Antibiotic Treatment of Children With

Sore Throat
Abstract
Context Of children with sore throat, 15% to 36% have pharyngitis caused by group A
-heolytic streptococci !"A#$%&' (erforance of a "A#$% test prior to antibiotic
prescribing is recoended for children with sore throat' (enicillin, ao)icillin,
erythroycin, and first-generation cephalosporins are the recoended antibiotics for
treatent of sore throat due to "A#$%'
Design, Setting, and Participants Analysis of visits by children aged 3 to 1* years with
sore throat to office-based physicians, hospital outpatient departents, and eergency
departents in the +ational Abulatory ,edical -are %urvey and +ational $ospital
Abulatory ,edical -are %urvey, 1..5 to /003 !+ 1 2153& and of a subset of visits with
"A#$% testing data !n 1 /*.*&'
Main Outcome Measures +ational rates of antibiotic prescribing, prescribing of
antibiotics recoended and not recoended for "A#$%, and "A#$% testing'
Results (hysicians prescribed antibiotics in 53% !.5% confidence interval 4-56, 2.%-
56%& of an estiated *'3 illion annual visits for sore throat and nonrecoended
antibiotics to /*% !.5% -5, /2%-31%& of children who received an antibiotic' Antibiotic
prescribing decreased fro 66% of visits in 1..5 to 52% of visits in /003 !P 1 '01 for
trend&' 7his decrease was attributable to a decrease in the prescribing of recoended
antibiotics !2.% to 33%8 P 1 '00/&' (hysicians perfored a "A#$% test in 53% !.5%
-5, 23%-5*%& of visits and in 51% !.5% -5, 25%-5*%& of visits at which an antibiotic
was prescribed' "A#$% testing was not associated with a lower antibiotic prescribing
rate overall !23% tested vs 51% not tested8 P 1 '20&, but testing was associated with a
lower antibiotic prescribing rate for children with diagnosis codes for pharyngitis,
tonsillitis, and streptococcal sore throat !5*% tested vs *3% not tested8 P9'001&'
Conclusions (hysicians prescribed antibiotics to 53% of children with sore throat, in
e)cess of the a)iu e)pected prevalence of "A#$%' Although there was a decrease
in the proportion of children receiving antibiotics between 1..5 and /003, this was due to
decreased prescribing of agents recoended for "A#$%' Although "A#$% testing
was associated with a lower rate of antibiotic prescribing for children with diagnosis
codes of pharyngitis, tonsillitis, and streptococcal sore throat, "A#$% testing was
underused'
(haryngitis accounts for 6% of visits by children to faily edicine physicians and
pediatricians'
1
7he ost coon anifestation of acute pharyngitis is sore throat'
/
,ost
sore throats are due to upper respiratory viruses such as rhinovirus, coronavirus, and
adenovirus'
3
7he ain bacterial cause of sore throat and the only coon cause of sore
throat warranting antibiotic treatent is group A -heolytic streptococci !"A#$%&'
2-5
"A#$% are cultured fro 15% to 36% of children with sore throat'
6-13
7he Aerican Acadey of (ediatrics !AA(&, the -enters for :isease -ontrol and
(revention !-:-&, and the 5nfectious :iseases %ociety of Aerica !5:%A& recoend
penicillin as the antibiotic of choice for children with sore throat due to "A#$%
/-3,5
but
also identify ao)icillin, erythroycin !for penicillin-allergic patients&, and first-
generation cephalosporins as acceptable alternatives' 5n addition, to iprove diagnostic
accuracy and reduce unnecessary antibiotic treatent, the AA(, -:-, and 5:%A all
recoend perforance of a "A#$% test prior to treating children with an antibiotic'
(rior studies have found high rates of antibiotic prescribing to children diagnosed with
pharyngitis
12-16
but have not focused on children presenting with a chief coplaint of sore
throat, a ore clinically relevant approach' An analysis of children with a chief coplaint
of sore throat would allow coparison between the antibiotic prescribing rate and the
;nown prevalence of "A#$%' 5n addition, these prior studies have not easured changes
in the rates of recoended and nonrecoended antibiotic prescribing over tie or
evaluated the role of "A#$% testing' 7o easure changes in the rate and type of
antibiotics prescribed to children with a chief coplaint of sore throat, and their
relationship to "A#$% testing, we analy<ed data fro the +ational Abulatory ,edical
-are %urvey !+A,-%& and the +ational $ospital Abulatory ,edical -are %urvey
!+$A,-%& fro 1..5 to /003'
MT!ODS
Data Sources
7he +A,-% and the +$A,-% are adinistered by the Abulatory -are %tatistics
#ranch of the -:- +ational -enter for $ealth %tatistics !+-$%&'
1*-1.
7he +A,-%
collects inforation on patient visits to non=federally funded, counity, office-based
physician practices throughout the >nited %tates' 7he +$A,-% collects inforation on
patient visits to hospital outpatient departents and hospital eergency departents as
separate coponents'
7he surveys have ultistage probability designs' 7he +A,-% has a 3-stage sapling
design, with sapling based on geographic location, physician practices within a
geographic location !stratified by physician specialty&, and visits within individual
physician practices' (hysicians who are selected to participate in the +A,-% during a
particular calendar year are not eligible to be selected again for at least another 3 years'
7he +$A,-% has a 2-stage sapling design, with sapling based on geographic area,
hospitals within a geographic area, clinics or eergency departents within hospitals,
and patient visits within clinics or eergency departents' 7he +$A,-% has a panel of
hospitals that rotates so that a given hospital participates every 15 onths'
(hysician !+A,-% only&, hospital !+$A,-% only&, and patient and clinical !both
surveys& inforation is collected at each selected visit and is recorded on patient record
fors by participating physicians, office staff, hospital staff, or -ensus #ureau
representatives' (atient inforation includes deographic data and insurance status'
/0-/1
?ace and ethnicity are classified by the person filling out the patient record for,
according to an office or hospital@s usual practice for collecting such inforation'
(hysician and hospital inforation includes self-identified specialty !in the +A,-%
only&, clinic type !in the +$A,-% only&, geographic region, and whether the practice is
in a rural area' -linical characteristics include up to 3 reasons for the visit !1 Aost
iportantB and / AotherB8 coded using the +-$% Reason for Visit Classification&, 3
diagnoses !1 priary and / secondary diagnoses8 coded using the International
Classification of Diseases, Ninth Revision, Clinical Modification 4ICD-9-CM6&, up to 3
edications, and the corresponding National Drug Code Directory class nuber for each
edicine'
//
7he +A,-% included a variable indicating perforance of a "A#$% test !culture or
rapid test& fro 1..* to /003' 7he +$A,-% included a variable indicating perforance
of a "A#$% test fro 1..* to /003 in hospital outpatient departents and fro /001 to
/003 in hospital eergency departents' +either survey includes "A#$% test results'
7he surveys collected *63 553 patient records between 1..5 and /003'
/0-/1
7he
participation rate of contacted physician practices in the +A,-% ranged fro 63% in
1... to *3% in 1..5' 7he participation rate of contacted hospitals in the +$A,-%
ranged fro ./% in /003 to .3% in 1..3' Cuality control was perfored using a /-way
independent verification procedure for 10% of the saple records' 5n /003, coding errors
for various ites ranged fro 0'/% to 1'1% in the +A,-% and fro 0% to 0'*% in the
+$A,-%'
7he +-$% weights each visit to allow e)trapolation to national estiates for all aspects
of the surveys' 7he visit weight accounts for selection probability, adDustent for no
response, and other adDustents to reflect the universe of abulatory visits in the >nited
%tates'
/0-/1
7he +-$% institutional review board approved the protocols for the +A,-% and
+$A,-%, including a waiver of the reEuireent for infored consent of participating
patients' 7he confidentiality of the data is protected by law'
/3
Stud" Population
Fe included visits by children aged 3 to 1* years !because children younger than 3 years
are unli;ely to have "A#$% pharyngitis& with a priary reason for visit of Asyptos
referable to the throatB !Reason for Visit Classification code 12558 .6% reported
AsorenessB or ApainB in the throat&' 5n the +A,-%, we included visits to physicians with
a specialty of pediatrics, faily practice, general practice, general internal edicine, and
eergency edicine' 5n the +$A,-%, we included visits to pediatric clinics, general
edicine clinics, and eergency departents' Fe considered visits to pediatric clinics as
