The Right Antibiotic

A letter from the CDC and others published online October 24 in JAMA Internal Medicine presents evidence that about half of patients thought to have bacterial otitis media, sinusitis, or pharyngitis are treated with the wrong antibiotic. First-line (correct) antibiotic therapy, according to the letter, would be amoxicillin or amoxicillin/clavulanate for otitis media or sinusitis and penicillin or amoxicillin for pharyngitis. Based on a survey conducted in 2010 and 2011, children with otitis media were treated with first-line antibiotics 67% of the time, while only 37% of adults with sinusitis or pharyngitis received the right drug. Given that these 3 conditions, according to the authors, generate more than 40 million prescriptions per year, that adds up to a lot of money spent on the wrong drugs.

In an interview with NBC News, one of the authors stated that the most commonly prescribed non-first-line antibiotics were macrolides, particularly azithromycin. He speculated that the convenience of the Z-Pak and the short course of treatment recommended may appeal to patients who have been treated with the drug in the past, and that they ask their doctors to prescribe it. Considering that most cases of pharyngitis and sinusitis are caused by viruses, that adds up to even more money wasted.

So what does The Medical Letter have to say about this? Periodically, we publish articles meant to help prescribers deal with the often complicated problem of choosing the right antibiotic for treatment of specific infections. Here, for example, is what we recently had to say about sinusitis:

Acute sinusitis in adults is often viral and can be managed with analgesics, a nasal corticosteroid, and/or nasal saline irrigation. When it is bacterial, it is usually caused by Streptococcus pneumoniae, Haemophilus influenza or Moraxella catarrhalis and can be treated with an oral antibacterial such as amoxicillin or amoxicillin/clavulanate. The addition of clavulanate improves coverage of beta-lactamase-producing strains of H. influenzae and M. catarrhalis. Doxycycline is an option for adults who are allergic to penicillin, but resistance to doxycycline has increased, particularly among isolates of S. pneumoniae that are resistant to penicillin. A respiratory fluoroquinolone (levofloxacin or moxifloxacin) is an alternative for penicillin-allergic patients.  Monotherapy with a macrolide (erythromycin, clarithromycin or azithromycin) or trimethoprim/sulfamethoxazole is generally not recommended because of increasing resistance among pneumococci.

If more prescribers read The Medical Letter, many of those inappropriate azithromycin prescriptions might never have been written.

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  1. Neal Steigbigel says:

    Very good, Mark. Neal

    Sent from my iPhone


  2. Everything in the article is consistent with what I see in patient care. The only thing I disagree with is the last sentence, and I find it self-serving. I hope it was written with a wry smile rather than condescension.

    All of use memorized the most common microbes that cause infections in different regions of the body, and stratified it based upon age, the environment the patient resides, and co-morbid conditions. It has been the mainstay for empiric treatment for infections. We all learned this.

    This argument about inappropriate use of antibiotic has been discussed for decades. I believe all clinician know the correct treatment, but choose to ignore it, because they don’t want to lose patients. While I don’t know the data, I suspect prescribing habits have changed little since this issue was recognized.

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