442


Table 2. Documentation of Diagnostic Criteria for Antibiotic Therapy in Patients With a Diagnosis of Rhinosinusitis or Pharyngitisa Acute rhinosinusitis symptoms


Characteristic All patients


Patients with ≥1 of the following rhinosinusitis symptoms or treatment criteria


Purulent nasal discharge


Facial pain, pressure, or fullness Prolonged >7dc


Worsening after >4dc Severe, fever >38.9°C (102°F)c Antibiotic prescribing symptoms criteria metd


Acute pharyngitis symptoms Characteristic


All patients


Centor criteria scoree 0 or not documented 1 2 3 4


0–1 Centor criteria documented ≥2 Centor criteria documented No RADT or throat culture


RADT or throat culture obtained


≥2 Centor criteria documented and RADT or throat culture


Total RADT and throat cultures positivef Group A Streptococcus


Group C or G Streptococcus


All Patients, No. (%)


715 (100) 567 (79)


144 (20) 443 (62) 284 (40) 41 (6)


2(<1) 216 (30) All Patients, No. (%) 558 (100)


213 (38) 219 (39) 96 (17) 30 (6) 0 (0)


432 (77) 126 (23) 373 (67) 185 (33) 53 (10)


33 (6) 17 (3) 8 (1)


Received


Antibiotics, No. (%) 633 (89) 507 (80)


134 (21) 396 (63) 262 (41) 38 (6)


2 (<1) 203 (32)


Received Antibiotics, No. (%)b


384 (69)


134 (35) 148 (31) 76 (20) 26 (7) 0 (0)


282 (73) 102 (27) 276 (72) 108 (28) 38 (10)


28 (7) 14 (4) 7 (2)


Did not Receive Antibiotics, No. (%)


82 (12) 60 (73)


10 (12) 47 (57) 22 (27) 3 (4)


0 (<1) 13 (16)


Did Not Receive Antibiotics, No. (%)b


174 (31)


79 (49) 71 (41) 20 (12) 4 (2) 0 (0)


150 (86) 24 (14) 97 (56) 77 (44) 15 (9)


5 (3) 3 (2) 1 (1)


P Valueb :: :


.15


.06 .36 .01 .39 .61


<.01 P Valuec :: :


.02 .61 .02 .03


:: :


<.01 <.01 <.01 <.01 .63


.04 .22 .25


Note. RADT, rapid antigen detection test. aDue to rounding, all percentages may not add up to 100%. bReported P values compared patients with antibiotics prescribed and patients with no antibiotics prescribed. Bold indicates significance. cSymptoms categorized as prolonged, worsening, or severe could have been rhinosinusitis symptoms or nonrhinosinusitis symptoms. dAntibiotic prescribing symptoms criteria met based on documentation of purulent nasal discharge and/or facial pain or pressure AND any combination of prolonged symptoms, severe criteria,


or worsening criteria was used to define antibiotic prescribing criteria. eThe Centor criteria is a 4-point scale. Patients get a point for each of the following criteria they meet: temperature ≥38.3°C (101°F), enlarged cervical nodes, tonsillar exudate, and absence


of cough.17 fThroat cultures were considered positive if there was growth of group A, C, or G Streptococcus reported.


54 of 230 (24%) versus 403 of 2,322 (17%; P = .02) and 12 of 230 (5%) versus 69 of 2,322 (3%; P=.06), respectively.No difference in outcomes based on appropriate or inappropriate antibiotic selec- tion was observed. Finally, no difference in rates of C. difficile infection or hospitalization between antibiotic recipients and nonrecipients, or differences related to the appropriateness of antibiotic management, was observed.


Discussion


This cross-sectional MUE generated a number of noteworthy observations. First, an excessive proportion of patients with uncomplicated ARIs were treated with antibiotics. Antibiotics were given to ~67% of patients, whereas we found full justification for


antibiotic therapy in ~10% of visits. Also, a chart-level review of rhinosinusitis and pharyngitis diagnostic documentation identi- fied limited congruence with guideline recommended criteria for antibiotic treatment. Whereas 89% of patients diagnosed with rhi- nosinusitis received antibiotics, <33% had documented diagnostic criteria for treatment, suggesting that many patients may have received unnecessary antibiotics. In addition, <25% of pharyngitis cases had documentation of ≥2 Centor criteria, the recommended threshold for performing streptococcal diagnostic testing. Testing was performed in ~33% of cases, and providers were more likely to test patients meeting the recommended testing threshold. Antibiotics were prescribed less frequently in patients who under- went testing for β-hemolytic Streptococcus than those not tested, suggesting that improvements in testing could lower antibiotic


Jefferson G. Bohan et al


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