Development of an Electronic Algorithm to Target Outpatient Antimicrobial Stewardship Efforts for Acute Bronchitis and Pharyngitis.

2022

ofac273

07/2022

2328-8957

Background: A major challenge for antibiotic stewardship programs is the lack of accurate and accessible electronic data to target interventions. We developed and validated separate electronic algorithms to identify inappropriate antibiotic use for adult outpatients with bronchitis and pharyngitis.

Methods: We used International Classification of Diseases, 10th Revision, diagnostic codes to identify patient encounters for acute bronchitis and pharyngitis at outpatient practices between 3/15/17 and 3/14/18. Exclusion criteria included immunocompromising conditions, complex chronic conditions, and concurrent infections. We randomly selected 300 eligible subjects each with bronchitis and pharyngitis. Inappropriate antibiotic use based on chart review served as the gold standard for assessment of the electronic algorithm, which was constructed using only data in the electronic data warehouse. Criteria for appropriate prescribing, choice of antibiotic, and duration were based on established guidelines.

Results: Of 300 subjects with bronchitis, 167 (55.7%) received an antibiotic inappropriately based on chart review. The electronic algorithm demonstrated 100% sensitivity and 95.3% specificity for detection of inappropriate prescribing. Of 300 subjects with pharyngitis, 94 (31.3%) had an incorrect prescribing decision. Among 29 subjects with a positive rapid streptococcal antigen test, 27 (93.1%) received an appropriate antibiotic and 29 (100%) received the correct duration. The electronic algorithm demonstrated very high sensitivity and specificity for all outcomes.

Conclusions: Inappropriate antibiotic prescribing for bronchitis and pharyngitis is common. Electronic algorithms for identifying inappropriate prescribing, antibiotic choice, and duration showed excellent test characteristics. These algorithms could be used to efficiently assess prescribing among practices and individual clinicians. Interventions based on these algorithms should be tested in future work.

10.1093/ofid/ofac273

Open Forum Infect Dis

35854991

COVID-19 and Antibiotic Prescribing in Pediatric Primary Care.

2022

2022 02 01

1098-4275

<p><strong>BACKGROUND AND OBJECTIVES: </strong>With the onset of the coronavirus disease 2019 (COVID-19) pandemic, pediatric ambulatory encounter volume and antibiotic prescribing both decreased; however, the durability of these reductions in pediatric primary care in the United States has not been assessed.</p>

<p><strong>METHODS: </strong>We conducted a retrospective observational study to assess the impact of the COVID-19 pandemic and associated public health measures on antibiotic prescribing in 27 pediatric primary care practices. Encounters from January 1, 2018, through June 30, 2021, were included. The primary outcome was monthly antibiotic prescriptions per 1000 patients. Interrupted time series analysis was performed.</p>

<p><strong>RESULTS: </strong>There were 69 327 total antibiotic prescriptions from April through December in 2019 and 18 935 antibiotic prescriptions during the same months in 2020, a 72.7% reduction. The reduction in prescriptions at visits for respiratory tract infection (RTI) accounted for 87.3% of this decrease. Using interrupted time series analysis, overall antibiotic prescriptions decreased from 31.6 to 6.4 prescriptions per 1000 patients in April 2020 (difference of -25.2 prescriptions per 1000 patients; 95% CI: -32.9 to -17.5). This was followed by a nonsignificant monthly increase in antibiotic prescriptions, with prescribing beginning to rebound from April to June 2021. Encounter volume also immediately decreased, and while overall encounter volume quickly started to recover, RTI encounter volume returned more slowly.</p>

<p><strong>CONCLUSIONS: </strong>Reductions in antibiotic prescribing in pediatric primary care during the COVID-19 pandemic were sustained, only beginning to rise in 2021, primarily driven by reductions in RTI encounters. Reductions in viral RTI transmission likely played a substantial role in reduced RTI visits and antibiotic prescriptions.</p>

10.1542/peds.2021-053079

Pediatrics

35102416

Legal implications of antibiotic stewardship programs.

