Potential Opportunities for Outpatient Antibiotic Stewardship

Reviewed by Cynthia T. Nguyen, PharmD; University of Chicago Medicine

Palms and colleagues evaluated antibiotic prescribing in retail clinics, emergency departments (EDs), urgent care centers, and medical offices associated with pharyngitis, sinusitis, and pediatric acute otitis media (AOM) outpatient visits using the 2014 IBM MarketScan Commercial Database. This database captures claims data on patients younger than 65 years old with employer-sponsored insurance. In this analysis, first-line antibiotics for pharyngitis were defined as amoxicillin and penicillin. For sinusitis and pediatric AOM, first-line antibiotics were amoxicillin or amoxicillin-clavulanate. Overall, among >4,800,000 antibiotic visits, 50% received first-line antibiotics. First-line therapy was prescribed in 70% of retail clinics, 57% of EDs, 49% of urgent care centers, and 50% of medical offices. First-line therapy was higher for children than adults in all settings (62% versus 41%). Macrolides were the most common non-first-line antibiotic therapy. Cephalosporins were also common. Based on previously published studies, the target rate of prescribing for first-line therapies is 80%, which accounts for treatment failures to previous antibiotics and for patients with reported allergies. Consequently, opportunities exist for optimizing antibiotic selection among these common outpatient infections.

Reducing duration of therapy is another potential opportunity to improve the management of outpatient infections. Previous studies have suggested antibiotic courses less than 10 days of therapy for group A streptococcal (GAS) pharyngitis were associated with more relapse/complications. To further evaluate this, Skoog Ståhlgren and colleagues conducted a multicenter, open-label, randomized controlled trial in Sweden. Patients at least 6 years old with GAS pharyngitis were randomized to receive either penicillin V 800mg four times daily for 5 days or 1000mg three times daily for 10 days. Among the 397 patients in the per protocol analysis, no difference in clinical cure at 5-7 days after the end of therapy was observed [89.6% versus 93.3%, difference -3.7 (95% CI -9.7 to 2.2)] but bacteriologic eradication was lower in the 5-day group [80.4% versus 90.7%, difference -10.2 (95% CI -17.8 to -2.7)]. No statistically significant differences in 30-day relapse (4.5% versus 3.9%) and new tonsillitis within 3-months (3.0% versus 6.9%) were observed. The 10-day group had greater frequency and duration of adverse events (mostly diarrhea, nausea, and vaginitis). Overall, this study suggests the potential to reduce durations of therapy for pharyngitis.


Palms DL, Hicks LA, Bartoces M, et al. First-Line Antibiotic Selection in Outpatient Settings. Antimicrob Agents Chemother. 2019 Oct 22;63(11). https://aac.asm.org/content/63/11/e01060-19.long 

Skoog StÃ¥hlgren G, Tyrstrup M, Edlund C, et al. Penicillin V four times daily for five days versus three times daily for 10 days in patients with pharyngotonsillitis caused by group A streptococci: randomised controlled, open label, non-inferiority study. BMJ. 2019 Oct 4;367:l5337. https://www.bmj.com/content/367/bmj.l5337 

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