Evaluation of Multisite Programmatic Bundle to Reduce Unnecessary Antibiotic Prescribing for Respiratory Infections: A Retrospective Cohort Study

Abstract

Background The aim of this study was to evaluate the frequency of unnecessary antibiotic prescribing for Tier 3 upper respiratory infection (URI) syndromes across the Mayo Clinic Enterprise before and after a multifaceted antimicrobial stewardship intervention, and to determine ongoing factors associated with antibiotic prescribing and repeat respiratory healthcare contact in the postintervention period. Methods This was a quasi-experimental, pre/post, retrospective cohort study from 1 January 2019 through 31 December 2022, with 12-month washout during implementation from 1 July 2020 through 30 June 2021. All outpatient encounters, adult and pediatric, from primary care, urgent care, and emergency medicine specialties with a Tier 3 URI diagnosis were included. The intervention was a multifaceted outpatient antibiotic stewardship bundle. The primary outcome was the rate of antibiotic prescribing in Tier 3 encounters. Secondary outcomes included 14-day repeat healthcare contact for respiratory indications and factors associated with persistent unnecessary prescribing. Results A total of 165 658 Tier 3 encounters, 96 125 in the preintervention and 69 533 in the postintervention period, were included. Following intervention, the prescribing rate for Tier 3 encounters decreased from 21.7% to 11.2% (P < .001). Repeat 14-day respiratory healthcare contact in the no antibiotic group was lower postintervention (9.9.% vs 9.4%; P = .004). Multivariable models indicated that increasing patient age, Charlson comorbidity index, and primary diagnosis selected were the most important factors associated with persistent unnecessary antibiotic prescribing. Conclusions Outpatient antibiotic stewardship initiatives can reduce unnecessary antibiotic prescribing for Tier 3 URIs without increasing repeat respiratory healthcare contact. Advancing age and number of comorbidities remain risk factors for persistent unnecessary antibiotic prescribing.

It takes a village: decreasing inappropriate antibiotic prescribing for upper respiratory tract infections

“…We divided respiratory ICD-10 codes into three tiers, including Tier 1 (“always prescribe antibiotics,” eg, pneumonia), Tier 2 (“sometimes prescribe,” eg, otitis media), and Tier 3 (“never prescribe,” eg, bronchitis), as previously reported (see supplemental material). 6 The departments included were Family Medicine, Community Internal Medicine, Emergency Medicine, and Women’s Health Internal Medicine. We included all patient encounters with a Tier 3 primary diagnosis without secondary Tier 1 or 2 diagnoses.…”

“…The resources included a syndromic ambulatory order panel (EZ ID Respiratory Order Panel) and a viral “prescription pad,” which contains simplified over-the-counter recommendations for symptomatic management of viral URIs, as well as patient education. 6 , 7 Providers were also shown how to optimize Epic preferences to Tier 1 and 2 diagnoses to facilitate selection of the appropriate diagnoses. Additionally, we provided quarterly peer comparison reports (sample in supplemental material) to the department chairs and site leads (Figure 1 ).…”