Operationalising outpatient antimicrobial stewardship to reduce system-wide antibiotics for acute bronchitis

Johnson, Morgan C; Hulgan, Todd; Cooke, R.; Kleinpell, Ruth; Roumie, Christianne L.; Callaway‐Lane, Carol; Mitchell, L.; Hathaway, Jacob; Dittus, Robert S.; Staub, Milner

doi:10.1136/bmjoq-2020-001275

Cited by 9 publications

(4 citation statements)

References 32 publications

(26 reference statements)

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“…Our study adds to mounting evidence that targeted outpatient antibiotic stewardship programs are effective at reducing unnecessary or inappropriate antibiotic prescribing for URIs [ 12 , 13 , 15 , 16 , 20–24 ]. We observed a 48.4% relative reduction in prescriptions for Tier 3 URI following comprehensive outpatient antimicrobial stewardship program implementation, amounting to approximately 7300 unnecessary antibiotic prescriptions avoided.…”

Section: Discussionmentioning

confidence: 82%

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

Ilges,

Jensen,

Draper

et al. 2023

Open Forum Infectious Diseases

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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.

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Section: Discussionmentioning

confidence: 82%

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

Ilges,

Jensen,

Draper

et al. 2023

Open Forum Infectious Diseases

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“…These Veterans were previously identified as part of a quality improvement project at VA TVHS. 20 From March to May 2020, eligible Veterans were screened. Veterans who had died since their URI visit, had documented dementia, or had not been evaluated in-person were excluded.…”

Section: Patient Populationmentioning

confidence: 99%

Association of antibiotics with veteran visit satisfaction and antibiotic expectations for upper respiratory tract infections

Staub

Pellegrino

Gettler

et al. 2022

ASHE

Self Cite

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Background and objective: Veterans’ Affairs (VA) healthcare providers perceive that Veterans expect and base visit satisfaction on receiving antibiotics for upper respiratory tract infections (URIs). No studies have tested this hypothesis. We sought to determine whether receiving and/or expecting antibiotics were associated with Veteran satisfaction with URI visits. Methods: This cross-sectional study included Veterans evaluated for URI January 2018–December 2019 in an 18-clinic ambulatory VA primary-care system. We evaluated Veteran satisfaction via the Patient Satisfaction Questionnaire Short Form (RAND Corporation), an 18-item 5-point Likert scale survey. Additional items assessed Veteran antibiotic expectations. Antibiotic receipt was determined via medical record review. We used multivariable regression to evaluate whether antibiotic receipt and/or Veteran antibiotic expectations were associated with satisfaction. Subgroup analyses focused on Veterans who accurately remembered antibiotic prescribing during their URI visit. Results: Of 1,329 eligible Veterans, 432 (33%) participated. Antibiotic receipt was not associated with differences in mean total satisfaction (adjusted score difference, 0.6 points; 95% confidence interval [CI], −2.1 to 3.3). However, mean total satisfaction was lower for Veterans expecting an antibiotic (adjusted score difference −4.4 points; 95% CI −7.2 to −1.6). Among Veterans who accurately remembered the visit and did not receive an antibiotic, those who expected an antibiotic had lower mean satisfaction scores than those who did not (unadjusted score difference, −16.6 points; 95% CI, −24.6 to −8.6). Conclusions: Veteran expectations for antibiotics, not antibiotic receipt, are associated with changes in satisfaction with outpatient URI visits. Future research should further explore patient expectations and development of patient-centered and provider-focused interventions to change patient antibiotic expectations.

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“…National health agencies (the CDC) and professional organizations (Infectious Diseases Society of America) have published a variety of resources for clinicians on antibiotic prescribing, for particular infections and for more appropriate use of antibiotics in general (17,(36)(37)(38)(39)(40)(41)(42). However, the complexity of the documents, the length of 10.3389/fmed.2022.901980 time between document updates, and the inclusion of some content that doesn't reflect real-world practice leads many community providers to turn instead to alternative resources, including decision support information sites such as UpToDate and Epocrates, or rely on their medical training (8,43). Some of the guidelines lack specific recommendations on duration of therapy, therapy choice, or how to interpret local resistance patterns.…”

Section: Guideline Disconnectmentioning

confidence: 99%

“…One-third (∼47 million) of these outpatient antibiotic prescriptions are considered unnecessary ( 6 ). This is largely attributable to antibiotics prescribed for viral infections (e.g., viral upper respiratory infections, pharyngitis, and middle ear infections), as well as non-bacterial conditions such as allergy/asthma and bronchitis ( 7 , 8 ).…”

Section: What’s the Problem?mentioning

confidence: 99%

It’s about the patients: Practical antibiotic stewardship in outpatient settings in the United States

Amin

Dellinger²,

Harnett³

et al. 2022

Front. Med.

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Antibiotic-resistant pathogens cause over 35,000 preventable deaths in the United States every year, and multiple strategies could decrease morbidity and mortality. As antibiotic stewardship requirements are being deployed for the outpatient setting, community providers are facing systematic challenges in implementing stewardship programs. Given that the vast majority of antibiotics are prescribed in the outpatient setting, there are endless opportunities to make a smart and informed choice when prescribing and to move the needle on antibiotic stewardship. Antibiotic stewardship in the community, or “smart prescribing” as we suggest, should factor in antibiotic efficacy, safety, local resistance rates, and overall cost, in addition to patient-specific factors and disease presentation, to arrive at an appropriate therapy. Here, we discuss some of the challenges, such as patient/parent pressure to prescribe, lack of data or resources for implementation, and a disconnect between guidelines and real-world practice, among others. We have assembled an easy-to-use best practice guide for providers in the outpatient setting who lack the time or resources to develop a plan or consult lengthy guidelines. We provide specific suggestions for antibiotic prescribing that align real-world clinical practice with best practices for antibiotic stewardship for two of the most common bacterial infections seen in the outpatient setting: community-acquired pneumonia and skin and soft-tissue infection. In addition, we discuss many ways that community providers, payors, and regulatory bodies can make antibiotic stewardship easier to implement and more streamlined in the outpatient setting.

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Operationalising outpatient antimicrobial stewardship to reduce system-wide antibiotics for acute bronchitis

Cited by 9 publications

References 32 publications

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

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

Association of antibiotics with veteran visit satisfaction and antibiotic expectations for upper respiratory tract infections

It’s about the patients: Practical antibiotic stewardship in outpatient settings in the United States

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