visits to pediatricians' Fe considered visits to faily practice, general practice, and
general internal edicine physicians as well as to general edical clinics as other
priary care visits' Fe considered visits to eergency edicine physicians as visits to
eergency departents' Fe e)cluded fro the analysis visits by children with a chief
coplaint of sore throat with a diagnosisGpriary, secondary, or tertiaryGthat could
account for an antibiotic prescription other than for "A#$% pharyngitis !eg, otitis edia,
sinusitis, pneuonia, cellulitis 4n 1 6606&' 7here were 2153 saple records for sore throat
that et all inclusion and e)clusion criteria'
Data Anal"sis
Fe identified antibiotics by using the National Drug Code Directory class prefi) 03
!AantiicrobialsB& and e)cluded polyy)ins, ainoglycosides !which generally are not
prescribed for systeic use in the outpatient setting&, and antiycobacterial, antifungal,
and antiviral agents' Fe defined penicillin, ao)icillin !including apicillin&,
erythroycin, and first-generation cephalosporins as antibiotics recoended for
treatent of "A#$% infection'
/-3,5
Fe considered all other antibiotics, including
ao)icillinHclavulanate, as nonrecoended for "A#$% treatent' 5f ore than 1
antibiotic was used in a single visit !1'3% of saple records&, we counted each antibiotic
prescribed in its respective subclass, but we counted the visit only once as an episode of
care in which an antibiotic was prescribed' 5f a patient received both a recoended and
a nonrecoended antibiotic, we considered hi or her to have received a recoended
antibiotic'
Fe analy<ed the subset of records for which "A#$% testing inforation was available
fro 1..* to /003 !n 1 /*.*&' 5n addition, to appro)iate a $ealth (lan Iployer :ata
and 5nforation %et !$I:5%& Euality easure that was introduced in /002, we analy<ed
visits for which "A#$% testing inforation was available and that had a priary
diagnosis code of acute pharyngitis !ICD-9-CM 26/&, acute tonsillitis !ICD-9-CM 263
and 265&, and streptococcal sore throat !ICD-9-CM 032, 021'0, 021'00, 021'01, and
021'0.&'
/2-/5
Fe also e)ained the copleentary set of visits by children with a report
of sore throat who had diagnoses that did not fall under the $I:5% easure definition'
Statistical Anal"sis
Fe calculated %Is for all results as recoended by the +-$% using %>:AA+
software, which accounts for the cople) sapling design of the +A,-%H+$A,-%'
/0-
/1
All statistical tests were based on estiates that had a less than 30% relative %I !ie, the
%I divided by the estiate e)pressed as a percentage of the estiate& and were based on
30 cases or ore in the saple data' According to the +-$%, estiates with a greater
than 30% relative %I or based on fewer than 30 saple cases ay be unreliable' :ue to
this restriction, and because of the sall si<e of nonwhite racial groups, we dichotoi<ed
the race variable into white and nonwhite categories'
Fe evaluated categorical variables with the J
/
test' 7o assess changes in prescribing over
tie, we used the linear trend test' All statistical trend tests ta;e into account data fro all
. years fro 1..5 through /003'
Fe developed 3 ultivariable logistic regression odels, adDusting for patient
deographic, insurance, and physician and hospital inforation' Fe included race and
ethnicity because we have previously found race and ethnicity to be associated with
differing prescribing practices for acute respiratory tract infections'
/6-/*
7he first logistic
regression odel included all sore throat visits and had antibiotic prescribing as the
dependent variable !n 1 2153&' 7he second logistic regression odel included visits at
which an antibiotic was prescribed and had prescribing of nonrecoended antibiotics
as the dependent variable !n 1 /313&' 7hese / odels reflect our hypothesis that
physicians first decide whether or not to prescribe an antibiotic and then decide which
antibiotic to prescribe' 7he third odel included visits for which data about "A#$%
testing were available fro 1..* to /003 and had "A#$% testing as the dependent
variable !n 1 /*.*&' All analyses were perfored with %A% version .'1 !%A% 5nstitute
5nc, -ary, +-& and %A%-callable %>:AA+ version .'0'1 !?esearch 7riangle 5nstitute,
?esearch 7riangle (ar;, +-&' All P values are /-tailed8 P9'05 was considered significant'
RS#$TS
Sore Throat %isit Rates and Characteristics
After e)cluding visits with a concoitant nonpharyngitis, antibiotic-appropriate
diagnosis, there were an estiated 66 illion !.5% confidence interval 4-56, 5. illion-
*3 illion& visits in the >nited %tates by children aged 3 to 1* years with sore throat to
pediatricians, other priary care physicians and clinics, and eergency departents
between 1..5 and /003' Annual visits for sore throat averaged *'3 illion visits per year,
ranging fro 6'/ illion visits in 1..* to .'* illion visits in /00/' $owever, there was
no significant change in the proportion of all visits that were for sore throat over tie,
decreasing fro 6'2% of visits in 1..5 to 5'.% in /001 and increasing to 3'1% in /003
!P 1 '1. for trend&'
7he ost freEuent physician-reported priary diagnoses for visits with a chief coplaint
of sore throat were acute pharyngitis !32% of visits&, streptococcal sore throat !1*%&, and
upper respiratory tract infection !1*%& !7able 1&' -hildren with sore throat were 2*%
ale and 35% white !7able /&' Kifty-si) percent of visits were to pediatricians or
pediatric clinics, 36% of visits were to other priary care physicians or clinics, and .%
of visits were to eergency departents'
Antibiotic Prescribing
Over the .-year study period, physicians prescribed antibiotics in 53% of visits !.5% -5,
2.%-56%8 7able 3&' Antibiotics recoended for treatent of "A#$% were prescribed
in 33% of visits !.5% -5, 36%-21%&, and nonrecoended antibiotics were prescribed
in 12% !.5% -5, 1/%-1*%&' (hysicians prescribed nonrecoended antibiotics to /*%
!.5% -5, /2%-31%& of children who received an antibiotic'
Table &' 7ype of Antibiotics (rescribed for -hildren Fith %ore 7hroat in the >nited
%tates, 1..5 to /003 !+ 1 2153&
Antibiotic prescribing for patients with sore throat decreased over tie fro 66% of
visits in 1..5 to 22% of visits in /00/, then increased to 52% of visits in /003 !P 1 '01
for linear trend fro 1..5 to /003& !Kigure&' ?ecoended antibiotic prescribing
decreased fro 2.% of visits in 1..5 to 33% of visits in /003 !P 1 '00/ for trend&, but
there was no significant change in the prescribing of nonrecoended antibiotics over
tie !13% in 1..5 to 16% in /0038 P 1 '3/ for trend&'
(igure' Antibiotic (rescribing for -hildren Fith %ore 7hroat in the >nited %tates, 1..5-
/003
+ational estiates based on 2153 visits in the +ational Abulatory ,edical -are %urvey
and the +ational $ospital Abulatory ,edical -are %urvey' ?ecoended antibiotics
are penicillin, ao)icillin, erythroycin, and first-generation cephalosporins' Kor trendL
P 1 '01 for any antibiotic, P 1 '00/ for recoended antibiotics, and P 1 '3/ for
nonrecoended antibiotics'
(hysicians prescribed ao)icillin !/6% of visits&, penicillin !*%&, first-generation
cephalosporins !3%&, and erythroycin !/%& !7able 3&' 7he ost coonly prescribed
nonrecoended antibiotics were other cephalosporins !6% of visits&, e)tended-
spectru acrolides !5%&, and ao)icillinHclavulanate !3%&'
5n ultivariable logistic regression odeling, independent predictors of any antibiotic
prescribing were calendar year !odds ratio 4O?6, 0'.3 per year8 .5% -5, 0'33-0'.*&, age 6
to 11 years !vs 3-5 yearsL O?, 1'5/8 .5% -5, 1'10-/'11&, nonwhite race !vs white raceL
O?, 0'6*8 .5% -5, 0'2*-0'.2&, other priary care visits !vs pediatric visitsL O?, 1'538
.5% -5, 1'13-/'/1&, eergency departent visits !vs pediatric visitsL O?, 1'608 .5% -5,
1'/1-/'11&, and southern region !vs +ortheastL O?, 1'618 .5% -5, 1'0*-/'22& !7able /&'
Aong children receiving antibiotics, independent predictors of prescribing
nonrecoended antibiotics were AotherB insurance !vs private insuranceL O?, 0'3*8
.5% -5, 0'13-0'*5& and eergency departent visits !vs pediatric visitsL O?, 0'618 .5%
-5, 0'3.-0'.5& !7able /&'
)A*!S Testing and Association With Antibiotic Prescribing
Kro 1..* to /003, when perforance of a "A#$% test was recorded, physicians
perfored a "A#$% test in 53% !.5% -5, 23%-5*%& of visits !n 1 /*.*&' 5n a
ultivariable logistic regression odel of "A#$% testing, there was no change in testing
over tie !O?, 1'01 per year8 .5% -5, 0'.3-1'11&, but independent predictors of "A#$%
testing were other priary care visit !vs pediatric visitsL O?, 0'268 .5% -5, 0'3/-0'66&,
eergency departent visit !vs pediatric visitsL O?, 0'258 .5% -5, 0'/.-0'*0&, and
