Antimicrobial Stewardship in Outpatient Settings: A Systematic Review

Drekonja, Dimitri; Filice, Gregory; Greer, Nancy; Olson, Andrew; MacDonald, Roderick; Rutks, Indulis; Wilt, Timothy J

doi:10.1017/ice.2014.41

Cited by 222 publications

(212 citation statements)

References 71 publications

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“…Similarly, continued education should focus on signs and symptoms that are and are not associated with an increased risk of bacterial infection. Guidelines have been useful in reducing the volume of antibiotic use (66). While a number of guidelines pertaining to respiratory tract infections exist, it may be beneficial to enhance them with clear descriptions both of signs and symptoms that are, and are not, likely to be associated with bacterial infection.…”

Section: Discussionmentioning

confidence: 99%

Systematic Review of Factors Associated with Antibiotic Prescribing for Respiratory Tract Infections

McKay

Mah

Law

et al. 2016

Antimicrob Agents Chemother

173

153

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Antibiotic use is a modifiable driver of antibiotic resistance. In many circumstances, antibiotic use is overly broad or unnecessary. We systematically assessed factors associated with antibiotic prescribing for respiratory tract infections (RTI). Studies were included if they used actual (not self-reported or intended) prescribing data, assessed factors associated with antibiotic prescribing for RTIs, and performed multivariable analysis of associations. We searched Medline, Embase, and International Pharmaceutical Abstracts using keyword and MeSH (medical subject headings) search terms. Two authors reviewed each abstract and independently appraised all included texts. Data on factors affecting antibiotic prescribing were extracted. Our searches retrieved a total of 2,848 abstracts, with 97 included in full-text review and 28 meeting full inclusion criteria. Compared to other factors, diagnosis of acute bronchitis was associated with increased antibiotic prescribing (range of adjusted odds ratios [aOR], 1.56 to 15.9). Features on physical exam, such as fever, purulent sputum, abnormal respiratory exam, and tonsillar exudate, were also associated with higher odds of antibiotic prescribing. Patient desire for an antibiotic was not associated or was modestly associated with prescription (range of aORs, 0.61 to 9.87), in contrast to physician perception of patient desire for antibiotics, which showed a stronger association (range of aORs, 2.11 to 23.3). Physician's perception of patient desire for antibiotics was strongly associated with antibiotic prescribing. Antimicrobial stewardship programs should continue to expand in the outpatient setting and should emphasize clear and direct communication between patients and physicians, as well as signs and symptoms that do and do not predict bacterial etiology of upper respiratory tract infections.T he rapid and ongoing spread of antimicrobial-resistant organisms threatens our ability to successfully treat a growing number of infectious diseases (1, 2). It is well established that antibiotic use is a significant, and modifiable, driver of antibiotic resistance (3-5), and that antibiotics are often misused (6). In settings where a prescription is required to access antibiotics, the prescriber-patient encounter is a logical target for improving appropriate use.Despite the importance of the topic, there is no existing systematic review to identify drivers of antibiotic prescribing from real prescription data. A narrative review of factors influencing antibiotic prescribing highlighted the multiple sources of influence affecting a potential prescribing encounter, including factors related to the prescribing physician (e.g., fear of failure, diagnostic uncertainty, or inadequate training), the patient (e.g., a high-risk or vulnerable patient history), and the environment (e.g., regulation of pharmaceutical prescribing and dispensing and lack of resources for etiological diagnosis) (7). Another study systematically reviewed reasons for inappropriate antibiotic prescriptions, f...

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Section: Discussionmentioning

confidence: 99%

Systematic Review of Factors Associated with Antibiotic Prescribing for Respiratory Tract Infections

McKay

Mah

Law

et al. 2016

Antimicrob Agents Chemother

173

153

View full text Add to dashboard Cite

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“…Targeting inpatient postprocedural antimicrobial orders may be relatively straightforward with currently available antimicrobial stewardship resources; however, outpatient and oral antimicrobial use may present a larger barrier to quality improvement because data regarding effective interventions for outpatient antimicrobial stewardship are limited. 21 A 48-hour review of necessity of antimicrobial therapy is an intervention recommended by the Society for Healthcare Epidemiology of America, Infectious Diseases Society of America and Pediatric Infectious Diseases Society (SHEA/IDSA/PIDS) to reduce antimicrobial use in inpatients. However, this intervention is not feasible in the outpatient setting.…”

Section: Discussionmentioning

confidence: 99%

Cardiac Electrophysiology Laboratories: A Potential Target for Antimicrobial Stewardship and Quality Improvement?

Branch‐Elliman

Stanislawski

Strymish

et al. 2016

Infect. Control Hosp. Epidemiol.

