CIDRAP ASP Journal Club - January 2017

Hersh AL, Fleming-Dutra KE, Shapiro DJ, et al. Frequency of first-line antibiotic selection among US ambulatory care visits for otitis media, sinusitis, and pharyngitis. JAMA Intern Med 2016 (published online Oct 24)

Our journal club for January 2017 will focus on the issue of outpatient antibiotic prescribing, and there will be several ways to share your thoughts on the research and/or your experiences in clinical practice, learn from experts involved in prescription data collection and analysis, and join a conversation about the implications of this study.

There are multiple ways to participate!

Read the article and/or the summary below, along with comments that have already been posted.

Listen to our podcast with study author Katherine Fleming-Dutra, MD, medical epidemiologist with the Office of Antibiotic Stewardship at the Centers for Disease Control and Prevention (CDC).

Comment on the study or on any issue you feel is important to the topic of antibiotic prescribing and stewardship in ambulatory care. Please feel free to also answer any of the questions below the summary. Comments are submitted via e-mail and posted when appropriate to ensure a respectful conversation.

View the Storify stream of our Jan 18 Twitter chat with Dr. Katherine Fleming-Dutra.

Tweet your comments on the study and/or the issue any time during the month of January. Make sure to include our handle (@CIDRAP_ASP) and the hashtag #ASPJournalClub.

Article summary

Why is this topic important?

A recent study in the Journal of the American Medical Association found that at least 30% of antibiotic prescriptions in outpatient settings are unnecessary, and the vast majority of antibiotic therapy in ambulatory care is prescribed for treatment of otitis media, sinusitis, and pharyngitis.1 In support of their research, Hersh et al cited treatment guidelines published by the American Academy of Pediatrics and the Infectious Diseases Society of America that recommend the use of narrow spectrum antibiotics (eg, amoxicillin, penicillin) for first-line treatment of these common conditions in pediatric and adult patients without penicillin allergy or previous first-line treatment failure.2, 3, 4, 5

According to the Centers for Disease Control and Prevention, approximately 20% of pediatric visits and 10% of adult visits to ambulatory care settings resulted in an antibiotic prescription during 2013. The agency’s recently published “Core Elements of Outpatient Antibiotic Stewardship” recommends adhering to evidence-based diagnostic criteria and treatment recommendations for otitis media, sinus infection, and pharyngitis as part of the national strategy to reduce unnecessary and inappropriate antibiotic use.6 Reducing overuse and achieving better bug-drug matches through the evidence-based use of first-line therapies in ambulatory care is essential for meeting the goal of reducing inappropriate outpatient antibiotic use by 50% by 2020, as set forth by the White House’s National Action Plan for Combating Antibiotic-Resistant Bacteria.7 A core concept of antimicrobial stewardship is appropriate use of antimicrobials, including “right drug, right dose, right time, and right duration.” This is a key theme for CDC’s Get Smart About Antibiotics Week, which is held each year during the month of November.  

What were the goals of the study?

The goal of the study was to measure the frequency with which first-line agents are prescribed for otitis media, sinusitis, and pharyngitis.

What methods did the authors use?

The authors represent a subset of an expert panel, including members of the Centers for Disease Control and Prevention (CDC), convened by the Pew Charitable Trusts to analyze prescribing data in the United States from 2010 to 2011 and set national targets for improving antibiotic selection for otitis media, sinusitis, and pharyngitis.

The researchers sampled data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) on more than 44 million antibiotic prescribing visits to office-based physicians and hospital outpatient and emergency departments for otitis media (limited to patients 19 years and younger), sinusitis, and pharyngitis during 2010 to 2011. Diagnostic codes were assigned using the International Classification of Diseases, Ninth Revision, Clinical Modification.

The primary outcome was the percentage of visits that resulted in a prescription for first-line antibiotics, which the authors defined as “the initial recommended antibiotics for treatment of patients without drug allergies, including alternative therapy indicated for specific situations.”

In the context of the study, first-line antibiotic therapy, as recommended by national guidelines, was considered to be amoxicillin or amoxicillin with clavulanate for otitis media (ie, amoxicillin with clavulanate would be an alternative therapy for otitis media with concurrent conjunctivitis), amoxicillin or amoxicillin with clavulanate for sinusitis, and penicillin or amoxicillin for pharyngitis. Treated patients returning for unplanned follow-up care with worsening symptoms suggesting treatment failure were considered ineligible for first-line therapy.

For the purposes of the study, the investigators stratified outpatient visits by pediatric (19 years or younger) and adult (older than 19 years) cases. Analyses were conducted with Stata statistical software, version 12. 

What did they find?

The investigators identified 1,705 sampled visits for otitis media, 1,686 visits for sinusitis (463 pediatric and 1,223 adult), and 1,836 visits for pharyngitis (1,006 pediatric and 830 adult). For all three conditions combined, first-line antibiotics were prescribed 52% of the time (95% Confidence Interval [CI], 49%-55%), and the use of first-line therapy was significantly more common in pediatric patients compared to adults (p<0.001 for sinusitis and pharyngitis).

