Frequency of First-line Antibiotic Selection Among US Ambulatory Care Visits for Otitis Media, Sinusitis, and Pharyngitis

The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotic use by 50% by 2020.¹ A recent study² estimated at least 30% of antibiotic prescriptions in ambulatory care settings in the United States from 2010 to 2011 were unnecessary. Inappropriate antibiotic prescribing also includes choosing an unnecessarily broad spectrum antibiotic instead of an equally or more effective narrower spectrum alternative. Otitis media (OM), sinusitis, and pharyngitis collectively account for nearly one-third of all antibiotics prescribed in outpatient settings,² and professional guidelines recommend narrow spectrum agents as first-line therapy for these conditions.² Alternatives to first-line therapy are indicated in selected circumstances, including for patients with penicillin allergy or recent treatment failure. Our objective was to measure the frequency with which first-line agents are prescribed for OM, sinusitis, and pharyngitis.

We identified antibiotic prescribing visits during 2010 to 2011 for OM (only patients ≤19 years old), sinusitis, and pharyngitis using the National Ambulatory Medical Care Survey (NAMCS), which samples office-based physicians and the National Hospital Ambulatory Medical Care Survey (NHAMCS), which samples hospital outpatient and emergency departments. The International Classification of Diseases, Ninth Revision, Clinical Modification, codes were used to identify visits and assign diagnoses as described previously.²

National guidelines recommend first-line antibiotic therapy for each condition: amoxicillin or amoxicillin with clavulanate (alternative) for OM, amoxicillin or amoxicillin with clavulanate for sinusitis, and penicillin or amoxicillin for pharyngitis.² First-line therapy represents the initial recommended antibiotics for treatment of patients without drug allergies, including alternative therapy indicated for specific situations (eg, amoxicillin-clavulanate for OM with concurrent conjunctivitis). First-line therapy would not apply to treated patients returning for unplanned follow-up care with worsening symptoms suggesting treatment failure.

For each condition, the primary outcome was the percentage of visits that received first-line antibiotics (stratified by age: pediatric, ≤19 years, adult >19 years). All analyses were performed using Stata statistical software (version 12; Stata Corp).

During 2010 to 2011, among visits where antibiotics were prescribed, physician prescribing of first-line antibiotics ranged from a low of 37% (95% CI, 32%-43%) for adult patients with sinusitis and pharyngitis to a high of 67% (95% CI, 63%-71%) for pediatric patients with OM (Figure). For all 3 conditions overall, use of first-line agents was 52% (95% CI, 49%-55%). Physicians prescribed first-line therapies more commonly to pediatric patients than to adults (P < .001 for sinusitis and pharyngitis). The most common non–first-line antibiotic class prescribed was macrolides (Figure).

Collectively, physicians prescribed first-line recommended antibiotics approximately half of the time during visits for OM, sinusitis, and pharyngitis. Overuse of non–first-line agents, especially macrolides, was higher for adults than children. Available evidence suggests that 10% of the population report penicillin allergy³ and 10% of visits for sinusitis⁴ and OM result from failed first-line therapy,⁵ suggesting that approximately 80% of visits for these diagnoses should be treated with first-line therapy.

This study has limitations. It was not possible to confirm the presence of allergy or previous treatment history, factors that influence appropriate antibiotic selection. These data are from 2010 to 2011 but are the most recent complete data available from NAMCS/NHAMCS, and we do not have reason to believe practice patterns have substantially changed.

This study provides evidence of substantial overuse of non–first-line antibiotics for 3 of the most common conditions in ambulatory care that collectively account for more than 40 million antibiotic prescriptions annually.² These findings indicate that the problem of inappropriate antibiotic prescribing includes not only prescriptions that are unnecessary altogether, but also selection of inappropriate agents.² As a result, stewardship interventions should address both antibiotic overuse and inappropriate antibiotic selection to improve patient safety and health care quality. Implementation of stewardship strategies is a key component to meeting the National Action Plan goal of reducing inappropriate antibiotic use by 50% in outpatient settings.¹

Corresponding Author: Adam L. Hersh, MD, PhD, 295 Chipeta Way, Salt Lake City, UT 84108 (adam.hersh@hsc.utah.edu).

Published Online: October 24, 2016. doi:10.1001/jamainternmed.2016.6625

Author Contributions: Drs Hersh and Shapiro had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Hersh, Fleming-Dutra, Hyun, Hicks.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Hersh, Hicks.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Hersh, Shapiro.

Obtained funding: Hicks.

Administrative, technical, or material support: Fleming-Dutra, Hyun, Hicks.

Study supervision: Hersh, Hicks.

Group Information: The Outpatient Antibiotic Use Target-Setting Workgroup Collaborators were Monina Bartoces, PhD, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia; Eva A. Enns, PhD, ‎Division of Health Policy & Management, University of Minnesota, Minneapolis; Thomas M. File Jr, MD, Summa Health System and Northeast Ohio Medical University, Akron; Jonathan A. Finkelstein, MD, MPH, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts; Jeffrey S. Gerber, MD, PhD, Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia; David Y. Hyun, MD, The Pew Charitable Trusts, Washington, DC; Jeffrey A. Linder, MD, MPH, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts; Ruth Lynfield, MD, Minnesota Department of Health, St Paul; David J. Margolis, MD, PhD, University of Pennsylvania Perelman School of Medicine, Philadelphia; Larissa S. May, MD, MSPH, Department of Emergency Medicine, University of California–Davis, Sacramento; Daniel Merenstein, MD, Department of Family Medicine, Georgetown University Medical Center, Washington, DC; Joshua P. Metlay, MD, PhD, Division of General Internal Medicine, Massachusetts General Hospital, Boston; ‎Jason G. Newland, MD, MEd, Division of Pediatric Infectious Diseases, Washington University School of Medicine, St Louis, Missouri; Jay F. Piccirillo, MD, Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri; Rebecca M. Roberts, MS, Centers for Disease Control and Prevention, Atlanta, Georgia; Guillermo Sanchez, MPH, PA-C, Centers for Disease Control and Prevention, Atlanta, Georgia; Katie J. Suda, PharmD MS, Department of Veterans Affairs, University of Illinois at Chicago, Chicago; Ann Thomas, MD, MPH, Oregon Public Health Division, Portland; Teri Moser Woo, PhD, Pacific Lutheran University, Tacoma, Washington; Rachel M. Zetts, The Pew Charitable Trusts, Washington, DC.

Conflict of Interest Disclosures: Dr Hersh has received funding from the CDC, the Agency for Healthcare Research and Quality, Pfizer/Joint Commission, and Merck. No other conflicts are reported.

Funding/Support: This project was made possible through a partnership with the CDC Foundation. Support for this project was provided by Pew Charitable Trusts.

Role of the Funder/Sponsor: The CDC participated in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The Pew Charitable Trusts participated in the interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The Pew Charitable Trusts sponsored in-person and telephone author meetings and supported some author travel to in-person meetings.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC.

Additional Contributions: Tia Carter, MS, Allan Coukell, BSc Pharm, and Elizabeth Jungman, JD, MPH, of The Pew Charitable Trusts assisted in convening author meetings. They did not receive any compensation for their role in the study.