2020

757-764

2020 07

1559-6834

<p>Infectious diseases professional societies, public health agencies, and healthcare regulatory agencies call for antibiotic stewardship programs (ASP) in many healthcare settings. However, medical legal implications of these programs remain largely uncharted territory. Although there is no legal precedent addressing issues of liability and standards of care on this subject, anticipating how the courts may assess questions of medical liability with respect to the various components of ASPs is important to define best practices in ASP operations, not only to manage the potential risk but also to improve patient care. This article seeks to address some of the common processes and interventions involved in antibiotic stewardship and the potential professional liability implications of these activities.</p>

10.1017/ice.2020.89

Infect Control Hosp Epidemiol

32398167

Improving Outpatient Antibiotic Prescribing for Respiratory Tract Infections in Primary Care; a Stepped-Wedge Cluster Randomized Trial.

2021

2021 Jul 02

1537-6591

<p><strong>BACKGROUND: </strong>Inappropriate antibiotic prescribing is common in primary care (PC), particularly for respiratory tract diagnoses (RTDs). However, the optimal approach for improving prescribing remains unknown.</p>

<p><strong>METHODS: </strong>We conducted a stepped-wedge study in PC practices within a health system to assess the impact of a provider-targeted intervention on antibiotic prescribing for RTDs. RTDs were grouped into tiers based on appropriateness of antibiotic prescribing: tier 1 (almost always indicated), tier 2 (may be indicated), and tier 3 (rarely indicated). Providers received education on appropriate RTD prescribing followed by monthly peer comparison feedback on antibiotic prescribing for (1) all tiers and (2) tier 3 RTDs. Chi-squared testing was used to compare the proportion of visits with antibiotic prescriptions before and during the intervention. Mixed-effects multivariable logistic regression analysis was performed to assess the association between the intervention and antibiotic prescribing.</p>

<p><strong>RESULTS: </strong>Across 30 PC practices and 185,755 total visits, overall antibiotic prescribing was reduced with the intervention, from 35.2% to 23.0% of visits (p&lt;0.001). In multivariable analysis, the intervention was associated with a reduced odds of antibiotic prescription for tiers 2 (OR 0.57; 95% CI 0.52 - 0.62) and 3 (OR 0.57; 95% CI 0.53 - 0.61), but not for tier 1 (OR 0.98; 95% CI 0.83 - 1.16).</p>

<p><strong>CONCLUSION: </strong>A provider-focused intervention reduced overall antibiotic prescribing for RTDs without affecting prescribing for infections that likely require antibiotics. Future research should examine the sustainability of such interventions, potential unintended adverse effects on patient health or satisfaction, and provider perceptions and acceptability.</p>

10.1093/cid/ciab602

Clin Infect Dis

34212177

Development of a Multifaceted Antimicrobial Stewardship Curriculum for Undergraduate Medical Education: The Antibiotic Stewardship, Safety, Utilization, Resistance, and Evaluation (ASSURE) Elective.

2021

ofab231

2021 Jun

2328-8957

<p>To address the growing need for dedicated stewardship training in undergraduate medical education, we developed an antimicrobial stewardship curriculum for medical students with the objectives of increasing expertise in antimicrobial prescribing, introducing antimicrobial stewardship fundamentals, and enhancing comfort with engagement in interprofessional antimicrobial stewardship activities.</p>

10.1093/ofid/ofab231

Open Forum Infect Dis

34164562

Survey to determine the relative importance of clinical factors used to make empiric antibiotic decisions.

2020

1-3

2020 Sep 02

1559-6834

<p>A cross-sectional survey study of inpatient prescribers in a university health system was performed to assess the importance they place on different clinical risk factors when making empiric antibiotic decisions. Our findings show that these clinical risk factors were weighted differently based on the clinical scenario and the type of prescriber.</p>

10.1017/ice.2020.378

Infect Control Hosp Epidemiol

32873345

Prescriber perceptions of fluoroquinolones, extended-spectrum cephalosporins, and infection.

