Background
In this pilot trial, we evaluated whether audit-and-feedback was a feasible strategy to improve antimicrobial-prescribing in EDs.
Methods
We evaluated an audit-and-feedback intervention using a quasi-experimental interrupted time-series design at 2 intervention and 2 matched-control EDs; there was a 12-month baseline, one-month implementation and 11-month intervention period. At intervention sites, clinicians received 1) a single, one-on-one education about antimicrobial-prescribing for common infections; 2) individualized feedback on total and condition-specific (uncomplicated ARI) antimicrobial use with peer-to-peer comparisons at baseline and every quarter. The primary outcome was the total antimicrobial-prescribing rate for all visits and was assessed using generalized linear models. In an exploratory analysis, we measured antimicrobial use for uncomplicated ARI visits and manually reviewed charts to assess guideline-concordant management for 6 common infections.
Results
In the baseline and intervention periods, intervention sites had 28,016 and 23,164 visits compared to 33,077 and 28,835 at control sites. We enrolled 27/31 (87.1%) eligible clinicians; they acknowledged receipt of 33.3% of feedback e-mails. Intervention sites compared to control sites had no absolute reduction in their total antimicrobial rate (incidence rate ratio 0.99; 95% CI, 0.98-1.01). At intervention sites, antimicrobial use for uncomplicated ARIs decreased [68.6% to 42.4% (p<0.01)] and guideline-concordant management improved [52.1% to 72.5% (p<0.01)]; these improvements were not seen at control sites.
Conclusions
At intervention sites, total antimicrobial use did not decrease, but an exploratory analysis showed reduced antimicrobial-prescribing for viral ARIs. Future studies should identify additional targets for condition-specific feedback while exploring ways to make electronic feedback more acceptable.
Fluoroquinolone resistance among Enterobacteriaceae is a notable challenge for appropriate empiric therapy in outpatient settings. We describe the spatial distribution of fluoroquinolone resistance and its chronological change between 2000 and 2017 in the nationwide Veterans’ Health Administration system. We found spatially concentrated increasing prevalence in the 2000s, followed by spatial dispersion in the 2010s.
An immunocompetent man in his 40s presented with 3 months of mid-thoracic back pain which progressed to include progressive paraesthesias and lower extremity weakness. Investigations revealed thoracic spine osteomyelitis with signs of cord compression. He underwent neurosurgical intervention, including laminectomy, spinal cord decompression and partial resection of an epidural mass. Initial intraoperative biopsy and surgical pathology results were concerning for an acid-fast bacillus as the causative pathogen, and the patient was given empiric therapy for presumed Mycobacterium tuberculosis. However, microbiology speciation revealed the presence of the non-tuberculous mycobacterium (NTM) Mycobacterium kansasii, which resulted in an alteration of his antimicrobial therapy. This case highlights the importance of considering NTM as a possible aetiology of spinal osteomyelitis, even among immunocompetent individuals or in low-prevalence regions.
to quantify health care-related greenhouse gas emissions in the world. Moving forward, the US health care industry would be well-served to create such programs as a means of developing nationwide sustainability metrics so that we can improve our understanding of the US health care industry's environmental impact. 7 The sheer magnitude of the climate change problem often results in decision paralysis. With telemedicine as an example, the study by Patel et al reminds us that individuals and institutions can still make a substantial impact on our health care system's carbon footprint.
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