The highest percentage of first-line antibiotics (67%; [95% CI, 63%-71%]) was prescribed during pediatric visits for otitis media. For pharyngitis, 60% of pediatric patients received first-line therapy, and 52% of children were treated with first-line antibiotics for sinusitis.

Only 37% (95% CI, 32%-43%) of adult visits for sinusitis and pharyngitis resulted in a prescription for a first-line agent. Macrolides were the most commonly prescribed non-first-line antibiotic class, with more than 25% of adult pharyngitis visits and pediatric and adult sinusitis visits resulting in a macrolide prescription.

Researchers also noted broad cephalosporin use (including second- and third-generation agents), especially in pediatric patients with sinusitis and otitis media. Among other non-first-line antibiotic use, prescription of fluoroquinolones was highest in adults with sinusitis.

What are the major study limitations?

The investigators were not able to confirm certain factors that may have affected appropriate antibiotic selection, such as allergy or treatment history/failure. The data were obtained from 2010 and 2011 and represent the most complete information available from the national ambulatory medical care surveys, however, the results may not be reflective of more recent prescribing patterns occurring after 2011.

What are the practice and policy implications?

The investigators state that the 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.”

While policy focused on addressing inappropriate antibiotic prescribing often focuses on reducing unnecessary prescriptions, the sampled data in this study demonstrate the importance of also addressing the selection of inappropriate antibiotics to treat common infections. The authors cited studies by the Joint Task Force on Practice Parameters et al, Piccarillo et al, and Capra et al, which suggest that, when excluding patients with penicillin allergy or prior first-line treatment failure, 80% of outpatient visits for otitis media, sinusitis, and pharyngitis can be treated with first-line, narrow spectrum antibiotics.8, 9, 10

Antimicrobial stewardship programs that address both antibiotic overuse when antibiotics are not indicated and inappropriate use when the best therapy must be matched to the infection will help meet the National Action Plan goal of decreasing inappropriate antibiotic use by 50% in outpatient settings by 2020. A report from the Pew Charitable Trusts associated with the Hersh et al study suggests updating practice and prescribing guidelines for first-line therapies, along with implementing audit and feedback mechanisms that allow clinicians to see their prescribing rates in real time.11  

Topics for discussion: Your feedback welcome!

Do you believe we can meet the National Action Plan goal of decreasing inappropriate antibiotic use by 50% in outpatient settings by 2020?

What are the biggest challenges of changing antibiotic prescribing for the three conditions described in the study.

Have you implemented interventions to improve antibiotic selection in your hospital or clinic? What practices worked, and what proved to be challenging?

Do you believe that current practice patterns may be different that those noted in the study, since data for the study were collected in 2011? In what way?


  1. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA 2016;315(17):1864-73
  2. Chow AW, Benninger MS, Brook I, et al. IDSA Clinical practice guidelines for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012;54(8):e72-112
  3. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131(3):e964-99
  4. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 2015 Apr;152(suppl 2):S1-39
  5. Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics 2013;132(1):e262-80
  6. Sanchez GV, Fleming-Dutra KE, Roberts RM, et al. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep 2016 Nov 11;65(6):1-12
  7. The White House. National action plan for combating antibiotic resistant bacteria. Accessed Nov 30, 2016
  8. Joint Task Force on Practice Parameters, American Academy of Allergy, Asthma and Immunology, American College of Allergy, Asthma and Immunology, et al. Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol 2010;105(4):259-273
  9. Piccirillo JF, Mager DE, FrisseME, et al. Impact of first-line vs second-line antibiotics for the treatment of acute uncomplicated sinusitis. JAMA 2001;286(15):1849-56
  10. Capra AM, Lieu TA, Black SB, et al. Costs of otitis media in a managed care population. Pediatr Infect Dis J 2000;19(4):354-5
  11. The Pew Charitable Trusts. Health experts establish national targets to improve outpatient antibiotic selection. (published online Oct 24)


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First Name

My comments address this question:

What are the biggest challenges of changing antibiotic prescribing for the three conditions described in the study (otitis media, sinusitis, pharyngitis)?

The challenge is two-fold, it requires behavior change of both physicians and consumers. However it is hard to change behavior if you don't perceive your behavior has any negative consequences.

1. Physicians need to understand the consequences of prescribing broad spectrum antibiotics when narrow spectrum antibiotics will do the job. Because cultures are not the norm in outpatient settings, they do not see the development of antibiotic resistance. This is where the ASP pharmacist or physician needs to step up and provide face to face round table discussions with their outpatient clinic providers. A reassuring voice by an ID expert that this is "best of care" can go a long way. More studies documenting the poor use of antibiotics for sinusitis, laryngitis, or otitis media will "go in one ear and out the other."

2. Consumers need to be educated to stop pressuring their doctor to prescribe antibiotics for their child or themselves. Consumer education about the "risk" of antibiotics (C diff and superbugs) can occur at health fairs, social media Twitter chats, and YouTube videos. It is the role of ASP to dispel the myth that antibiotics are benign drugs. ASP pharmacists and physicians need to speak to consumers and be the voice for responsible use of antibiotics.​


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