1268: PROCALCITONIN-GUIDED ANTIBIOTIC STEWARDSHIP DECREASES ANTIBIOTICS FOR RESPIRATORY INFECTIONS IN PICU

Background: Although antibiotic stewardship programs (ASP) are now required in nursing homes, assimilating and responding to data to improve prescribing in nursing homes is novel. Four Atlanta-based skilled nursing facilities (SNFs) began collaborating (EASIL: Emory Antibiotic Stewardship in Long-Term Care) to share standardized prescribing data to allow interfacility comparisons and action. Methods: After SNF ASPs were evaluated and trained, standardized prescribing logs were submitted (January 2019 to June 2019) including the following data: start date, treatment site, prescriber attribution of order (ie, SNF order vs hospital order) and monthly resident days. SNF-specific point estimates of usage rates were calculated as pooled means for all antibiotic starts, SNF-order starts, and days of therapy (DOT), by treatment site per 1,000 resident days. Duration of urinary tract infection (UTI) therapy was assessed by calculating percentage of SNF-UTI starts over recommended duration defined by the local treatment guideline. Rate ratios (RRs) of use were calculated to compare SNF-specific rates to the largest SNF. The 95% CIs were calculated using normal approximation. Results: Monthly starts ranged from 124 to 177, with a pooled mean of 7.8 antibiotic starts (any type), 4.5 SNF-order starts, and 1.2 SNF-UTI starts per 1,000 resident days. Approximately half of all starts were SNF starts (range, 43%–53%), and less than half of DOT were attributed to SNF starts (range, 35%–45%). Overall, SNF-order treatment sites were most often UTIs (29%), lower respiratory infections (17%), and skin and soft-tissue infections (17%). SNF-order UTI starts per 1,000 patient days varied at 1 SNF (SNF B RR, 1.57; 95% CI, 1.04–2.36). SNF-order UTI DOT per 1,000 patient days was more variable, with SNFs B and C having significantly higher rates (B RR, 1.49, 1.24, and 1.82; C RR, 5.42; 95% CI, 4.65–6.34) than SNF A (Fig. 1). The percentage of SNF-order UTI starts that were over recommended duration ranged from 8% (nitrofurantoin, SNF A) to 100% (fluoroquinolones, SNF C) (Fig. 1). Conclusions: Although UTIs are the single most common reason to prescribe antibiotics after arriving in a SNF, they account for a small fraction of overall starts and an even smaller fraction of DOT. We identified outlier prescribing by different SNFs using 3 metrics, suggesting that distinct corrective actions are necessary to target distinct prescribing challenges (starts, duration, and transitions of care).Funding: NoneDisclosures: Scott Fridkin reports that his spouse receives consulting fees from the vaccine industry.

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Dissecting the mechanisms of a 5-year decline in antibiotic prescribing

10.1101/2020.01.02.20016329 ◽

2020 ◽

Author(s):

Stephen M. Kissler ◽

R. Monina Klevens ◽

Michael L. Barnett ◽

Yonatan H. Grad

Keyword(s):

