The effect of a multimodal stewardship approach on antibiotic prescribing for outpatients with acute respiratory tract infections: Order set implementation and education

Abstract

Introduction Although antimicrobial stewardship initiatives in the outpatient setting have been increasing, the effect of order set implementation on antibiotic prescribing for acute respiratory tract infections (ARTI) has not been fully established. Objective This study's objective was to determine the impact of order sets and education on antibiotic prescribing for ARTI in the outpatient setting. Methods This was a quasi‐experimental research study conducted from January 2015 through December 2016. The study was conducted at an adult ambulatory care clinic associated with a tertiary care medical center. Order sets and prescriber education were created and implemented to aid in the diagnosis and treatment of ARTI. The primary end point was a composite of antibiotic prescribing frequency for ARTI. Secondary objectives included antibiotic appropriateness, patients requiring follow‐up clinic visits, and development of Clostridioides difficile infection. Results A total of 3292 patients were included in the study. Unspecified respiratory tract infection (RTI) was the most common diagnosis. Antibiotic prescribing decreased from 33% to 24% in the postintervention period (relative risk 0.74 [0.64‐0.85], P = <.0005). Antibiotic appropriateness was increased in the postintervention period (70%‐85%, P = <.0005) and significant reductions in clinic revisits were observed in the postintervention group, from 2.3% to 0.2% (odds ratio 15.2 [3.6‐64.1], P = .0002). Conclusions Implementation of order sets and education to aid in the management of ARTI at an outpatient clinic resulted in an overall decrease in antibiotic prescribing, improvements in antibiotic appropriateness, and decreased 30‐day clinic revisits. Order sets and education should be considered as a part of a multimodal approach to outpatient antimicrobial stewardship.

Outcomes of an ambulatory care pharmacist-led antimicrobial stewardship program within a family medicine resident clinic

“…19 Previous studies evaluating multifaceted approaches to implementing ASPs in outpatient settings have also demonstrated success when targeting syndrome-specific prescribing by combining educational interventions with EHR optimization and peer-to-peer comparison. [20][21][22][23] As of January 2020, The Joint Commission requires all accredited ambulatory health organizations to implement ASPs. 24 Our study findings demonstrate that the new elements of performance are measurable and achievable when given adequate resources.…”

Impact of order sentence implementation on outpatient antibiotic prescribing for urinary tract infection and skin and soft tissue infection

“…11 A decrease in antibiotic prescribing from 33% to 24% (P < .001) was observed following order set implementation; additionally, antibiotic appropriateness increased from 70% to 85% (P < .001). 11 The authors concluded that antibiotic order sets positively impact antibiotic prescribing and should be considered as part of multimodal outpatient ASPs. This study was limited in that it only examined order sentence implementation for ARTI.…”

“…Few studies have been conducted since that time evaluating the impact of EHR order sentence implementation on outpatient antibiotic prescribing and have had varying results. A quasi‐experimental study by Peterson et al aimed to determine the impact of order sets and education on antibiotic prescribing for 3292 patients with acute respiratory tract infections (ARTI) in the outpatient setting 11 . A decrease in antibiotic prescribing from 33% to 24% ( P < .001) was observed following order set implementation; additionally, antibiotic appropriateness increased from 70% to 85% ( P < .001) 11 .…”

“…A quasi‐experimental study by Peterson et al aimed to determine the impact of order sets and education on antibiotic prescribing for 3292 patients with acute respiratory tract infections (ARTI) in the outpatient setting 11 . A decrease in antibiotic prescribing from 33% to 24% ( P < .001) was observed following order set implementation; additionally, antibiotic appropriateness increased from 70% to 85% ( P < .001) 11 . The authors concluded that antibiotic order sets positively impact antibiotic prescribing and should be considered as part of multimodal outpatient ASPs.…”

“…Due to this limitation, methods other than manual audit‐and‐feedback must be explored to optimize antibiotic prescribing with limited resources. Optimizing prescribing through order sentence creation within the ambulatory electronic health record (EHR) may allow ASPs to extend their reach with limited resources; however, limited data are available evaluating this method of stewardship and their results are conflicting 10‐13 . The purpose of this study was to determine whether implementation of stewardship‐driven order sentences within the outpatient EHR and education improves guideline‐concordant antibiotic prescribing for urinary tract infections (UTI) and skin and soft tissue infections (SSTI).…”