Infection Control & Hospital Epidemiology
Table 1. Multivariable Logistic Regression Models of Factors Associated With Common Prescribing Errors
Model Variable
Bivariate Analysis OR (95% CI)
Adjusted Analysis OR (95% CI)
Factors associated with prescription of antibiotic for sinusitis when not indicated
Physician (vs advanced practice provider)
Urgent care/ED site of visit (vs outpatient clinic)
Cough Purulent nasal discharge
Prescription of nonantibiotic adjuvant therapy
Physician (vs advanced practice provider)
Urgent care/ED site of visit (vs outpatient clinic)
Diabetes mellitus Asthma
Prescription of nonantibiotic adjuvant therapy
Prescription of azithromycin
Physician (vs advanced practice provider)
Urgent care/ED site of visit (vs outpatient clinic)
Weight (kilograms) Prescription of amoxicillin 2.1 (1.0–4.2)
1.8 (0.6–5.2) 0.3 (0.1–0.6)a 1.5 (0.7–3.1)a
0.8 (0.4–1.7) 1.8 (0.8–4.2)
3.7 (1.0–13.3) 0.2 (0.1–0.5) 2.6 (1.1–6.4)
0.5 (0.2–1.1) Factors associated with excessive duration of therapy for sinusitis 2.1 (1.0–4.2)
1.8 (0.6–5.2) 1.1 (0.4–2.8)a 1.4 (0.6–3.4)a
0.8 (0.4–1.7) 0.6 (0.2–1.9)a
0.7 (0.3–1.6)
6.6 (1.8–24.9) 0.1 (0.04–0.5) 0.4 (0.1–1.3)
0.9 (0.3–2.3) 0.04 (0.004–0.3) Factors associated with incorrect antibiotic dose for pharyngitis 1.0 (0.5–2.2)
0.5 (0.2–1.3) 1.8 (0.8–4.2)a 2.9 (1.3–6.6)a
0.8 (0.3–1.8)
0.4 (0.1–1.3) 1.9 (0.7–5.0) 3.8 (1.6–9.1)
NOTE. OR, odds ratio; CI, confidence interval; ED, emergency department. aP value<.20 on bivariate analysis.
993
incomplete medical record documentation may have led to over- estimation of the proportion of sinusitis cases in which an anti- biotic was not indicated. Finally, the relatively small sample size limited the statistical power of the logistic regression models and precluded inclusion of all potentially relevant variables in the final models. In conclusion, considerable opportunity exists to reduce inappropriate antibiotic prescriptions in both acute sinusitis and pharyngitis. This study highlights the idea that optimizing pre- scribing in ambulatory care requires attention to all 4 aspects of the stewardship mantra: “Right antibiotic, at the right dose, at the right time, and for the right duration,” and our findings support the CDC recommendation to identify high-priority conditions for initial stewardship interventions.2
Supplementary material. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2018.117
Acknowledgments Financial support. No financial support was provided relevant to this article.
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
References 1. National action plan for combating antibiotic-resistant bacteria. March 2015. The White House website.
https://www.whitehouse.gov/sites/ default/files/docs/national_action_plan_for_combating_antibotic-resistant_ bacteria.pdf. Published 2015. Accessed April 6, 2015.
2. Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core elements of outpatient antibiotic stewardship. MMWR 2016;65:1–12.
3. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA 2016;315:1864–1873.
4. Fairlie T, Shapiro DJ, Hersh AL, Hicks LA. National trends in visit rates and antibiotic prescribing for adults with acute sinusitis. Arch Int Med 2012;172:1513–1514.
5. Hersh AL, Fleming-Dutra KE, Shapiro DJ, Hyun DY, Hicks LA. Frequency of first-line antibiotic selection among US ambulatory care visits for otitis media, sinusitis, and pharyngitis. JAMA Intern Med 2016;176:1870–1872.
6. McCaig LF, Hicks LA, Roberts RM, Fairlie TA. Office-related antibiotic prescribing for persons aged ≤14 years—United States, 1993–1994 to 2007–2008. MMWR 2011;60:1153–1156.
a substantial opportunity to shorten treatment durations. In aggregate, our data highlight that in addition to prescription of antibiotics when not indicated, incorrect antibiotic choice, dose, and duration of therapy are common prescribing errors that are important targets for intervention. These errorsmay be particularly amenable to electronic health record–based interventions. Our logistic regression models suggest that the urgent care and emer- gency department settings may be an important area of focus. This study has several limitations. This study was performed in
a single ambulatory-care network with an active antibiotic stew- ardship program; hence, these results may not be generalizable to other practice settings. Furthermore, given the retrospective design,
7. Barnett ML, Linder JA. Antibiotic prescribing to adults with sore throat in the United States, 1997–2010. JAMA Intern Med 2014;174:138–140.
8. King LM, Sanchez GV, Bartoces M, Hicks LA, Fleming-Dutra KE. Antibiotic therapy duration in US adults with sinusitis. JAMA Intern Med 2018. doi: 10.1001/jamainternmed.2018.0407.
9. Gabow P, Eisert S, Wright R. Denver Health: a model for the integration of a public hospital and community health centers. Ann Intern Med 2003;138:143–149.
10. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012;54:e72–e112.
11. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012;55:1279–1282.
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