western region !vs +ortheastL O?, 0'558 .5% -5, 0'32-0'./&'
(hysicians prescribed antibiotics at 23% of visits in which they perfored a "A#$% test
and 51% of visits in which they did not perfor a "A#$% test !P 1 '20& !7able 2&' 7here
was no association between "A#$% testing and antibiotic prescribing after adDusting for
study year !P 1 '20&' Aong children with a priary diagnosis code for acute
pharyngitis, tonsillitis, and streptococcal sore throat !n 1 1*..&, 63% !.5% -5, 5*%-6.%&
had a "A#$% test perfored' 7here was a significant difference in antibiotic prescribing
between those who had a "A#$% test perfored !5*%& and those who did not !*3%&
!P9'001&' Kor children with a diagnosis code for upper respiratory tract infection,
unspecified viral infection, acute bronchitis, and other diagnoses, those who had a
"A#$% test perfored had an antibiotic prescribed at /1% of visits vs 30% for those
who did not !n 1 ..38 P 1 '11&'
Table +' Association of "A#$% 7esting and Antibiotic (rescribing Aong -hildren
Fith %ore 7hroat, %tratified by :iagnostic "roup, 1..*-/003M
Overall, physicians perfored a "A#$% test in 51% !.5% -5, 25%-5*%& of visits for
sore throat at which they prescribed an antibiotic' Aong children with a diagnosis code
for pharyngitis, tonsillitis, and streptococcal sore throat who received antibiotics !ie, the
subgroup targeted by the $I:5% easure&, 5*% !.5% -5, 50%-63%& had a "A#$% test
perfored'
COMM,T
Although 15% to 36% of children with sore throat have "A#$%,
*-3,11-1/
we found that
physicians prescribed antibiotics to 53% of children with a chief coplaint of sore throat
between 1..5 and /003' Incouragingly, we found a significant decrease in the proportion
of patients receiving antibiotics over the study period' $owever, even at the end of the
study period, the proportion of children prescribed an antibiotic still e)ceeded the
a)iu e)pected prevalence of "A#$% aong children with sore throat'
Of note, the decrease in prescribing was due to a decreased use of agents recoended
for "A#$%8 there was no change in the proportion of children prescribed
nonrecoended agents' 5ndeed, we found a trend over tie toward increased use of
nonrecoended antibiotics aong children receiving antibiotics !O?, 1'05 per year8
.5% -5, 0'.*-1'1/&' 7his is consistent with other studies suggesting an increase in the use
of broad-spectru agents !especially clarithroycin and a<ithroycin aong children&
during the study period, even as overall antibiotic prescribing rates were stable or
decreasing'
16, /3-/.
7his is of particular interest given the increasing prevalence of
acrolide resistance found in "A#$% and other coon pediatric pathogens, such as
Streptococcus pneuoniae'
30-3/
(hysicians were ore li;ely to prescribe antibiotics to children aged 6 to 11 years,
consistent with the higher prevalence of "A#$% in this age group'
/, 2
Other priary care
physicians and eergency departents were appro)iately 50% less li;ely to use
"A#$% testing and appro)iately 60% ore li;ely to prescribe antibiotics than
pediatricians' Other priary care physicians and eergency departent clinicians,
because they care for both adults and children, ay have been e)posed to conflicting
essages about the role of clinical criteria and "A#$% testing in adults and e)trapolated
this conflict to their treatent of children'
6, .-10,33-36
-hildren seen in eergency departents were less li;ely to receive nonrecoended
antibiotics than children seen in pediatric practices, despite a higher antibiotic prescribing
rate in eergency departents' (hysicians were less li;ely to prescribe antibiotics to
nonwhite children, which appears to reflect antibiotic overprescribing to white children'
(hysicians in the %outh were ore li;ely to prescribe antibiotics, consistent with other
analyses showing higher rates of antibiotic and broad-spectru antibiotic prescribing in
the %outh'
12, 3*-33
(hysicians were less li;ely to prescribe nonrecoended antibiotics to
children with AotherB insurance, a sall group for who insurance inforation was
blan; or un;nown or who received charity care'
5n the >nited %tates, to better target antibiotic treatent of children with sore throat, the
AA(, -:-, and 5:%A all recoend laboratory confiration of "A#$% prior to
prescribing antibiotics,
/-3,32
a strategy that has been epirically validated'
36
#ecause ost
tests for "A#$% are negative,
2, 3.
one would e)pect there to be an association between
"A#$% testing and lower antibiotic prescribing rates' 5n an unstratified analysis of
children with sore throat, we found no association between perforing a "A#$% test and
antibiotic prescribing' 5n a stratified analysis, aong children with a diagnosis code for
upper respiratory tract infection, unspecified viral infections, acute bronchitis, and other
diagnoses, "A#$% testing was not associated with a statistically lower antibiotic
prescribing rate, although this ay in part reflect a sall saple si<e, a Afloor effect,B or
antibiotic prescribing for nonpharyngitis indications' Aong children with a diagnosis
code for pharyngitis, tonsillitis, and streptococcal sore throatGalthough the antibiotic
prescribing rate was higher than for other diagnosesG"A#$% testing was associated
with a 16% absolute reduction in the rate of antibiotic prescribing'
7his subgroup best appro)iates the population used in a new $I:5% easure that
assesses the fraction of antibiotic-treated pharyngitis cases that received "A#$%
testing'
/2
(rior studies have reported variable rates of testing aong children with
pharyngitis treated with an antibiotic, ranging fro /3% to 32%'
20-21
A ore recent
report, validating the new $I:5% easure in 5 health plans, found rates of testing of
5.% to 33%, slightly higher than the ore nationally representative 5*% found here'
/5
Our analysis suggests that perforing well on this Euality easure will li;ely be
associated with a lower rate of antibiotic prescribing'
Our analysis has caveats and liitations that should be considered' Kirst, our analysis was
liited to children with a chief coplaint of sore throat' -linicians should reeber that
children could have pharyngitis due to "A#$% without a chief coplaint of sore throat'
5n a suppleentary analysis we found that, aong children with a priary diagnosis code
of pharyngitis, tonsillitis, and streptococcal sore throat, the ost coon reasons for
visit were sore throat !55%&, fever !1.%&, cough !6%&, and earache !/%&' %econd,
children ay have sore throat not as a chief coplaint, but as a secondary reason for their
visit' Our findings were Eualitatively unchanged when including children with a second
or third Reason for Visit Classification code of Asyptos referable to the throat'B
7hird, the +A,-% and +$A,-% are dependent on coplete, accurate entry of clinical
inforation by physicians, clinic staff, hospital staff, and -ensus #ureau representatives'
Kourth, the +A,-% and +$A,-% lac; detailed clinical inforation such as syptos,
physical e)aination findings, or patient allergies' %iilarly, the +A,-% and +$A,-%
lac; data about what type of "A#$% test was perfored !ie, rapid test or culture& and
lac; the results of "A#$% tests' #ecause of this, we could not assess the appropriateness
of perforing "A#$% testing, the appropriateness of the diagnosis, or the
appropriateness of antibiotic prescribing' %ince we do not ;now how any of these tests
were cultures, we have no estiate of the freEuency of the practice of prescribing
antibiotics pending a culture result' Kinally, data about "A#$% testing were only
available for a subset of visits that occurred in the latter portion of the study period'
:espite these liitations, we found that physicians prescribed antibiotics in e)cess of the
e)pected prevalence of "A#$% aong children with sore throat and that testing was
underused, even in children with a diagnosis code for pharyngitis, tonsillitis, and
streptococcal sore throat treated with antibiotics'
Attention to prescribing for sore throat has been part of coprehensive attepts to
proote Dudicious antibiotic prescribing by the -:- and others'
5
%uccessful interventions
to proote Dudicious antibiotic prescribing have included acadeic detailing,
2/
forulary
restrictions,
23
and ultidiensional interventions involving patients and clinicians'
22-26
Other progras have been less successful'
2*-23
7he sustainability of ost successful
interventions is un;nown, and sipler, less e)pensive interventions are needed' 7he
widening deployent of electronic health records with integrated clinical decision
support holds the proise of iproving care for acute respiratory tract infections'
2.
