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Lakshmi Chauhan et al
Fig. 1. Frequency of inappropriate antibiotic prescriptions overall and by specific prescribing error in cases of acute sinusitis and pharyngitis. Note. The analysis was limited to cases in which the antibiotic was prescribed only for sinusitis (n=112) or pharyngitis (n=109).
bivariate analysis and those deemed to be clinically important were used to develop the regression models.
Results
During the study period, 674 cases of acute sinusitis and 2,942 cases of pharyngitis were identified by our ICD-10 search. Among them, 201 cases of sinusitis and 338 of pharyngitis were reviewed; 130 and 275 cases, respectively, were included for analysis.
Acute sinusitis
The median age of patients with sinusitis was 46 years, and 75% were female. Other demographic and clinical characteristics are shown in Supplemental Table 3. Penicillin allergy was docu- mented in 18 cases (14%). In total, 117 patients (90%) with sinusitis were prescribed an
antibiotic; 87 of these prescriptions (74%) were for a first-line agent (ie, amoxicillin or amoxicillin-clavulanate). The median duration of therapy was 7 days (interquartile range, 7–10 days) (Supplemental Table 4). Of 112 cases in which sinusitis was the sole indication for the prescription, 91 prescriptions (81%) were classified as inappropriate due to 1 or more prescribing errors (Fig. 1). Lack of an indication for antibiotics (48% of cases) and excessive duration of therapy (47% of cases) were the most common errors. By logistic regression, factors independently associated with prescription of antibiotics when not indicated included urgent care or emergency department site of visit (odds ratio [OR], 3.7; 95% confidence interval [CI], 1.0–13.3) and presence of purulent nasal discharge (OR, 2.6; 95% CI, 1.1–6.4) (Table 1). The only factor independently associated with excessive duration of therapy was urgent care or emergency department visit (OR, 6.6; 95% CI, 1.8–24.9).
Pharyngitis
The median age of patients with pharyngitis was 13 years. Other demographic and clinical characteristics are shown in Supplemental Table 3. Penicillin allergy was documented in 15 cases (5%).
In total, 130 patients with pharyngitis (47%) were prescribed
an antibiotic; 105 of these prescriptions (81%) were for a first-line agent (eg, penicillin V potassium, amoxicillin, or benzathine penicillin) (Supplemental Table 4). Of 109 cases in which phar- yngitis was the sole indication for the prescription, 52 prescrip- tions (48%) were classified as inappropriate (Fig. 1). Incorrect antibiotic dose was the most common error, which occurred in 35 prescriptions (32%). In all but 1 case, the dose was higher than recommended. By logistic regression, prescription of amoxicillin was the only factor independently associated with incorrect antibiotic dose (OR, 3.8; 95% CI, 1.6–9.1) (Table 1).
Discussion
A substantial proportion of both acute sinusitis and pharyngitis cases involved inappropriate antibiotic prescriptions; however, the types of prescribing errors differed between these 2 infections. Using national administrative datasets, Fleming-Dutra et al.3
estimated that antibiotic prescriptions could be reduced by 51% in adult sinusitis cases and by 34% in pediatric pharyngitis cases.3 In our patient-level analysis, we confirmed that for sinusitis, nearly half of prescriptions were not indicated, whereas this was much less common in pharyngitis (14% not indicated). Lack of an objective diagnostic test and difficulty in clinically distinguishing bacterial from viral sinusitis likely contribute to this marked antibiotic overuse and highlight the need for novel interventions to reduce overprescribing for sinusitis. Hersh et al.5 recently estimated that 48%–63% of prescriptions
for sinusitis and 40%–67% for pharyngitis are for non–first-line antibiotics.5 Our study revealed substantially lower rates of incor- rect antibiotic choice for both sinusitis (20%) and pharyngitis (5%), underscoring the importance of understanding prescribing prac- tices at one’s own institution prior to developing stewardship interventions. We also identified a high frequency of dosing errors (nearly always higher doses than recommended) in ~33% of pre- scriptions for pharyngitis. Finally, similar to findings from a recent CDC study,8 almost half of prescriptions for sinusitis were for 10 or more days rather than the recommended 5–7 days, demonstrating
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