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Published online by Cambridge University Press: 02 November 2020
Background: A multicenter audit-and-feedback intervention was conducted to improve management of acute respiratory infections (ARIs) including group A streptococcal (GAS) pharyngitis within 6 VA medical Centers (VAMCs). A relative reduction (24.8%) in azithromycin prescribing after the intervention was observed. Within these facilities during 2015–2018, 2,266 cases of GAS occurred, and susceptibility to erythromycin ranged from 55% to 70%. We evaluated whether prescribing a macrolide for GAS pharyngitis was associated with an increase in outpatient return visits. Methods: A cohort of ambulatory adults treated for GAS pharyngitis (years 2014–2019) at 6 VAMCs was created. Demographic, diagnostic, treatment, and revisit data were extracted from the Corporate Data Warehouse. GAS pharyngitis was defined by an acute pharyngitis diagnostic code combined with a GAS-positive rapid strep test or throat culture ≤3 days of index date. Antibiotic prescriptions were included if filled ≤3 days of index date and were classified as first line (penicillin/amoxicillin), second line (cephalexin/clindamycin), macrolides (azithromycin, clarithromycin, erythromycin), or other (remaining antibiotics). A return visit was defined as a new visit to primary care, urgent care, or the emergency department with a diagnostic code for an ARI ≤30 days from the index visit. Logistic regression was used to adjust for nonantibiotic covariates and to compare treatments. Results are reported as odds ratio (OR ± 95% CI; P value). Results: Of 12,666 patients with a diagnostic code for acute pharyngitis, 2,923 (23.1%) had GAS testing performed. Of those, 582 (19.9%) were GAS-positive and 460 (15.7%) received antibiotics. The mean age was 39.0 years (±SD, 11.7) and 73.7% were male. Antibiotics included penicillins for 363 patients (78.9%), cephalosporins for 21 (4.6%), clindamycin for 32 (7.0%), macrolides for 47 (10.2%), and other for 17 (3.9%). Penicillin allergy was documented in 48 patients (10.5%), and these patients received cephalosporins (18.8%), clindamycin (35.4%), macrolides (41.7%), and other antibiotics (4.2%). Return visits occurred in 47 cases (10.4%). Limited chart review indicated that 6 of 10 macrolide recipients (60.0%) with return visits had recurrence or unresolved symptoms. After adjustment for calendar month and facility, odds of a return visit for treatment with a macrolide relative to penicillins was 2.79 (OR, 1.19; 95% CI, ±6.56; P = .02). The audit-feedback intervention was not associated with ARI-related return visits (OR, 0.53; 95% CI, 0.26–1.06; P = .07). Conclusions: Return visit rates were higher for GAS pharyngitis patients treated with a macrolide than for those treated with penicillins. Macrolides were the most commonly prescribed non-penicillin therapy irrespective of penicillin allergy. Further work is necessary to determine the reason for the increase in return visits.
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