7he evaluation and treatent of ost children with sore throat is reasonably
straightforward' All children with sore throat should be offered adeEuate analgesia with
acetainophen or ibuprofen' (hysicians should restrict testing to children li;ely to have
"A#$% pharyngitisL those older than 3 years with acute onset of sore throat, fever,
headache, pain on swallowing, abdoinal pain, nausea, voiting, or tender anterior
cervical lyphadenopathy'
/
-hildren with syptos suggestive of viral infections, such
as cory<a, conDunctivitis, hoarseness, cough, anterior stoatitis, or diarrhea are unli;ely
to have "A#$% and should generally not be tested' 5f a child is initially treated with
antibiotics pending test results, antibiotics should be stopped if the "A#$% test result is
negative' 7he antibiotic of choice for pharyngitis caused by "A#$% is penicillin, which
is narrow-spectru, ine)pensive, and to which "A#$% is universally susceptible'
/
5n conclusion, we found that physicians prescribed antibiotics less freEuently over tie to
children with sore throat' $owever, the overall antibiotic prescribing rate continues to
e)ceed the e)pected prevalence of "A#$%, and physicians continue to select
unnecessarily broad-spectru antibiotics' >nnecessary antibiotic prescriptions are not
benignL they increase the prevalence of antibiotic-resistant bacteria,
50
e)pose patients to
adverse drug events,
51-5/
and increase costs' (erhaps uniEue aong upper respiratory tract
infections, clinicians have good, obDective criteria in the for of "A#$% testing to guide
the antibiotic treatent of children with sore throat' Niiting antibiotic prescribing to
children with a positive "A#$% test result is a feasible goal for priary care physicians
and an iportant step toward Dudicious use of antibiotics overall'
A#T!OR -,(ORMAT-O,
!" Author Affiliations: Division of #eneral Medicine, $righa and %oen&s
'ospital and 'arvard Medical School, $oston, Mass (Drs )inder and $ates*+
Center for Child 'ealth Care Studies and Departent of ,-ulatory Care and
Prevention, 'arvard Medical School, and 'arvard Pilgri 'ealth Care, $oston
(Drs )ee and .in/elstein*+ and Divisions of Infectious Diseases (Dr )ee* and
#eneral Pediatrics (Dr .in/elstein*, Children&s 'ospital, $oston"
Corresponding Author. Oeffrey A' Ninder, ,:, ,($, :ivision of "eneral ,edicine,
#righa and Foen@s $ospital, 16/0 7reont %t, #--3-/P, #oston, ,A 0/1/0
!DlinderQpartners'org&'
Author Contributions. :r Ninder had full access to all of the study data, which are
publicly available fro the +ational -enter for $ealth %tatistics, and ta;es responsibility
for the accuracy of the data analysis'
Study concept and design+ study supervisionL Ninder, #ates, Kin;elstein'
,c0uisition of dataL Ninder'
,nalysis and interpretation of data+ critical revision of the anuscript for iportant
intellectual contentL Ninder, #ates, Nee, Kin;elstein'
Drafting of the anuscriptL Ninder, #ates'
Statistical analysisL Ninder, #ates, Nee'
(inancial Disclosures. +one reported'
(unding/Support. 7his study was supported by the Agency for $ealthcare ?esearch and
Cuality through a -areer :evelopent Award to :r Ninder !R03 $%012563&' :r Nee is
supported by an Agency for $ealthcare ?esearch and Cuality -areer :evelopent Award
!R03 $%013.03&'
Role of the Sponsor. 7he Agency for $ealthcare ?esearch and Cuality had no role in the
design or conduct of the study8 the collection, anageent, analysis, or interpretation of
the data8 or the preparation, review, or approval of the anuscript'
httpLHHDaa'aa-assn'orgHcontentH/.2H13H/315'fullSsid12be03*11-cb33-23f0-3f3*-
5*c0.2/3db*3
Antibioti0 Pengobatan Ana0 Dengan Tenggoro0an
Abstra0
Ronte;s :ari ana;-ana; dengan sa;it tenggoro;an, 15% sapai 36% eili;i faringitis
disebab;an oleh grup A strepto;o;us -heoliti; !"A#$%&' RinerDa suatu "A#$% tes
sebelu antibioti; resep dianDur;an untu; ana;-ana; dengan sa;it tenggoro;an' (enisilin,
ao;sisilin, eritroisin, dan sefalosporin generasi pertaa adalah antibioti; yang
dire;oendasi;an untu; pengobatan sa;it tenggoro;an ;arena "A#$%'
7uDuan >ntu; engu;ur ting;at penguDian antibioti; resep dan "A#$% dan untu;
engevaluasi hubungan antara penguDian dan pengobatan antibioti; untu; ana;-ana;
dengan sa;it tenggoro;an'
:esign, %etting, dan (eserta Analisis dilihat oleh ana; usia 3 sapai 1* tahun dengan
sa;it tenggoro;an ;e do;ter ;antor berbasis ruah sa;it departeen rawat Dalan, dan
departeen darurat di +ational Abulatory ,edical -are %urvey dan +ational $ospital
Abulatory ,edical -are %urvey, 1..5-/003 !+ 1 2153& dan bagian dari ;unDungan
dengan data uDi "A#$% !n 1 /*.*&'
>;uran $asil >taa ting;at +asional antibioti; resep, resep antibioti; yang
dire;oendasi;an dan tida; dire;oendasi;an untu; "A#$%, dan penguDian "A#$%'
$asil do;ter diresep;an antibioti; di 53% !.5% confidence interval 4-56, 2.% -56%& dari
*,3 Duta ;unDungan diper;ira;an tahunan untu; sa;it tenggoro;an dan antibioti;
nonrecoended sapai /*% !.5% -5, /2% -31%& dari ana;-ana; yang eneria
antibioti;' ?esep antibioti; enurun dari 66% dari ;unDungan tahun 1..5 enDadi 52%
dari ;unDungan pada /003 !( 1 '01 for trend&' (enurunan ini disebab;an oleh penurunan
resep antibioti; yang dire;oendasi;an !2.% sapai 33%, ( 1 0,00/&' :o;ter
ela;u;an tes "A#$% di 53% !.5% -5, 23% -5*%& dari ;unDungan dan di 51% !.5%
-5, 25% -5*%& RunDungan di ana antibioti; telah ditentu;an' "A#$% penguDian tida;
berhubungan dengan ting;at yang lebih rendah resep antibioti; secara ;eseluruhan !23%
vs 51% diuDi tida; diuDi8 ( 1 '20&, tetapi penguDian di;ait;an dengan ting;at yang lebih
rendah resep antibioti; untu; ana;-ana; dengan ;ode diagnosis faringitis, tonsilitis, dan
%treptococcus sa;it tenggoro;an !5*% vs *3% diuDi tida; diuDi8 ( 9'001&'
Resipulan do;ter diresep;an antibioti; untu; 53% ana; dengan sa;it tenggoro;an,
yang elebihi a;siu yang diharap;an prevalensi "A#$%' ,es;ipun terDadi
penurunan proporsi ana; yang eneria antibioti; antara tahun 1..5 dan /003, hal ini
disebab;an ;arena penurunan resep agen dire;oendasi;an untu; "A#$%' ,es;ipun
"A#$% penguDian di;ait;an dengan tarif yang lebih rendah dari antibioti; resep untu;
ana;-ana; dengan ;ode diagnosis faringitis, tonsilitis, dan sa;it tenggoro;an
strepto;o;us, "A#$% (enguDian terbeng;alai'
Account Karingitis 6% dari ;unDungan ana;-ana; untu; do;ter obat ;eluarga dan
pediatricians'1 ,anifestasi paling uu faringitis a;ut adalah sa;it throat'/ Rebanya;an
sa;it tenggoro;an ;arena virus pernapasan bagian atas seperti rhinovirus, coronavirus,
