Impact of Implementation of the Core Elements of Outpatient Antibiotic Stewardship Within Veterans Health Administration Emergency Departments and Primary Care Clinics on Antibiotic Prescribing and Patient Outcomes

Abstract

Background The Core Elements of Outpatient Antibiotic Stewardship provide a framework to improve antibiotic use, but evidence supporting safety are limited. We report the impact of Core Elements implementation within Veterans Health Administration sites. Methods A quasi-experimental controlled study assessed the effects of an intervention targeting antibiotic prescription for uncomplicated acute respiratory tract infections (ARI). Outcomes included per-visit antibiotic prescribing, treatment appropriateness, potential benefits and complications of reduced antibiotic treatment, and change in ARI diagnoses over a 3-year pre-implementation and 1-year post implementation period. Logistic regression adjusted for covariates [OR (95% CI)] and a difference-in-differences analysis compared outcomes between intervention and control sites. Results From 2014-2019, there were 16,712 and 51,275 patient-visits in 10 intervention and 40 control sites, respectively. Antibiotic prescribing rates pre-post implementation in intervention sites were 59.7% and 41.5%, respectively; in control sites they were 73.5% and 67.2%, respectively [difference-in-differences p<0.001]. The intervention site pre-post implementation odds ratio to receive appropriate therapy increased [1.67 (1.31, 2.14)] which remained unchanged within control sites [1.04 (0.91, 1.19)]. There was no difference in ARI-related return visits post-implementation [(-1.3% vs. -2.0%; difference-in-differences p=0.76] but all-cause hospitalization was lower within intervention sites [(-0.5% vs. -0.2%); difference-in-differences p=0.02]. The odds ratio to diagnose upper respiratory tract infection not otherwise specified compared to other non-ARI diagnosis increased post-implementation for intervention [1.27(1.21,1.34)] but not control [0.97(0.94,1.01)] sites. Conclusions Implementation of the Core Elements was associated with reduced antibiotic prescribing for uncomplicated ARIs and a reduction in hospitalizations. ARI diagnostic coding changes were observed.

Improving antibiotic prescribing for pediatric acute respiratory tract infections: A cluster randomized trial to evaluate individual versus clinic feedback

“…7 We suspect that these changes reflect more appropriate diagnostic coding resulting from education, as suggested by others. 29,30 Total antibiotic prescribing changed little after the intervention, as expected, since we did not focus on prescribing reduction but rather on guideline-concordant care. The reduction in use with improved URI performance likely represented a small proportion of total antibiotic use.…”

Comparative effectiveness of amoxicillin versus amoxicillin‐clavulanate among adults with acute sinusitis in emergency department and urgent care settings

“…Potential infectious complications (ie, Clostridioides difficile infections, pneumonia, meningitis, mastoiditis, or facial cellulitis) were identified by a new outpatient or inpatient diagnostic code for these conditions within 30 days following the index visit (eTable S7). [9][10][11] Return visits for gastrointestinal-related adverse antibiotic events were identified by outpatient visits or inpatient admissions with diagnostic codes consistent with potential gastrointestinal-related adverse antibiotic events (ie, diarrhea, colitis, hepatitis, nausea) for visits that occurred within 14 days after the index acute sinusitis visit if the patient did not have a similar diagnostic code within 6 months preceding the visit (eTable S7). 10 Hospitalizations were defined by an admission date that occurred between 1 and 30 days following the index visit.…”

“…In addition, the ICD-based measurement of gastrointestinal-related adverse events had limited sensitivity and specificity to identify true antibiotic adverse events. 10 Conservatively, application of the findings should be limited to episodes of uncomplicated acute sinusitis in primarily elderly adult males without recent antibiotic exposures.…”

Guidelines on Implementing Antimicrobial Stewardship Programs in Korea

“…This increased to 85% in 2018 [ 97 ]. After implementation of the core elements, the CDI incidence and antimicrobial use decreased [ 98 99 ].…”