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BACKGROUND Infections following cardiovascular implantable electronic device (CIED) procedures, including pacemaker and implantable cardioverter-defibrillators, are devastating and costly. Preimplantation prophylactic antimicrobials are effective for reducing postprocedural infections. However, routine postprocedural antimicrobials are not associated with improved outcomes, and they may be harmful. Thus, we sought to characterize antimicrobial use patterns following CIED procedures. DESIGN All patients who underwent CIED procedures from October 1, 2007 to September 30, 2013 and had procedural information entered into the VA Clinical Assessment Reporting and Tracking (CART) software program were included in this study. All antibiotic prescriptions lasting more than 24 hours following device implantation or revision were identified using pharmacy databases, and postprocedural antibiotic use lasting more than 24 hours was characterized. RESULTS In total, 3,712 CIED procedures were performed at 34 VA facilities on 3,570 patients with a mean age of 71.7 years (standard deviation [SD], 11.1 years), 98.4% of whom were male. Postprocedural antibiotics >24 hours were prescribed following 1,579 of 3,712 CIED procedures (42.5%). The median duration of therapy was 5 days (interquartile range [IQR], 3-7 days). The most commonly prescribed antibiotic was cephalexin (1,152 of 1,579; 72.9%), followed by doxycycline (118 of 1,579; 7.47%) and ciprofloxacin (93 of 1,579; 5.9%). Vancomycin was used in 73 of 1,579 prescriptions (4.62%). Among the highest quartile of procedural volume, prescribing practices varied considerably, ranging from 3.2% to 77.6%. CONCLUSIONS Nearly 1 in 2 patients received prolonged postprocedural antimicrobial therapy following CIED procedures, and the rate of postprocedural antimicrobial therapy use varied considerably by facility. Given the lack of demonstrated benefit of routine prolonged antimicrobial therapy following CIED procedures, antimicrobial use following cardiac device interventions may be a potential target for quality improvement programs and antimicrobial stewardship. Infect Control Hosp Epidemiol 2016;37:1005-1011.

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“…[27][28][29] Several initiatives have raised awareness of inappropriate antimicrobial use and have promoted prudent prescribing. 30,31 However, interventions for outpatient antimicrobial stewardship are challenging to implement, 32 and surveillance of ambulatory prescribing in Canada has been limited despite calls to prioritize such efforts. 33 The objective of Research our study was to describe patterns of outpatient antimicrobial prescribing in older residents of Ontario from 2006 to 2015.…”

mentioning

confidence: 99%

A decade of outpatient antimicrobial use in older adults in Ontario: a descriptive study

Tan

Graves

et al. 2017

CMAJ Open

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Background: Antimicrobials are frequently prescribed to community-dwelling older adults. Our aim was to examine the prevalence, quantity and indications of antimicrobial prescriptions to older residents of Ontario. Methods:We conducted a population-based analysis of outpatient antimicrobial prescriptions to residents of Ontario aged 65 years or more from 2006 to 2015. Antimicrobial prescriptions, infectious disease diagnoses and prescriber information were determined from linked health care databases. Our analyses were primarily focused on antibiotics, which account for most antimicrobial use. Results:We identified 2 879 779 unique Ontario residents aged 65 years or more over our study period. On average, 40.7% (range 40.1%-41.5%) of older adult outpatients in any given year received 1 or more antibiotic prescriptions. Antibiotic use remained stable over the study period, averaging 25.1 (range 24.1-25.6) defined daily doses per 1000 person-days per year. Selection of antibiotics evolved, with increasing use of penicillins and decreasing use of fluoroquinolones and macrolides. For 65.7% of prescriptions, no infectious disease diagnoses were identified within 7 days of the prescription. Among prescriptions with an associated diagnosis, upper respiratory tract infection was most common (18.9%), followed by urinary tract infection (6.2%), skin/soft-tissue infection (4.3%), lower respiratory tract infection (4.2%) and other infection (1.2%). Most antibiotics were prescribed by family physicians. MethodsWe conducted a province-wide analysis of antimicrobial prescriptions to older adults (aged ≥ 65 yr) in Ontario from Jan. 1, 20061, , to Dec. 31, 2015. Data sourcesThis study used population-based administrative databases housed at the Institute for Clinical Evaluative Sciences. These databases are well validated and have been used in studies on antimicrobial prescribing. [34][35][36][37][38] The Ontario Drug Benefit Program database, which contains all publicly funded medications prescribed to Ontario residents aged 65 years or more, was used for information on antimicrobial prescribing. This database exhibits greater than 99% accuracy when compared against pharmacy dispensing data. 34 To identify older adults and determine infectious disease diagnoses, the following databases were linked to the Ontario Drug Benefit Program database at the patient level: the Registered Persons Database, which contains demographic information for Ontario residents with publicly funded health insurance (> 95% of residents); the Ontario Health Insurance Plan database, which contains all billing claims made by health care providers for services performed in Ontario; the Discharge Abstracts Database, which contains information on all admissions, discharges and same-day surgical procedures in Ontario hospitals; and the National Ambulatory Care Reporting System, which contains information on all emergency department visits in Ontario hospitals. Antimicrobial prescriptionsWe used the Registered Persons Database to identify all Ontario reside...

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Antimicrobial Stewardship in Outpatient Settings: A Systematic Review

Cited by 222 publications

References 71 publications

Systematic Review of Factors Associated with Antibiotic Prescribing for Respiratory Tract Infections

Systematic Review of Factors Associated with Antibiotic Prescribing for Respiratory Tract Infections

Cardiac Electrophysiology Laboratories: A Potential Target for Antimicrobial Stewardship and Quality Improvement?

A decade of outpatient antimicrobial use in older adults in Ontario: a descriptive study

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