dan adenovirus'3 #a;teri penyebab utaa sa;it tenggoro;an dan satu-satunya penyebab
uu sa;it tenggoro;an penDain perawatan antibioti; ;elopo; A strepto;o;us -
heoliti; !"A#$%& 0,2-5 "A#$% yang dibudidaya;an dari 15% sapai 36% ana;
dengan throat'6 sa;it
Aerican Acadey of (ediatrics !AA(&, (usat (engendalian dan (encegahan (enya;it
!-:-&, dan (enya;it 5nfe;si %ociety of Aerica !5:%A& ere;oendasi;an penisilin
sebagai antibioti; pilihan untu; ana;-ana; sa;it tenggoro;an ;arena "A#$%/-3, 5 tetapi
Duga engidentifi;asi ao;sisilin, eritroisin !untu; pasien alergi penisilin&, dan
sefalosporin generasi pertaa sebagai alternatif yang bisa diteria' %elain itu, untu;
ening;at;an a;urasi diagnosti; dan engurangi pengobatan antibioti; yang tida; perlu,
AA(, -:-, dan 5:%A seua ere;oendasi;an ;inerDa tes "A#$% sebelu erawat
ana;-ana; dengan antibioti;'
7ing;at tinggi %ebelu studi telah eneu;an resep antibioti; ;epada ana;-ana;
didiagnosis dengan pharyngitis12 -16 tetapi belu terfo;us pada ana;-ana; enyaDi;an
dengan ;eluhan utaa sa;it tenggoro;an, pende;atan yang lebih ;linis relevan' Analisa
ana;-ana; dengan ;eluhan utaa sa;it tenggoro;an a;an eung;in;an perbandingan
antara ting;at resep antibioti; dan prevalensi di;enal "A#$%' %elain itu, penelitian
sebelunya tida; diu;ur perubahan dala ting;at yang disaran;an dan nonrecoended
antibioti; resep dari wa;tu ;e wa;tu atau dievaluasi peran penguDian "A#$%' >ntu;
engu;ur perubahan dala tarif dan Denis antibioti; diresep;an untu; ana;-ana; dengan
;eluhan utaa sa;it tenggoro;an, dan hubungannya dengan penguDian "A#$%, ;ai
enganalisis data dari +ational Abulatory ,edical -are %urvey !+A,-%& dan
+ational $ospital Abulatory ,edical -are %urvey !+$A,-%& dari tahun 1..5 hingga
/003'
MTOD
%uber :ata
(ara +A,-% dan +$A,-% di;elola oleh Abulatory -are %tatisti; -abang dari -:-
(usat +asional %tatisti; Resehatan !+-$%& '1* -1. ini +A,-% engupul;an
inforasi tentang ;unDungan pasien non-federal didanai, asyara;at, pra;te; do;ter
berbasis ;antor di seluruh Aeri;a %eri;at' 7he +$A,-% engupul;an inforasi
tentang ;unDungan pasien untu; departeen rawat Dalan ruah sa;it dan departeen
ruah sa;it darurat sebagai ;oponen terpisah'
%urvei eili;i desain ultistage probabilitas' 7he +A,-% eili;i desain sapling
3-stage, dengan pengabilan sapel berdasar;an lo;asi geografis, do;ter pra;te; dala
lo;asi geografis !di;elopo;;an berdasar;an ;husus do;ter&, dan ;unDungan dala
pra;te; do;ter individu' :o;ter yang dipilih untu; berpartisipasi dala +A,-% selaa
tahun ;alender tertentu tida; eenuhi syarat untu; dipilih lagi setida;nya selaa 3
tahun' 7he +$A,-% eili;i desain sapling 2 tahap, dengan sapling berdasar;an
lo;asi geografis, ruah sa;it di daerah geografis, ;lini; atau darurat departeen dala
ruah sa;it, dan ;unDungan pasien di ;lini; atau departeen darurat' 7he +$A,-%
eili;i panel ruah sa;it yang berputar sehingga ruah sa;it berpartisipasi diberi;an
setiap 15 bulan'
:o;ter !+A,-% saDa&, ruah sa;it !+$A,-% saDa&, dan inforasi pasien dan ;linis
!;edua survei& di;upul;an pada setiap ;unDungan yang dipilih dan dicatat di forulir
catatan pasien oleh do;ter yang berpartisipasi, staf ;antor, staf ruah sa;it, atau #iro
%ensus perwa;ilan' 5nforasi pasien eliputi data deografi dan asuransi status'/0 -/1
?as dan etnis di;lasifi;asi;an oleh orang yang engisi forulir re;aan pasien, enurut
sebuah ;antor atau pra;te; yang biasa ruah sa;it untu; engupul;an inforasi
tersebut' :o;ter dan inforasi ruah sa;it terasu; diri diidentifi;asi ;husus !dala
+A,-% saDa&, tipe ;lini; !dala +$A,-% saDa& wilayah, geografis, dan apa;ah pra;te;
tersebut adalah di daerah pedesaan' Rara;teristi; ;linis enca;up hingga 3 alasan
;unDungan !1 Tpaling pentingT dan / Tlain T8 di;ode;an engguna;an Alasan +-$%
untu; RunDungan Rlasifi;asi&, 3 diagnosis !1 prier dan / diagnosa se;under8 di;ode;an
engguna;an Rlasifi;asi 5nternasional (enya;it, Resebilan ?evisi, Rlini; ,odifi;asi
45-:-.--,6&, sapai dengan 3 obat-obatan, dan +ational :rug -ode sesuai noor
:ire;tori ;elas untu; setiap edicine'//
7he +A,-% terasu; variabel yang enunDu;;an ;inerDa tes "A#$% !budaya atau tes
cepat& dari 1..* hingga /003' 7he +$A,-% terasu; variabel yang enunDu;;an
;inerDa tes "A#$% 1..*-/003 di departeen rawat Dalan ruah sa;it dan /001-/003 di
bagian gawat darurat ruah sa;it' #ai; survei terasu; hasil uDi "A#$%'
%urvei di;upul;an *63 553 catatan pasien antara 1..5 dan /003,/0-/1 7ing;at
partisipasi pra;te; do;ter dihubungi dala +A,-% ber;isar dari 63% pada tahun 1...
enDadi *3% pada tahun 1..5' 7ing;at partisipasi ruah sa;it dihubungi di +$A,-%
ber;isar dari ./% pada tahun /003 enDadi .3% pada tahun 1..3' Rontrol ;ualitas
dila;u;an dengan engguna;an /-way prosedur verifi;asi independen untu; 10% dari
catatan sapel' (ada tahun /003, ;esalahan coding untu; berbagai ite ber;isar dari
0,/% enDadi 1,1% pada +A,-% dan dari 0% sapai dengan 0,*% di +$A,-%'
#erat +-$% setiap ;unDungan untu; eung;in;an e;strapolasi estiasi nasional untu;
seua aspe; dari survei' A;un berat ;unDungi untu; probabilitas peilihan, penyesuaian
untu; Dawaban, dan penyesuaian lain untu; encerin;an ala seesta ;unDungan
rawat Dalan di %tates'/0 %eri;at-/1
:ewan eninDau +-$% ;elebagaan enyetuDui proto;ol untu; +A,-% dan
+$A,-%, terasu; pengecualian yang untu; infored consent dari pasien yang
berpartisipasi' Rerahasiaan data dilindungi oleh law'/
Studi Populasi
Rai enyerta;an dilihat oleh ana; usia 3 sapai 1* tahun !;arena ana;-ana; uda dari
3 tahun tida; ung;in eili;i "A#$% faringitis& dengan alasan utaa untu;
;unDungan TgeDala dapat diDadi;an acuan ;e tenggoro;anT !Alasan untu; RunDungan ;ode
Rlasifi;asi 1255, .6% dilapor;an Tnyeri TatauT sa;it Tdi tenggoro;an&' :ala +A,-%,
;ai terasu; ;unDungan ;e do;ter dengan spesialisasi pediatri, pra;te; ;eluarga,
pra;ti; uu, pengobatan internal uu, dan pengobatan darurat' :ala +$A,-%,
;ai terasu; ;unDungan ;e ;lini; ana;, ;lini; ;edo;teran uu, dan departeen
darurat' Rai epertibang;an ;unDungan ;e ;lini; pediatri; sebagai ;unDungan ;e
do;ter ana;' Rai epertibang;an ;unDungan ;e pra;te; ;eluarga, pra;ti; uu,
dan do;ter ;edo;teran uu internal aupun untu; ;lini; ;esehatan uu lainnya
;unDungan perawatan prier' Rai epertibang;an ;unDungan ;e do;ter pengobatan
darurat sebagai ;unDungan ;e bagian gawat darurat' Rai di;ecuali;an dari ;unDungan
analisis oleh ana; dengan ;eluhan utaa sa;it tenggoro;an dengan diagnosis-prier,
se;under, atau tersier-yang bisa account untu; resep antibioti; selain untu; "A#$%
faringitis !isalnya, edia otitis, sinusitis, pneuonia, selulitis 4n 1 6606&' Ada catatan
