Pharyngitis treatment by emergency physicians from 1995 to 2001: do our antibiotic choices conform to national guidelines?

Study objectives: Group A β-hemolytic streptococci (GABHS) is the only common cause of pharyngitis warranting antibiotics. Penicillin and erythromycin are recommended for GABHS in adults (≥12 years) by the Infectious Diseases Society of America (IDSA); aminopenicillins are recommended for children (<12 years) because of their palatability. We assessed trends in emergency department (ED) antibiotic therapy for pharyngitis patients. Methods: This retrospective, observational study used the National Hospital Ambulatory Medical Care Survey ED data, which annually conducts population-weighted, randomized sampling of EDs nationwide, from 1995 to 2001. Outcome measures were treatment with antibiotics according to IDSA guidelines. Comparisons were made with Pearson χ2 and analysis of variance; α was set at 0.01. Results: Fifty-one percent of the pharyngitis cohort received antibiotics. During the 7-year study period, antibiotic use decreased for children from 62% to 47% (P<.009) and for adults from 56% to 49% (P<.001). Recommended antibiotic use decreased from 49% to 30% for children (P<.001) and decreased from 21% to 9% for adults (P<.001). Penicillin and aminopenicillin therapy for children decreased from 45% to 27% (P<.006), with a subsequent increase in extended macrolides (eg, azithromycin, clarithromycin) from 0% to 9% (P<.001). For adults, penicillin and erythromycin use decreased from 9% to 6% (P<.003) and 12% to 3% (P<.001), respectively. Concurrently, extended macrolide and fluoroquinolone (eg, levofloxacin, gatifloxacin) use increased from 3% to 13% (P<.001) and 0.8% to 2.5% (P<.002), respectively. Emergency physicians prescribed antibiotics for 54% of pharyngitis cases compared with 43% for residents and 61% for physician extenders (P<.008). Emergency physicians prescribed recommended antibiotics to 20% compared with 18% for residents and 23% for physician extenders (P<.22). Conclusion: From 1995 to 2001, there was a trend toward less antibiotic usage for ED pharyngitis patients, with a concurrent increase in use of expensive, broad-spectrum antibiotics.