Clinical records of patients for whom a rapid diagnostic test (RDT) was ordered in the ED for Streptococcus pyogenes in May-June 2016 were reviewed. Patients diagnosed with GABHS pharyngitis with positive RDT were included. A prescription was considered inconsistent if there was a mismatch or error with the existing ED protocol; type of antibiotic, dose, frequency of administration, and duration of treatment.

Two hundred twenty-seven cases were included. A first line antibiotic was prescribed for 217 (93.5%) patients [penicillin V for 74 (32.6%) and amoxicillin for 143 (63%)]. The prescription was consistent with legal guideline in 132 (58.1%) cases, 69 (93.2%) cases of penicillin V, 56 (39.2%) cases of amoxicillin and 7 (70%) cases of other antibiotics. The reasons for inconsistent prescription were type of antibiotic (5, 2.2%), dose (51, 22.5%), interval (72, 31.7%), and duration (33, 14.5%). Prescription consistency was significantly better (P=0.004) among physicians within the hospital (61.2%) than external physicians (28.6%).

The present study revealed an increase in the prescription of penicillin V administered to one-third patients with GABHS pharyngitis after introduction of sensitization sessions. The inconsistency in antibiotic prescription in the present study was similar to other studies which report prescription inconsistency between 22 and 51% [6,7]. The main reason for inconsistency in the present study was related to dosing frequency of amoxicillin advised eight hourly instead of twelve hourly as per standard guidelines [8-10]. This error may be explained by the greater familiarity with eight hourly dosing of amoxicillin for other infections [5,10]. Nevertheless, this dosing interval is not only inconsistent, but could additionally lead to lower patient adherence to treatment. The degree of consistency for the four assessed factors was high with penicillin V, unlike amoxicillin. Also, the quality of the prescription was poorer when the prescribing physician was external to the hospital. Therefore, better training of external pro-fessionals working in the ED should be a prerequisite to the optimization of antibiotic prescription.

In conclusion, this study corroborates the usefulness of observational studies in the assessment of compliance to antibiotic policy. Knowledge of the prescription and its critical analysis allows for identification and improvement in the use of the antibiotics. Antibiotic prescription was inconsistent in a significant percentage of patients with GABHS pharyngitis, mainly for amoxicillin. Given the easy guidelines for penicillin V administration and its narrow spectrum, it should be the main prescribed antibiotic for patients with GABHS pharyngitis.

Contributors: DP,AS: data collection, drafting the article, final approval of the version to be published; SH: conception and design of the work, drafting the article, final approval of the version to be published; VT: conception and design of the work, data analysis and interpretation, critical revision of the article, final approval of the version to be published; CL: conception and design of the work, critical revision of the article, final approval of the version to be published. All authors approved the final version of manuscript and agree to be accountable for authenticity and integrity of the work.

Funding: None; Competing interest: None stated.

1. Stam J, van Stuijvenberg M, Grüber C, Mosca F,　Arslanoglu S,　Chirico G,　et al. Multicenter infection prevention study 1 (MIPS 1) study group. Antibiotic use in infants in the ûrst year of life in ûve European countries. Acta Paediatr. 2012;101:929-34.

2. Llor C, Cots JM, Boada A, Bjerrum L, Gahrn-Hansen B, Munck A, et al. Variabilidad de la prescripción antibiótica en las infecciones respiratorias en dos países de Europa. Enferm Infecc Microbiol Clin. 2005;23:598-604.

3. Youngster I, Avorn J, Belleudi V, 　Cantarutti A,　Díez-Domingo J,　Kirchmayer U, et al. Antibiotic use in children – a cross-national analysis of 6 countries. J Pediatr. 2017;182:239-44.

4. Ranji SR, Steinman MA, Shojania KG, 　Gonzales R. Interventions to reduce unnecessary antibiotic prescribing: A systematic review and quantitative analysis. Med Care. 2008;46:847-62.

5. Alkhazi AA, Alessa KM, Almutairi AM, Almadi HA, Akkam A, Almutairi MK, et al. Improving pediatric emergency department physicians’ adherence to clinical practice guidelines on the diagnosis and management of group A beta-hemolytic streptococcal pharyngitis-a cross-sectional study. Int J Emerg Med. 2018;11:49.

6. Durán Fernández-Feijóo C, Marqués Ercilla S, Hernández-Bou S, 　Trenchs Sainz de la Maza V,　García García JJ,　Luaces Cubells C. Calidad de la prescripción antibiótica en un servicio de urgencias pediátrico hospitalario. An Pediatr (Barc). 2010;73:115-20.

7. Ochoa C, Anglada L, Eiros JM, Solís G, Vallano A, Guerra L; Spanish Study Group on Antibiotic Treatments. Appropriateness of antibiotic prescriptions in community acquired acute pediatric respiratory infections in Spanish emergency rooms. Pediatr Infect Dis J. 2001;20:751-8.

8. Wessels MR. Streptococcal Pharyngitis. N Engl J Med. 2011;364:648-55.

9. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, et al. Infectious Diseases Society of America. Clinical Practice Guideline For the Diagnosis and Management of group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clin Infect Dis.　2012;55:e86-102.