sapel 2153 untu; sa;it tenggoro;an yang eenuhi seua ;riteria in;lusi dan
e;s;lusi'
Analisis Data
Rai diidentifi;asi antibioti; dengan engguna;an Obat +asional Rode :ire;tori
awalan ;elas 03 !Tantii;robaT& dan polyy)ins di;ecuali;an, ainogli;osida !yang
uunya tida; diresep;an untu; penggunaan sistei; dala pengaturan rawat Dalan&,
dan agen antiycobacterial, antiDaur, dan antivirus' Rai pasti penisilin, ao;sisilin
!apisilin terasu;&, eritroisin, dan sefalosporin generasi pertaa sebagai antibioti;
yang dire;oendasi;an untu; pengobatan "A#$% infection'/ -3,5 Rai
epertibang;an seua antibioti; lainnya, terasu; ao;sisilin H ;lavulanat, sebagai
nonrecoended untu; pengobatan "A#$%' Oi;a lebih dari 1 antibioti; diguna;an
dala satu ;unDungan !1,3% dari catatan sapel&, ;ai enghitung setiap antibioti;
yang ditentu;an dala subclass asing-asing, tapi ;ai enghitung ;unDungan hanya
se;ali sebagai sebuah episode dari perawatan di ana antibioti; telah ditentu;an' Oi;a
seorang pasien eneria bai; dianDur;an dan antibioti; nonrecoended, ;ita
enganggap dia untu; telah eneria dire;oendasi;an antibioti;'
Rai enganalisis subset dari catatan yang "A#$% enguDi inforasi yang tersedia
1..*-/003 !n 1 /*.*&' %elain itu, untu; per;iraan $ealth ?encana RerDa :ata dan
5nforasi %et !$I:5%& ;ualitas u;uran yang diper;enal;an pada tahun /002, ;ai
enganalisis ;unDungan yang "A#$% enguDi inforasi yang tersedia dan yang
eili;i ;ode diagnosis utaa faringitis a;ut !5-:-.--, 26/&, a;ut tonsilitis !5-:-.-
-, 263 dan 265&, dan sa;it tenggoro;an strepto;o;us !5-:-.--, 032, 021,0, 021,00,
021,01, dan 021'0.&,/2-/5 Rai Duga eeri;sa set peleng;ap dari ;unDungan oleh
ana;-ana; dengan laporan sa;it tenggoro;an yang telah diagnosa yang tida; terasu;
dala definisi u;uran $I:5%'
Analisis Statisti0
Rai dihitung >R untu; seua hasil seperti yang dire;oendasi;an oleh +-$%
engguna;an %>:AA+ perang;at luna;, yang re;ening untu; desain sapling
;ople;s +A,-%H+$A,-%'/0-/1 %eua uDi statisti; didasar;an pada per;iraan yang
eili;i ;urang dari 30% relatif %I !yaitu , %I dibagi dengan per;iraan dinyata;an
sebagai persentase dari estiasi& dan didasar;an pada 30 ;asus atau lebih dala data
sapel' ,enurut +-$%, per;iraan dengan lebih dari 30% %I relatif atau berdasar;an
;urang dari 30 ;asus sapel dapat diandal;an' Rarena pebatasan ini, dan ;arena u;uran
;ecil ;elopo; ras ;ulit putih, ;ita dichotoi<ed variabel ras ;e dala ;ategori putih dan
;ulit putih'
Rai engevaluasi variabel ;ategori dengan uDi J/' >ntu; enilai perubahan dala
resep dari wa;tu ;e wa;tu, ;ai engguna;an uDi trend linier' %eua uDi statisti; tren
epertibang;an seua data account dari . tahun seDa; 1..5 sapai /003'
Rai engebang;an 3 odel ultivariabel regresi logisti;, enyesuai;an untu;
asuransi pasien deografis,, dan do;ter dan inforasi ruah sa;it' Rai terasu; ras
dan etnis ;arena ;ai sebelunya telah eneu;an ras dan etnis untu; dihubung;an
dengan pra;te;-pra;te; resep yang berbeda untu; saluran pernafasan a;ut infections'/6-
/* ,odel regresi logisti; pertaa eliputi seua ;unDungan sa;it tenggoro;an dan
eili;i resep antibioti; sebagai variabel dependen !n 1 2153&' ,odel regresi logisti;
;edua eliputi ;unDungan di ana antibioti; telah ditentu;an dan eili;i resep
antibioti; nonrecoended sebagai variabel dependen !n 1 /313&' / odel ini
encerin;an hipotesis ;ai bahwa do;ter pertaa eutus;an apa;ah atau tida;
eresep;an antibioti; dan ;eudian eutus;an untu; eresep;an antibioti;' ,odel
;etiga eliputi ;unDungan yang data tentang penguDian "A#$% yang tersedia dari 1..*
sapai /003 dan telah "A#$% penguDian sebagai variabel dependen !n 1 /*.*&' %eua
analisa dila;u;an dengan versi .'1 %A% !%A% 5nstitute 5nc, -ary, +-& dan %A%-callable
%>:AA+ versi .'0'1 !?esearch 7riangle 5nstitute, ?esearch 7riangle (ar;, +-&' %eua
nilai ( /-tailed8 ( 9'05 dianggap signifi;an'
!AS-$
$arga %a;it 7enggoro;an RunDungi dan Rara;teristi;
%etelah tida; terasu; ;unDungan dengan nonpharyngitis bersaaan, diagnosis antibioti;
yang sesuai, ada yang diper;ira;an 66 Duta !.5% confidence interval 4-56, 5.000000-
*3000000& dilihat di Aeri;a %eri;at oleh ana; usia 3 sapai 1* tahun dengan sa;it
tenggoro;an untu; do;ter ana;, do;ter perawatan prier dan ;lini; lainnya, dan
departeen darurat antara 1..5 dan /003' RunDungan tahunan untu; sa;it tenggoro;an
rata-rata *,3 Duta ;unDungan per tahun, ulai dari 6,/ Duta ;unDungan pada 1..*-.*00000
;unDungan pada tahun /00/' +aun, tida; ada perubahan signifi;an dala proporsi dari
seua ;unDungan yang untu; sa;it tenggoro;an dari wa;tu ;e wa;tu, enurun dari 6,2%
dari ;unDungan tahun 1..5 enDadi 5,.% pada tahun /001 dan ening;at enDadi 3,1%
pada tahun /003 !( 1 '1. for trend&'
:iagnosa yang paling sering prier do;ter-dilapor;an untu; ;unDungan dengan ;eluhan
utaa sa;it tenggoro;an adalah faringitis a;ut !32% RunDungan&, sa;it tenggoro;an
strepto;o;us !1*%&, dan infe;si saluran pernapasan atas !1*%& !7abel 1&' Ana; dengan
sa;it tenggoro;an adalah 2*% la;i-la;i dan 35% putih !7abel /&' Nia puluh ena
persen dari ;unDungan adalah untu; do;ter ana; atau ;lini; pediatri;, 36% dari
;unDungan adalah untu; lain do;ter atau ;lini; perawatan prier, dan .% dari ;unDungan
adalah untu; departeen darurat'
Peresepan Antibioti0
%elaa asa studi . tahun, do;ter diresep;an antibioti; di 53% dari dilihat !.5% -5,
2.% -56%, 7abel 3&' Antibioti; dire;oendasi;an untu; pengobatan "A#$% diberi
resep di 33% dari dilihat !.5% -5, 36% -21%&, dan antibioti; nonrecoended diberi
resep dala 12% !.5% -5, 1/% -1*%&' :o;ter diresep;an antibioti; nonrecoended
sapai /*% !.5% -5, /2% -31%& dari ana;-ana; yang eneria antibioti;'
Antibioti; resep untu; pasien dengan sa;it tenggoro;an enurun dari wa;tu ;e wa;tu
dari 66% dari ;unDungan tahun 1..5 enDadi 22% dari ;unDungan tahun /00/, ;eudian
ening;at enDadi 52% dari ;unDungan pada /003 !( 1 0,01 untu; ;ecenderungan linier
1..5-/003& !"abar& ' Kitur penulisan antibioti; enurun dari 2.% dari ;unDungan
tahun 1..5 enDadi 33% dari ;unDungan pada /003 !( 1 0,00/ for trend&, naun tida;
ada perubahan signifi;an dala resep antibioti; nonrecoended sepanDang wa;tu !13%
pada tahun 1..5 enDadi 16% di /0038 ( 1 '3/ for trend&'
:o;ter diresep;an ao;sisilin !/6% RunDungan&, penisilin !*%&, generasi pertaa
sefalosporin !3%&, dan eritroisin !/%& !7abel 3&' Antibioti; nonrecoended paling
sering diresep;an adalah sefalosporin lainnya !6% RunDungan&, acrolides diperpanDang-
spe;tru !5%&, dan ao;sisilin H ;lavulanat !3%&'
:ala peodelan regresi logisti; ultivariat, predi;tor independen dari resep antibioti;
