Non-first-line antibiotics prescribed half the time for otitis media, sinusitis, pharyngitis
There is 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.
Physicians prescribed first-line recommended antibiotics only half of the time during visits for otitis media, sinusitis, and pharyngitis, and overuse of non-first-line agents, especially macrolides, was higher for adults than children, according to a recent study.
Otitis media, sinusitis, and pharyngitis account for nearly one-third of antibiotics prescribed in outpatient settings, and professional guidelines recommend narrow-spectrum agents as first-line therapies unless patients have penicillin allergies or a recent treatment failure. According to national guidelines, first-line antibiotic therapy is amoxicillin or amoxicillin with clavulanate (alternative) for otitis media, amoxicillin or amoxicillin with clavulanate for sinusitis, and penicillin or amoxicillin for pharyngitis.
To measure the frequency with which first-line agents were prescribed for these 3 conditions, researchers identified antibiotic prescribing visits 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 primary outcome for each condition was the percentage of visits at which first-line antibiotics were prescribed. Visits were stratified by age: pediatric, or 19 years or younger, and adult, or older than 19 years. Study results were published as a research letter in JAMA Internal Medicine on Oct. 24.
Among visits from 2010 to 2011 where antibiotics were prescribed, prescription of first-line antibiotics ranged from a low of 37% (95% CI, 32% to 43%) for adult patients with sinusitis and pharyngitis to a high of 67% (95% CI, 63% to 71%) for pediatric patients with otitis media. First-line agents were used in 52% of visits (95% CI, 49% to 55%) for all 3 conditions overall and were more likely to be prescribed to pediatric patients than to adults (P<0.001 for sinusitis and pharyngitis). The most common non-first-line antibiotic class prescribed was macrolides.
The researchers noted that available evidence suggests that 10% of the population reports a penicillin allergy and that 10% of visits for sinusitis and otitis media result from failed first-line therapy, suggesting that approximately 80% of visits for these diagnoses should be treated with first-line therapy. “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,” they wrote. “These findings indicate that the problem of inappropriate antibiotic prescribing includes not only prescriptions that are unnecessary altogether, but also selection of inappropriate agents.”