Evaluating Guideline-Recommended Antibiotic Prescribing Practices: Azithromycin for what?
Azithromycin is often prescribed for unclear indications. Our objectives were: 1) to evaluate adherence to published guidelines for respiratory infections, and 2) to determine patterns for azithromycin use among community providers.
A case-based survey was developed and emailed to members of a statewide registry. Providers chose their preferred management for infections with published treatment guidelines: otitis media, sinusitis, and community acquired pneumonia. After survey completion, participants could request an “answer key” detailing appropriate management of each scenario. A follow-up questionnaire was distributed inquiring whether the exercise had prompted reevaluation of current practices.
We received a 10% response rate and analyzed 163 completed surveys. There was general agreement on half the questions, with ≥ 75% of respondents choosing the recommended antibiotic. The remaining scenarios showed more divided choices. For example, nearly all (97%) agreed to hospitalize a patient with focal pneumonia and low oxygen saturations, but differed in preferred antibiotic regimen, with equal numbers choosing ampicillin alone, ampicillin + azithromycin, or vancomycin + ceftriaxone. For a 5 year old with 3 days of otalgia, the group was divided between watchful waiting versus treatment with amoxicillin.
In cases where azithromycin was indicated, there was clear agreement from the group on its use. We also observed azithromycin preference in cases of recurrent otitis media and sinusitis. Those who varied from the guidelines to choose azithromycin in one scenario were significantly (28%) more likely to do so in other scenarios (p<0.001).
On the post-survey questionnaire, 26% reported adjusting their practice, 69% reviewed the guidelines, 9% used cases for teaching, and 21% discussed the guidelines with colleagues.
The majority of respondents followed published guidelines, though we did observe variance with more ambiguous cases. When the group did vary from the guidelines, their choices would not likely have adversely affected care. Our results suggest room still exists for improved antibiotic stewardship. Our results and feedback suggest that future guidelines including case-based recommendations or discussions may enhance adherence.