adalah tahun ;alender !rasio odds 4O?6, 0,.3 per tahun8 .5% -5, 0,33-0,.*&, usia 6
sapai 11 tahun !vs 3-5 tahunL O?, 1,5/ 8 .5% -5, 1,10-/,11&, ras ;ulit putih !ras ;ulit
putih vsL O?, 0,6*, .5% -5, 0,2*-0,.2&, lain dilihat perawatan prier !;unDungan
pediatri; vsL O?, 1,53, .5% -5, 1,13-/,/1 &, ;unDungan gawat darurat !;unDungan
pediatri; vsL O?, 1,60, .5% -5, 1,/1-/,11&, dan wilayah selatan !vs 7iur NautL O?,
1,61, .5% -5, 1,0*-/,22& !7abel /&' :iantara ana; yang eneria antibioti;, predi;tor
independen dari resep antibioti; nonrecoended adalah TlainnyaT asuransi !asuransi
swasta vsL O?, 0,3*, .5% -5, 0,13-0,*5& dan ;unDungan darurat departeen !;unDungan
pediatri; vsL O?, 0,61, .5% -5, 0'3.-0'.5&
)A*!S Pengu1ian dan Asosiasi Dengan Peresepan Antibioti0
:ari tahun 1..* sapai /003, ;eti;a ;inerDa tes "A#$% tercatat, do;ter ela;u;an tes
"A#$% di 53% !.5% -5, 23% -5*%& dilihat !n 1 /*.*&' :ala odel regresi
ultivariabel logisti; penguDian "A#$%, tida; ada perubahan dala penguDian dari
wa;tu ;e wa;tu !O?, 1,01 per tahun8 .5% -5, 0,.3-1,11&, tetapi predi;tor independen
dari penguDian "A#$% yang lain perawatan ;unDungan prier !;unDungan pediatri; vsL
O?, 0,26, .5% -5, 0,3/-0,66&, darurat ;unDungi departeen !pediatri; RunDungan vsL
O?, 0,25, .5% -5, 0,/.-0,*0&, dan wilayah barat !vs 7iur NautL O?, 0,55, .5% -5, 0,32
-0,./&'
:o;ter diresep;an antibioti; pada 23% RunDungan di ana ere;a ela;u;an tes
"A#$% dan 51% dari ;unDungan di ana ere;a tida; ela;u;an tes "A#$% !( 1
0,20& !7abel 2&' 7ida; ada hubungan antara penguDian "A#$% dan antibioti; resep
setelah disesuai;an untu; tahun studi !( 1 '20&' :i antara ana;-ana; dengan ;ode
diagnosis utaa untu; faringitis a;ut, tonsilitis, dan sa;it tenggoro;an strepto;o;us !n 1
1*..&, 63% !.5% -5, 5*% -6.%& enDalani tes "A#$% dila;u;an' 7erdapat perbedaan
yang signifi;an dala penulisan antibioti; antara ere;a yang enDalani tes "A#$%
dila;u;an !5*%& dan ere;a yang tida; !*3%& !( 9'001&' >ntu; ana;-ana; dengan ;ode
diagnosis untu; infe;si saluran pernafasan atas, infe;si virus yang tida; ditentu;an,
bron;itis a;ut, dan diagnosis lain, ere;a yang enDalani tes "A#$% dila;u;an
eili;i antibioti; diresep;an di /1% RunDungan vs 30% bagi ere;a yang tida; !n 1
..38 ( 1 '11&'
%ecara ;eseluruhan, do;ter ela;u;an tes "A#$% di 51% !.5% -5, 25% -5*%& dari
;unDungan untu; sa;it tenggoro;an di ana ere;a ditentu;an antibioti;' :i antara ana;-
ana; dengan ;ode diagnosis untu; faringitis, tonsilitis, dan sa;it tenggoro;an
strepto;o;us yang eneria antibioti; !yaitu, sub ;elopo; yang ditarget;an oleh
u;uran $I:5%&, 5*% !.5% -5, 50% -63%& enDalani tes "A#$% dila;u;an'
2OM,TAR
,es;ipun 15% sapai 36% ana; dengan sa;it tenggoro;an eili;i "A#$%,*-3,11-1/
;ai eneu;an bahwa do;ter diresep;an antibioti; untu; 53% ana; dengan ;eluhan
utaa sa;it tenggoro;an antara 1..5 dan /003' ,ebesar;an hati, ;ai eneu;an
penurunan signifi;an dala proporsi pasien yang eneria antibioti; selaa asa studi'
+aun, bah;an pada a;hir asa studi, proporsi ana;-ana; diresep;an antibioti; asih
elebihi prevalensi diharap;an a;sial "A#$% antara ana;-ana; dengan sa;it
tenggoro;an'
:ari catatan, penurunan resep disebab;an penurunan penggunaan agen dire;oendasi;an
untu; "A#$%8 tida; ada perubahan dala proporsi ana; ditentu;an agen
nonrecoended' ,eang, ;ai eneu;an ;ecenderungan dari wa;tu ;e wa;tu
enuDu pening;atan penggunaan antibioti; nonrecoended antara ana;-ana;
eneria antibioti; !O?, 1,05 per tahun8 .5% -5, 0,.*-1,1/&' $al ini ;onsisten dengan
studi lain enunDu;;an pening;atan penggunaan agen spe;tru luas !;hususnya
;laritroisin dan a<itroisin antara ana;-ana;& selaa asa studi, bah;an sebagai
;eseluruhan ting;at resep antibioti; yang stabil atau decreasing'16, /3 -/. ini adalah
perhatian ;husus diberi;an pening;atan prevalensi resistensi acrolide diteu;an di
"A#$% dan patogen pediatri; uu, seperti %treptococcus pneuoniae'30 -3/
:o;ter cenderung eresep;an antibioti; pada ana; beruur 6 sapai 11 tahun,
;onsisten dengan prevalensi yang lebih tinggi "A#$% di era group'/, 2 do;ter perawatan
lainnya prier dan bagian gawat darurat adalah se;itar 50% lebih ;ecil ;eung;inannya
untu; engguna;an penguDian "A#$% dan ;ira-;ira 60% lebih ung;in untu;
eresep;an antibioti; dari do;ter ana;' :o;ter perawatan lainnya prier dan do;ter
gawat darurat, ;arena ere;a peduli untu; dewasa dan ana;-ana;, ung;in telah
terpapar pesan yang bertentangan tentang peran ;riteria ;linis dan "A#$% penguDian
pada orang dewasa dan e;strapolasi ;onfli; ini untu; perla;uan ere;a terhadap
children'6, . -10,33-36
Ana;-ana; terlihat di bagian gawat darurat ;urang ung;in untu; eneria antibioti;
nonrecoended daripada ana;-ana; terlihat pada pra;ti; pediatri;, walaupun ting;at
resep antibioti; yang lebih tinggi di bagian gawat darurat' :o;ter ;urang ung;in
eresep;an antibioti; untu; ;ulit putih ana;-ana;, yang uncul untu; encerin;an
overprescribing antibioti; ;epada ana;-ana; putih' :o;ter di %elatan lebih ung;in
untu; eresep;an antibioti;, ;onsisten dengan analisis lainnya yang enunDu;;an
ting;at lebih tinggi dari antibioti; dan antibioti; spe;tru luas resep di %outh'12 itu, 3*
-33 :o;ter ;urang ung;in eresep;an antibioti; nonrecoended untu; ana;-ana;
dengan TlainT asuransi, sebuah ;elopo; ;ecil untu; siapa inforasi asuransi ;osong
atau tida; di;etahui atau yang eneria perawatan aal'
:i Aeri;a %eri;at, untu; pengobatan yang lebih bai; antibioti; target ana;-ana; dengan
sa;it tenggoro;an, AA(, -:-, dan 5:%A seua ere;oendasi;an ;onfirasi
laboratoriu "A#$% sebelu antibioti; resep, / -3,32 strategi yang telah epiris
validated'36 Rarena uDi paling untu; "A#$% negatif, 2, 3. orang a;an berharap a;an ada
hubungan antara penguDian "A#$% dan enurun;an ting;at resep antibioti;' :ala
analisis unstratified ana;-ana; dengan sa;it tenggoro;an, ;ai eneu;an tida; ada
hubungan antara ela;u;an tes "A#$% dan resep antibioti;' :ala analisis berting;at,
di antara ana;-ana; dengan ;ode diagnosis untu; infe;si saluran pernafasan atas, infe;si
virus yang tida; ditentu;an, bron;itis a;ut, dan diagnosis lain, "A#$% penguDian tida;
di;ait;an dengan ting;at statisti; yang lebih rendah resep antibioti;, es;ipun hal ini
ung;in sebagian encerin;an sapel ;ecil u;uran, sebuah Tefe; lantai,T atau
antibioti; resep untu; indi;asi nonpharyngitis' :i antara ana;-ana; dengan ;ode
diagnosis untu; faringitis, tonsilitis, dan sa;it tenggoro;an strepto;o;us-es;ipun ang;a
resep antibioti; lebih tinggi dibanding;an yang lain diagnosis-"A#$% penguDian