Infectious Disease ◽

Antibiotic Stewardship ◽

Respiratory Infections ◽

Medical Condition ◽

Outpatient Visit ◽

Antibiotic Prescribing ◽

Medical Conditions ◽

Outpatient Visits ◽

Prescribing Trends ◽

Tract Infections

AbstractImportanceThe mechanisms driving the recent decline in outpatient antibiotic prescribing are unknown.ObjectiveTo estimate the extent to which reductions in the number of antibiotic prescriptions filled per outpatient visit (stewardship) and reductions in the monthly rate of outpatient visits (observed disease) for infectious disease conditions each contributed to the decline in annual outpatient antibiotic prescribing rate in Massachusetts between 2011 and 2015.DesignOutpatient medical and pharmacy claims from the Massachusetts All-Payer Claims Database were used to estimate rates of antibiotic prescribing and outpatient visits for 20 medical conditions and their contributions to the overall decline in antibiotic prescribing. Trends were compared to those in the National Ambulatory Medical Care Survey (NAMCS).SettingOutpatient visits in Massachusetts between January 2011 and September 2015.Participants5,075,908 individuals with commercial health insurance or Medicaid in Massachusetts under the age of 65 and 495,515 patients included in NAMCS.Main outcomes and measuresThe number of antibiotic prescriptions avoided through reductions in observed disease and reductions in per-visit prescribing rate per medical condition.ResultsBetween 2011 and 2015, the January antibiotic prescribing rate per 1,000 individuals in Massachusetts declined by 18.9% and the July antibiotic prescribing rate declined by 13.6%. The mean prescribing rate for children under 5 declined by 42.8% (95% CI 21.7%, 59.4%), principally reflecting reduced wintertime prescribing. The monthly rate of outpatient visits per 1,000 individuals in Massachusetts declined (p < 0.05) for respiratory infections and urinary tract infections. Nationally, visits for medical conditions that merit an antibiotic prescription also declined between 2010 and 2015. Of the estimated 358 antibiotic prescriptions per 1,000 individuals avoided over the study period in Massachusetts, 59% (95% CI 54%, 63%) were attributable to reductions in observed disease and 41% (95% CI 37%, 46%) to reductions in prescribing per outpatient visit.Conclusions and relevanceThe decline in antibiotic prescribing in Massachusetts was driven by a decline in observed disease and improved antibiotic stewardship, with a contemporaneous reduction in visits for conditions prompting antibiotics observed nationally. A focus on infectious disease prevention should be considered alongside antibiotic stewardship as a means to reduce antibiotic prescribing.Key pointsQuestionHow did the separate mechanisms of improved stewardship and reductions in observed disease contribute to a 5-year decline in outpatient antibiotic prescribing in Massachusetts from 2011-2015?FindingsIn an observational analysis of insurance claims, reduced monthly rates of outpatient visits for infectious conditions and reduced probability of prescribing an antibiotic per outpatient visit both contributed to the decline in antibiotic prescribing. An estimated 358 antibiotic prescriptions per 1,000 individuals were avoided over the study period through the two mechanisms, 211 of which were attributable to reductions in outpatient visits and 147 to reduced antibiotic prescribing per visit.MeaningPreventing the need for outpatient visits should be considered alongside antibiotic stewardship as a means of reducing antibiotic prescribing.

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An antibiotic stewardship programme to reduce inappropriate antibiotic prescribing for acute respiratory infections in rural Chinese primary care facilities: study protocol for a clustered randomised controlled trial

10.21203/rs.3.rs-18556/v1 ◽

2020 ◽

Author(s):

Chao Zhuo ◽

Xiaolin Wei ◽

Zhitong Zhang ◽

Joseph Paul Hicks ◽

Jinkun Zheng ◽

...

Keyword(s):