2020

1-7

2020 May 29

1559-6834

<p><strong>BACKGROUND: </strong>Fluoroquinolones (FQs) and extended-spectrum cephalosporins (ESCs) are associated with higher risk of Clostridioides difficile infection (CDI). Decreasing the unnecessary use of FQs and ESCs is a goal of antimicrobial stewardship. Understanding how prescribers perceive the risks and benefits of FQs and ESCs is needed.</p>

<p><strong>METHODS: </strong>We conducted interviews with clinicians from 4 hospitals. Interviews elicited respondent perceptions about the risk of ESCs, FQs, and CDI. Interviews were audio recorded, transcribed, and analyzed using a flexible coding approach.</p>

<p><strong>RESULTS: </strong>Interviews were conducted with 64 respondents (38 physicians, 7 nurses, 6 advance practice providers, and 13 pharmacists). ESCs and FQs were perceived to have many benefits, including infrequent dosing, breadth of coverage, and greater patient adherence after hospital discharge. Prescribers stated that it was easy to make decisions about these drugs, so they were especially appealing to use in the context of time pressures. They described having difficulty discontinuing these drugs when prescribed by others due to inertia and fear. Prescribers were skeptical about targeting specific drugs as a stewardship approach and felt that the risk of a negative outcome from under treatment of a suspected bacterial infection was a higher priority than the prevention of CDI.</p>

<p><strong>CONCLUSIONS: </strong>Prescribers in this study perceived many advantages to using ESCs and FQs, especially under conditions of time pressure and uncertainty. In making decisions about these drugs, prescribers balance risk and benefit, and they believed that the risk of CDI was acceptable in compared with the risk of undertreatment.</p>

10.1017/ice.2020.183

Infect Control Hosp Epidemiol

32468967

Physician Perceptions Regarding Antimicrobial Use in End-of-Life Care.

2018

383-90

2018 Apr

1559-6834

<p>BACKGROUND The decision to utilize antimicrobials in end-of-life situations is complex. Understanding the reasons why physicians prescribe antimicrobials in this patient population is important for informing the design of antimicrobial stewardship interventions. METHODS A 51-item survey containing both closed and open-ended questions on end-of-life antimicrobial use was administered to physicians affiliated with the University of Pennsylvania and Children's Hospital of Philadelphia from January through April 2017. A mixed-methods approach was used to analyze responses. RESULTS Of 637 physicians surveyed, 283 responses (44.4%) were received. Most (86.2%) physicians believed that respecting a patient's wish to continue antimicrobials was important. Approximately half of physicians (49.8%) believed that antimicrobial use at the end of life contributes to resistance. A higher proportion of pediatricians would often or always continue antimicrobial treatment for active infections and for hospice patients whose death was imminent compared to adult physicians (P&lt;.001). Analysis of free-text responses revealed additional reasons why physicians may continue antimicrobials at end of life, including meeting family expectations, wanting to avoid the perception of "giving up," uncertainty about prognosis, and reducing patient pain or discomfort. CONCLUSIONS Physician decision making concerning antimicrobial use in patients at the end of life is multifactorial. Clinicians may overweigh the benefits of antimicrobial therapy in end-of-life situations and view the importance of adhering to stewardship policies differently. Pediatric and adult clinicians have different approaches to this patient population. Better understanding of the complex decision making that occurs in the end-of-life patient population can help guide antimicrobial stewardship policies and improve patient care. Infect Control Hosp Epidemiol 2018;1-8.</p>

10.1017/ice.2018.6

Infect Control Hosp Epidemiol

29428002

Point-of-prescription interventions to improve antimicrobial stewardship.

2015

1252-8

04/2015

1537-6591

<p>Antimicrobial stewardship is pivotal to improving patient outcomes, reducing adverse events, decreasing healthcare costs, and preventing further emergence of antimicrobial resistance. In an era in which antimicrobial resistance is increasing, judicious antimicrobial use is the responsibility of every healthcare provider. Antimicrobial stewardship programs (ASPs) have made headway in improving antimicrobial prescribing using such "top-down" methods as formulary restriction and prospective audit with feedback; however, engagement of prescribers has not been fully explored. Strategies that include frontline prescribers and other unit-based healthcare providers have the potential to expand stewardship, both to augment existing centralized ASPs and to provide alternative approaches to perform stewardship at healthcare facilities with limited resources. This review discusses interventions focusing on antimicrobial prescribing at the point of prescription as well as a pilot project to engage unit-based healthcare providers in antimicrobial stewardship.</p>

10.1093/cid/civ018

Clin. Infect. Dis.

25595748