di;ait;an dengan penurunan absolut 16% di ting;at penulisan antibioti;'
%ub;elopo; ini terbai; ende;ati pendudu; diguna;an dala u;uran $I:5% baru
yang enilai fra;si ;asus yang diobati dengan antibioti; faringitis yang eneria
"A#$% testing'/2 %ebelu penelitian telah elapor;an ang;a variabel penguDian antara
ana;-ana; dengan radang tenggoro;an diobati dengan antibioti;, ulai dari /3% untu;
32%,20-21 %ebuah laporan yang lebih baru, evalidasi u;uran $I:5% baru dala 5
rencana ;esehatan, eneu;an ting;at penguDian dari 5.% enDadi 33%, sedi;it lebih
tinggi dari 5*% lebih perwa;ilan nasional diteu;an here'/5 Analisis ;ai enunDu;;an
yang ber;inerDa bai; pada engu;ur ;ualitas ;eung;inan a;an di;ait;an dengan tarif
yang lebih rendah dari resep antibioti;
Analisis ;ai eili;i batasan dan ;eterbatasan yang harus dipertibang;an' (ertaa,
analisis ;ai terbatas pada ana;-ana; dengan ;eluhan utaa sa;it tenggoro;an' :o;ter
harus ingat bahwa ana;-ana; bisa faringitis ;arena "A#$% tanpa ;eluhan utaa sa;it
tenggoro;an' :ala analisis tabahan yang ;ai eneu;an bahwa, di antara ana;-
ana; dengan ;ode diagnosis utaa faringitis, tonsilitis, dan sa;it tenggoro;an
strepto;o;us, alasan paling uu untu; ;unDungan adalah sa;it tenggoro;an !55%&,
dea !1.%&, batu; !6%& , dan sa;it telinga !/%&' Redua, ana;-ana; ung;in sa;it
tenggoro;an bu;an sebagai ;eluhan utaa, tetapi sebagai alasan se;under untu;
;unDungan ere;a' 7euan ;ai secara ;ualitatif berubah ;eti;a terasu; ana;-ana;
dengan Alasan ;edua atau ;etiga untu; RunDungan ;ode Rlasifi;asi TgeDala dapat
diDadi;an acuan untu; tenggoro;an'T
Retiga, +A,-% dan +$A,-% tergantung pada leng;ap, a;urat asu;nya inforasi
;linis oleh do;ter, staf ;lini;, staf ruah sa;it, dan #iro %ensus perwa;ilan' Reepat,
+A,-% dan +$A,-% ;urangnya inforasi rinci ;linis seperti geDala, teuan
peeri;saan fisi;, atau alergi pasien' :ei;ian pula, +A,-% dan data ;urangnya
+$A,-% tentang apa Denis tes "A#$% dila;u;an !yaitu, tes cepat atau budaya& dan
;urangnya hasil tes "A#$%' Rarena itu, ;ai tida; bisa enilai ;elaya;an "A#$%
ela;u;an penguDian, ;esesuaian diagnosis, atau ;esesuaian penulisan antibioti;' Rarena
;ita tida; tahu berapa banya; dari penguDian ini budaya, ;ita tida; eili;i per;iraan
fre;uensi pra;te; eresep;an antibioti; enunggu hasil budaya' A;hirnya, data tentang
penguDian "A#$% hanya tersedia untu; subset ;unDungan yang terDadi di bagian tera;hir
dari asa studi' ,es;ipun ;eterbatasan ini, ;ai eneu;an bahwa do;ter diresep;an
antibioti; yang elebihi prevalensi diharap;an dari "A#$% antara ana;-ana; dengan
sa;it tenggoro;an dan penguDian yang ;urang dianfaat;an, bah;an pada ana;-ana;
dengan ;ode diagnosis untu; faringitis, tonsilitis, dan sa;it tenggoro;an strepto;o;us
diobati dengan antibioti;'
(erhatian untu; resep untu; sa;it tenggoro;an telah enDadi bagian dari upaya
enyeluruh untu; eproosi;an biDa;sana antibioti; resep oleh -:- dan others'5
intervensi %u;ses untu; eproosi;an biDa;sana penulisan antibioti; telah
easu;;an a;adei; rincian, 2/ pebatasan forulariu, 23 dan ultidiensi
intervensi yang elibat;an pasien dan do;ter 0,22-26 (rogra lain telah ;urang
successful'2*-23 ReberlanDutan intervensi paling su;ses tida; di;etahui, dan sederhana,
intervensi lebih urah diperlu;an' (enyebaran pelebaran catatan ;esehatan ele;troni;
dengan pendu;ung ;eputusan ;linis yang terintegrasi eegang DanDi untu;
eperbai;i perawatan saluran pernafasan a;ut infections'2
Ivaluasi dan pengobatan ;ebanya;an ana;-ana; dengan sa;it tenggoro;an cu;up udah'
%eua ana; dengan sa;it tenggoro;an harus ditawar;an analgesia yang eadai dengan
acetainophen atau ibuprofen' :o;ter harus ebatasi penguDian untu; ana;-ana;
cenderung eili;i faringitis "A#$%L ere;a lebih dari 3 tahun dengan onset a;ut sa;it
tenggoro;an, dea, sa;it ;epala, nyeri saat enelan, nyeri perut, ual, untah, atau
anterior servi;s tender lyphadenopathy'/ Ana; dengan geDala sugestif infe;si virus,
seperti cory<a, ;onDungtivitis, suara sera;, batu;, stoatitis anterior, atau diare tida;
ung;in eili;i "A#$% dan uunya seharusnya tida; diuDi' Oi;a seorang ana;
awalnya diobati dengan antibioti;a tertunda hasil tes, antibioti; harus dihenti;an Di;a
hasil tes "A#$% negatif' Antibioti; pilihan untu; faringitis yang disebab;an oleh
"A#$% adalah penisilin, yang spe;tru sepit, urah, dan yang "A#$% secara
universal susceptible'/
%ebagai ;esipulan, ;ai eneu;an bahwa do;ter diresep;an antibioti; lebih Darang
dari wa;tu ;e wa;tu untu; ana;-ana; dengan sa;it tenggoro;an' +aun, ting;at resep
antibioti; secara ;eseluruhan terus elebihi prevalensi diharap;an "A#$%, dan do;ter
terus pilih tida; perlu antibioti; spe;tru luas' 7ida; perlu resep antibioti; tida; Dina;L
ere;a ening;at;an prevalensi ba;teri resisten antibioti;, 50 enge;spos pasien untu;
;eDadian obat yang erugi;an,51-5/ dan biaya ening;at' ,ung;in yang uni; antara
infe;si saluran pernapasan bagian atas, do;ter sudah bai;, ;riteria obye;tif dala bentu;
"A#$% penguDian untu; eandu pengobatan antibioti; ana;-ana; dengan sa;it
tenggoro;an' ,ebatasi penulisan antibioti; untu; ana;-ana; dengan hasil tes "A#$%
positif adalah tuDuan yang laya; untu; do;ter perawatan prier dan lang;ah penting
enuDu penggunaan biDa;sana antibioti; secara ;eseluruhan
P,#$-S -,(ORMAS-
Author AffiliationsL :ivisi >u, #righa Redo;teran dan ?uah %a;it Fanita dan
%e;olah Redo;teran $arvard, #oston, ,ass !:rs Ninder dan #ates&8 (usat %tudi
(erawatan Ana; Resehatan dan :eparteen (erawatan ?awat Oalan dan (encegahan,
%e;olah Redo;teran $arvard, dan (erawatan Resehatan $arvard (ilgri , #oston !:rs
Nee dan Kin;elstein&, dan :ivisi of 5nfectious :iseases !:r Nee& dan (ediatrics >u
!Kin;elstein :r&, -hildrenUs $ospital, #oston'
(enulis ;orespondensiL Oeffrey A' Ninder, ,:, ,($, :ivisi Redo;teran >u,
#righa dan FoenUs $ospital, 16/0 7reont %t, %,-3-/P, #oston, ,A 0/1/0
!DlinderQpartners'org&'
Rontribusi (enulisL :r Ninder eili;i a;ses penuh ;e seua data penelitian, yang
tersedia untu; uu dari (usat +asional %tatisti; Resehatan, dan bertanggung Dawab
atas ;ea;uratan analisis data
(endanaan H %upportL (enelitian ini didu;ung oleh #adan Resehatan (enelitian dan
Rualitas elalui (engebangan Rarir Award ;epada :r Ninder !R03 $%012563&' :r Nee
adalah didu;ung oleh #adan Resehatan (enelitian dan (engebangan Rualitas Rarir
Award !R03 $%013.03&' (eran %ponsorL #adan Resehatan (enelitian dan Rualitas tida;
eili;i peran dala desain atau pela;sanaan studi8 pengupulan, anaDeen, analisis,
atau penafsiran data8 atau persiapan, review, atau persetuDuan dari nas;ah