Appropriateness of antibiotic prescriptions for acute sinusitis and pharyngitis in ambulatory care settings of an integrated health care system

Abstract

Background: Outpatient antibiotic use constitutes over 80% of total antibiotic use. Acute sinusitis and pharyngitis are among the top three conditions which result in inappropriate antibiotic prescriptions. The objective of the study was to perform a comprehensive patient-level analysis to evaluate the appropriateness of antibiotic prescriptions and factors associated with inappropriate prescriptions in acute sinusitis and pharyngitis.

Methods: This was a retrospective cross-sectional study involving patients >1 year old with an initial visit for acute sinusitis or pharyngitis to a clinic, emergency department, or urgent care center of an integrated health care system. A random sample of cases occurring between May and October 2016 were reviewed manually for clinical, diagnostic, and treatment data.  The primary endpoint was inappropriate antibiotic prescriptions, defined as lack of an indication for an antibiotic or antibiotic choice, dose, or duration of therapy discordant with Infectious Diseases Society of America guidance.

Results: Of 540 patients reviewed, 130 patients with sinusitis and 275 patients with pharyngitis were included for analysis; the median age was 46 and 13 years, respectively. In total, antibiotics were prescribed at 117 (90%) visits for sinusitis and 130 (47%) visits for pharyngitis. In cases where the antibiotic was prescribed only for sinusitis or pharyngitis, the prescription was overall inappropriate in 92 of 113 (81%) cases of sinusitis and 53 of 111 (48%) cases of pharyngitis.  The reasons for classification as inappropriate prescriptions are shown in the Figure. Antibiotics were given when not indicated in 54 of 113 (48%) cases of sinusitis and 16/111 (14%) cases of pharyngitis. The most common prescribing error in sinusitis was longer duration of therapy while dosing errors were more common in pharyngitis.

Figure 1: Inappropriate antibiotic prescriptions in acute pharyngitis and sinusitis

Conclusion: Inappropriate antibiotic prescriptions are common in both acute sinusitis and pharyngitis, but more so in sinusitis.  The types of prescribing errors differed markedly between the two infections. This suggests individualized approaches to improve antimicrobial use for these infections are necessary.