Beyond antibiotic prescribing rates: first-line antibiotic selection, prescription duration, and associated factors for respiratory encounters in urgent care

Abstract Objective: Assess urgent care (UC) clinician prescribing practices and factors associated with first-line antibiotic selection and recommended duration of therapy for sinusitis, acute otitis media (AOM), and pharyngitis. Design: Retrospective cohort study. Participants: All respiratory UC encounters and clinicians in the Intermountain Health (IH) network, July 1st, 2019–June 30th, 2020. Methods: Descriptive statistics were used to characterize first-line antibiotic selection rates and the duration of antibiotic prescriptions during pharyngitis, sinusitis, and AOM UC encounters. Patient and clinician characteristics were evaluated. System-specific guidelines recommended 5–10 days of penicillin, amoxicillin, or amoxicillin-clavulanate as first-line. Alternative therapies were recommended for penicillin allergy. Generalized estimating equation modeling was used to assess predictors of first-line antibiotic selection, prescription duration, and first-line antibiotic prescriptions for an appropriate duration. Results: Among encounters in which an antibiotic was prescribed, the rate of first-line antibiotic selection was 75%, the recommended duration was 70%, and the rate of first-line antibiotic selection for the recommended duration was 53%. AOM was associated with the highest rate of first-line prescriptions (83%); sinusitis the lowest (69%). Pharyngitis was associated with the highest rate of prescriptions for the recommended duration (91%); AOM the lowest (51%). Penicillin allergy was the strongest predictor of non–first-line selection (OR = 0.02, 95% CI [0.02, 0.02]) and was also associated with extended duration prescriptions (OR = 0.87 [0.80, 0.95]). Conclusions: First-line antibiotic selection and duration for respiratory UC encounters varied by diagnosis and patient characteristics. These areas can serve as a focus for ongoing stewardship efforts

Beyond antibiotic prescribing rates: first-line antibiotic selection, prescription duration, and associated factors for respiratory encounters in urgent care

OBJECTIVE: Assess urgent care (UC) clinician prescribing practices and factors associated with first-line antibiotic selection and recommended duration of therapy for sinusitis, acute otitis media (AOM), and pharyngitis. DESIGN: Retrospective cohort study. PARTICIPANTS: All respiratory UC encounters and clinicians in the Intermountain Health (IH) network, July 1st, 2019-June 30th, 2020. METHODS: Descriptive statistics were used to characterize first-line antibiotic selection rates and the duration of antibiotic prescriptions during pharyngitis, sinusitis, and AOM UC encounters. Patient and clinician characteristics were evaluated. System-specific guidelines recommended 5-10 days of penicillin, amoxicillin, or amoxicillin-clavulanate as first-line. Alternative therapies were recommended for penicillin allergy. Generalized estimating equation modeling was used to assess predictors of first-line antibiotic selection, prescription duration, and first-line antibiotic prescriptions for an appropriate duration. RESULTS: Among encounters in which an antibiotic was prescribed, the rate of first-line antibiotic selection was 75%, the recommended duration was 70%, and the rate of first-line antibiotic selection for the recommended duration was 53%. AOM was associated with the highest rate of first-line prescriptions (83%); sinusitis the lowest (69%). Pharyngitis was associated with the highest rate of prescriptions for the recommended duration (91%); AOM the lowest (51%). Penicillin allergy was the strongest predictor of non-first-line selection (OR = 0.02, 95% CI [0.02, 0.02]) and was also associated with extended duration prescriptions (OR = 0.87 [0.80, 0.95]). CONCLUSIONS: First-line antibiotic selection and duration for respiratory UC encounters varied by diagnosis and patient characteristics. These areas can serve as a focus for ongoing stewardship efforts

Subgroup analysis of differences in ordinal scale at days 28–35.

Estimated proportional odds ratios comparing day 28–35 ordinal scale in HCQ/CQ versus control groups. Estimates are given for the pooled patient population and for subgroups. Blue circles represent model-standardized estimates; blue horizontal lines represent 95% credible intervals. Open grey circles represent plug-in estimates; grey horizontal lines represent 95% confidence intervals. Grey circle size represents the number of patients in the corresponding subgroup. Arrows indicate uncertainty intervals extending beyond plot limits. Study acronyms are explained in Fig 1. Two trials did not have study acronyms (only trial registration numbers). Abbreviations: 95% CrI, 95% credible intervals; HCQ/CQ, hydroxychloroquine or chloroquine; NA, not applicable; NIV, noninvasive ventilation (includes BiPAP/CPAP and/or high-flow oxygen); OR, odds ratio.</p

Trial characteristics: Treatment groups, participant assessment, and inclusion/exclusion criteria.

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Trial selection process.

aTwo of the trials did not have study acronyms (only trial registration numbers). Abbreviations: COVID MED, Comparison Of Therapeutics for Hospitalized Patients Infected With SARS-CoV-2 In a Pragmatic aDaptive randoMizED Clinical Trial During the COVID-19 Pandemic; HAHPS, Hydroxychloroquine vs. Azithromycin for Hospitalized Patients With Suspected or Confirmed COVID-19; OAHU-COVID19, A Randomized, Controlled Clinical Trial of the Safety and Efficacy of Hydroxychloroquine for the Treatment of COVID-19 in Hospitalized Patients; ORCHID, Outcomes Related to COVID-19 Treated With Hydroxychloroquine Among In-patients With Symptomatic Disease; TEACH, Treating COVID-19 With Hydroxychloroquine; WU352, Washington University 352: Open-label, Randomized Controlled Trial of Hydroxychloroquine Alone or Hydroxychloroquine Plus Azithromycin or Chloroquine Alone or Chloroquine Plus Azithromycin in the Treatment of SARS CoV-2 Infection.</p

Assessing between-study heterogeneity.

Estimated study coefficients from the primary outcome model, with 66% and 95% credible intervals (CrI) indicated. “Control” terms represent differences in predicted outcomes between sites under control, for individuals with similar baseline covariates, on the proportional log-odds scale. Treatment effect terms represent differences in predicted treatment effect between sites, again for individuals with similar baseline covariates. Positive coefficients represent, respectively, better ordinal scale outcomes under control and benefit of HCQ/CQ at days 28–35 post-enrollment. Estimated between-study standard deviations were 1.48 for the “Control” terms (95% CrI, 0.16–5.98; on the log-odds scale) and 0.87 for the treatment effects (95% CrI, 0.01–5.17). Tests of publication bias applied to unadjusted study-specific proportional ORs from the 6 studies with patients assigned to both HCQ/CQ and control yielded inconclusive results (Egger’s test: p = 0.10; Begg’s test: p = 0.57); these should be interpreted with caution given the small number of included studies. HCQ/CQ indicates hydroxychloroquine or chloroquine. (PDF)</p