Rise in inappropriate antibiotic prescriptions for Streptococcal Pharyngitis in an era of antibiotic shortages

Abstract Background Group A streptococcal (GAS) pharyngitis is the most common cause of bacterial pharyngitis. It accounts for about a quarter of pharyngitis cases seen in children. The American Academy of Pediatrics (AAP) and Infectious Disease Society of America (IDSA) have issued guidelines for the diagnosis and treatment of GAS pharyngitis. Penicillin is the antibiotic of choice for GAS infections along with Amoxicillin. Based on a previous study at Loyola University Medical Center (LUMC), over 1/3rd of all antibiotics prescribed in our sample of 7000 encounters were considered inappropriate. During our intervention period, there was an increased incidence in GAS infections along with multiple antibiotic shortages from Oct 2022. Our study aimed to 1) Do provider education on evaluation of streptococcal pharyngitis and treatment 2) Evaluation of adherence to the evidence-based protocol 3) Determine frequency of inappropriate testing and antibiotic management 4) Determine the antibiotic when treating GAS at LUMC. Methods A retrospective chart review of patients between the ages of 0-18 years presented at LUMC with the pharyngitis diagnoses codes between Jan 2022-Dec 2022 and post-education between Jan 2023-June 2023 was done. LUMC providers were educated via different forums and an evidence-based protocol was shared. Patient-level data extracted from the Electronic Health Record (EHR) included race, gender, age in years, insurance type, drug allergies and encounter type i.e., clinic visit, immediate care (IMC) or emergency department (ED). P-values were calculated with repeated patients’ statement and exchangeable correlation matrix. Results Individuals with allergies and individuals who received antibiotics due to secondary diagnoses were excluded. The baseline year of 2022 had a lower incidence of positive GAS cases (5.7%) compared to the 2023 Q1 (27.5%) and Q2 (22.9%). Overall inappropriate prescribing was 19.2% in 2022 and increased to 39.2% and 40.9% in Q1 and Q2 of 2023, respectively. While there was an increased use of Penicillin in post-education period, there was an increase in use of other broad-spectrum antibiotics as well. Conclusion This study showed despite provider education, due to a significant increase in GAS cases across the US and national antibiotic shortages (amoxicillin and then penicillin) during our post-education period, there was an increase in inappropriate management of GAS cases. With reduction in antibiotic shortages, and continued provider education, future clinical management for GAS pharyngitis will improve for pediatric patients. Fig 1. Summary of incorrect prescribing: By Scenario Fig 2. Trends over time (by month) with reference lines for antibiotic shortages Table 1. Summary of Testing and Prescribing by Time