Antibiotic stewardship to reduce inappropriate antibiotic prescribing in integrated academic health-system urgent care clinics

Abstract

Objective: To develop and implement antibiotic stewardship activities in urgent care targeting non–antibiotic-appropriate acute respiratory tract infections (ARIs) that also reduces overall antibiotic prescribing and maintains patient satisfaction. Patients and setting: Patients and clinicians at the urgent care clinics of an integrated academic health system. Intervention and methods: The stewardship activities started in fiscal 2020 and included measure development, comparative feedback, and clinician and patient education. We measured antibiotic prescribing in fiscal years 2019, 2020, and 2021 for the stewardship targets, potential diagnosis-shifting visits, and overall. We also collected patient satisfaction data for ARI visits. Results: From FY19 to FY21, 576,609 patients made 1,358,816 visits to 17 urgent care clinics, including 105,781 visits for which stewardship measures were applied and 149,691 visits for which diagnosis shifting measures were applied. The antibiotic prescribing rate decreased for stewardship-measure visits from 34% in FY19 to 12% in FY21 (absolute change, −22%; 95% confidence interval [CI], −23% to −22%). The antibiotic prescribing rate decreased for diagnosis-shifting visits from 63% to 35% (−28%; 95% CI, −28% to −27%), and the antibiotic prescribing rate decreased overall from 30% to 10% (−20%; 95% CI, −20% to −20%). The patient satisfaction rate increased from 83% in FY19 to 89% in FY20 and FY21. There was no significant association between antibiotic prescribing rates of individual clinicians and ARI visit patient satisfaction. Conclusions: Although it was affected by the COVID-19 pandemic, an ambulatory antimicrobial stewardship program that focused on improving non–antibiotic-appropriate ARI prescribing was associated with decreased prescribing for (1) the stewardship target, (2) a diagnosis shifting measure, and (3) overall antibiotic prescribing. Patient satisfaction at ARI visits increased over time and was not associated with clinicians’ antibiotic prescribing rates.

Implementation of an Antibiotic Stewardship Initiative in a Large Urgent Care Network

“…This study adds to growing evidence about effective outpatient stewardship programs, including those focused on UC settings . Features of successful programs include the use of audit and feedback, clinician and patient education, EHR tools, and peer comparison or benchmarking.…”

“…This study adds to growing evidence about effective outpatient stewardship programs, including those focused on UC settings. [9][10][11][17][18][19] Features of successful programs include the use of audit and feedback, clinician and patient education, EHR tools, and peer comparison or benchmarking. The interventions used in our program were integrated into the UC service line in a a First-line antibiotic prescriptions among sinusitis, otitis media, and pharyngitis encounters where an antibiotic was prescribed.…”

“…Most outpatient stewardship interventions have been designed and evaluated in primary care (PC) settings or emergency departments (EDs), with few interventions being applied specifically to UC. [9][10][11] Urgent care incorporates features common to PC settings (eg, uncomplicated low-acuity respiratory conditions) and EDs (eg, expanded hours, walk-in visits, rotating clinicians, and expectations for fast turnaround). Therefore, stewardship programs that best meet the needs of patients and clinicians in UC settings should understand and incorporate these characteristics.…”

“…This guidance provides a framework for outpatient stewardship implementation. Most outpatient stewardship interventions have been designed and evaluated in primary care (PC) settings or emergency departments (EDs), with few interventions being applied specifically to UC . Urgent care incorporates features common to PC settings (eg, uncomplicated low-acuity respiratory conditions) and EDs (eg, expanded hours, walk-in visits, rotating clinicians, and expectations for fast turnaround).…”

Outpatient treatment of pneumonia in a setting with and without an infectious disease doctor

“…The reasons are manifold -from rare but concerning side effects (10,11), a role in the pathogenesis of the Clostridioides difficile epidemic (12) to their effect in selecting bacteria resistant to both fluoroquinolones and beta-lactam antibiotics (13). The overuse of broad-spectrum antibiotics, in this case especially fluoroquinolones, may be thwarted by antibiotic stewardship, which has been shown to reduce inappropriate antibiotic use even with a non-restrictive approach (14,15).…”