhan L, et al. (2018). Appropriateness of antibiotic prescriptions
for acute sinusitis and pharyngitis in an integrated healthcare system. Infection Control & Hospital Epidemiology 2018, 39, 991–993. doi:10.1017/ice.2018.117
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. Statistical analyses
Multivariable logistic regression models were developed to eval- uate patient and prescriber factors associated with the 3 most common prescribing errors identified. Factors with P<.20 in
Tenth Revision (ICD-10) codes for acute rhinosinusitis, acute streptococcal pharyngitis, acute pharyngitis, and acute tonsillitis (Supplemental Table 1). The medical records of a random sample of cases were manually reviewed. The main exclusion criteria were symptoms lasting >28 days, not the initial visit for the infection, specialty clinic appointment, recurrent infection, <1 year of age, pregnancy, or hospitalization. Antibiotic prescrip- tions were recorded based on the provider’s intent, irrespective of patient adherence to the treatment.
Definitions
A prescription was classified as inappropriate if any of 4 pre- scribing errors occurred: an antibiotic was not indicated or the antibiotic choice, dose, or duration of therapy was discordant with Infectious Diseases Society of America (IDSA) guidance (Supplemental Table 2).10,11 For acute sinusitis, an antibiotic was deemed to be indicated when at least 1 criteria for acute bacterial sinusitis was present: (1) persistent symptoms not improving for ≥10 days; (2) severe symptoms (temperature >38°C [101°F] or severe sinus pain) for ≥3 days; or (3) initial improvement fol- lowed by worsening symptoms.10 Although amoxicillin is not recommended in the current IDSA guideline, Denver Health guidance advocates its first-line use; thus, it was classified as appropriate for the purposes of the study. For pharyngitis, an antibiotic was deemed to be indicated if (1) signs or symptoms of acute pharyngitis were present and (2) a rapid antigen test or throat culture was positive for group A streptococcus.11
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