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Jefferson G. Bohan et al
Fig. 1. Application of inclusion and exclusion criteria for acute respiratory tract infection (ARI) management evaluation. aVisits may have met >1 criteria resulting in exclusion or prevent- ing inclusion. bComorbid conditions include neoplasia, chronic lung disease (eg, COPD, asthma), end-stage renal disease, solid organ transplantation, or other immunocompromised
state (Supplementary Appendix A online). cOther infectious diseases not excluded: concur- rent hepatitis, genital herpes, or superficial (cutaneous) fungal infections. dVisits were not excluded if antibiotic agent was prescribed by a provider ≤2 days prior to the encounter if
the antibiotic was for ARI signs or symptoms. ePatients with mixed ARI diagnoses, delayed antibiotic prescriptions, or with missing antibi- otic prescription data were excluded from the appropriate antibiotic management and out- comes analyses.
outcomes (Fig. 1). Most patients were male and middle-aged, with limited comorbidity (Table 1). Few patients exhibited abnormal vital signs. Overall, 2,897 of 4,285 patients with uncomplicated ARIs (68%) received antibiotics. Recipients were more likely male, smokers, and to have been seen in the emergency department than antibiotic nonrecipients. Mid-level providers prescribed anti- biotics more often than staff physicians, and medical trainees pre- scribed antibiotics less often than staff physicians or mid-level providers. Of 715 patients diagnosed with rhinosinusitis, 567 (79%) had
documentation of purulent nasal discharge and/or facial pain, pressure, or fullness upon presentation (Table 2). Of those 567 patients, 216 (38%) had documentation of additional criteria for antibiotic therapy, predominantly prolonged symptoms (≥7 days). Antibiotics were prescribed in 633 of 709 rhinosinusitis visits eligible for evaluation (89%); of these 633, 203 (32%) met complete diagnostic criteria for antibiotic therapy. When antibiotics were prescribed, 389 of these 633 patients (61%) received first-line antibiotics and 66 (10%) received second-line antibiotics. The remaining 178 patients (28%) received nonrecommended antibi- otics. Based on chart documentation of rhinosinusitis symptoms, antibiotic selection, and appropriately withheld antibiotics, 226 of 709 patients (32%) received appropriate antibiotic management. Of 558 patients with a pharyngitis diagnosis, 432 (77%) lacked
Centor score component documentation or had Centor scores <2, indicating that few patients met streptococcal testing recommen- dations (Table 2).17 Furthermore, β-hemolytic Streptococcus test- ing was performed in 185 of 558 visits (33%) and was more likely to be performed for patients with ≥2 Centor criteria (ie, 53 of 126 patients, 42%) than those with <2 criteria (ie, 13 of 432
patients, 31%; P ≤ .02). Overall, 17 of 558 patients diagnosed with pharyngitis (3%) had a positive test for group A Streptococcus. Antibiotic therapy was prescribed to 384 of 556 patients with pharyngitis eligible for evaluation (69%); of these 384, 102 (27%) had ≥2 Centor criteria documented, indicating a likelihood of streptococcal pharyngitis high enough to warrant testing. Of the 384 patients with pharyngitis prescribed antibiotics, 147 (38%) received first-line therapy, 123 (32%) received second-line therapy, and 34 (9%) that received antibiotics had a documented penicillin allergy. Streptococcal tests were ordered less frequently for patients who received antibiotics (ie, 108 of 185, 28%) than those who did not receive antibiotics (ie, 77 of 185, 44%; P < .01). Based on evi- dence of β-hemolytic streptococcal infection, antibiotic selection, and appropriately withheld antibiotics, of 556 patients with pharyngitis eligible for evaluation, 194 (35%) received appropriate antibiotic management of pharyngitis. Of 1,154 patients with an acute bronchitis diagnosis, 7 (<1%)
had documentation of concern for pertussis exposure, confirmed exposure, or infection. These patients underwent diagnostic test- ing, but none tested positive for pertussis. Antibiotics were pre- scribed in 990 of 1,148 acute bronchitis visits eligible for evaluation (86%); among them, azithromycin was prescribed to 614 patients (62%). Based on chart documentation of pertussis concerns and appropriately withheld antibiotics, 159 of these 1,148 patients (14%) received appropriate antibiotic management for acute bronchitis. Antibiotics were prescribed to 550 of 1,471 patients (37%) eligible for evaluation and diagnosed with URI- NOS; among these 550, 330 (60%) received primarily azithromy- cin. Based on the proportion of patients who received antibiotics, 924 of 1,471 patients diagnosed with URI-NOS (63%) received
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