Primary Care ◽

Antibiotic Stewardship ◽

Respiratory Infections ◽

Inappropriate Prescribing ◽

Antibiotic Prescribing ◽

Acute Respiratory Infections ◽

Care Facilities ◽

Randomised Controlled ◽

Antibiotic Stewardship Programme

Abstract Background: Inappropriate prescribing of antibiotics for acute respiratory infections at primary care level represents the major source of antibiotic misuse in healthcare, and is a major driver for antimicrobial resistance worldwide. In this study we will develop, pilot and evaluate the effectiveness of a comprehensive antibiotic stewardship programme in China’s primary care hospitals to reduce inappropriate prescribing of antibiotics for acute respiratory infections among all ages.Methods: We will use a parallel-group, cluster-randomised, controlled, superiority trial with blinded outcome evaluation but unblinded treatment (providers and patients). We will randomise 34 primary care hospitals from two counties within Guangdong province into the intervention and control arm (1:1 overall ratio) stratified by county (8:9 within-county ratio). In the control arm, antibiotic prescribing and management will continue through usual care. In the intervention arm, we will implement an antibiotic stewardship programme targeting family physicians and patients/caregivers. The family physician components include: 1) training using new operational guidelines, 2) improved management and peer-review of antibiotic prescribing, 3) improved electronic medical records and smart phone app facilitation. The patient/caregiver component involves patient education via family physicians, leaflets and videos. The primary outcome is the proportion of prescriptions for acute respiratory infections (excluding pneumonia) that contain any antibiotic(s). Secondary outcomes will address how frequently specific classes of antibiotics are prescribed, how frequently key non-antibiotic alternatives are prescribed and the costs of consultations. We will conduct a qualitative process evaluation to explore operational questions regarding acceptability, cultural appropriateness and burden of technology use, as well as a cost-effectiveness analysis and a long-term benefit evaluation. The duration of the intervention will be 12 months, with another 24 months post-trial long-term follow-up.Discussion: Our study is one of the first trials to evaluate the effect of an antibiotic stewardship programme in primary care settings in a low- or middle-income country (LMIC). All intervention activities will be designed to be embedded into routine primary care with strong local ownership. Through the trial we intend to impact on clinical practice and national policy in antibiotic prescription for primary care facilities in rural China and other LMICs.Trial registration: ISRCTN, ISRCTN96892547. Registered 18 August 2019, http://www.isrctn.com/ISRCTN96892547

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Differences in antibiotic prescriptions between direct-to-consumer telehealth and telehealth in the emergency department

Journal of Telemedicine and Telecare ◽

10.1177/1357633x211034994 ◽

2021 ◽

pp. 1357633X2110349

Author(s):

Peter Yao ◽

Kriti Gogia ◽

Sunday Clark ◽

Hanson Hsu ◽

Rahul Sharma ◽

...

Keyword(s):

Emergency Department ◽

Confidence Interval ◽

Respiratory Infection ◽

Antibiotic Stewardship ◽

Odds Ratio ◽

Acute Respiratory Infection ◽

Respiratory Infections ◽

Antibiotic Prescribing ◽

Acute Respiratory Infections ◽

Direct To Consumer

Background Telemedicine, which allows physicians to assess and treat patients via real-time audiovisual conferencing, is a rapidly growing modality for providing medical care. Antibiotic stewardship is one important measure of care quality, and research on antibiotic prescribing for acute respiratory infections in direct-to-consumer telemedicine has yielded mixed results. We compared antibiotic prescription rates for acute respiratory infections in two groups treated by telemedicine: (1) patients treated via a direct-to-consumer telemedicine application and (2) patients treated via telemedicine while physically inside the emergency department. Methods We included direct-to-consumer telemedicine and emergency department telemedicine visits for patients 18 years and older with physician-coded International Classification of Diseases, Tenth Revision acute respiratory infection diagnoses between November 2016 and December 2018. Patients in both groups were seen by the same emergency department faculty working dedicated telemedicine shifts. We compared antibiotic prescribing rates for direct-to-consumer telemedicine and emergency department telemedicine visits before and after adjustment for age, sex, and diagnosis. Results We identified a total of 468 acute respiratory infection visits: 191 direct-to-consumer telemedicine visits and 277 emergency department telemedicine visits. Overall, antibiotics were prescribed for 47% of visits (59% of direct-to-consumer telemedicine visits vs 39% of emergency department telemedicine visits; odds ratio 2.23; 95% confidence interval 1.53–3.25; P < 0.001). The difference in antibiotic prescribing rates remained significant after adjustment for age, sex, and diagnosis (odds ratio 2.49; 95% confidence interval 1.65–3.77; P < 0.001). Conclusion Patients seen by the same group of physicians for acute respiratory infection were significantly more likely to be prescribed antibiotics by direct-to-consumer telemedicine care compared with telemedicine care in the emergency department. This work suggests that contextual factors rather than evaluation over video may contribute to differences in antibiotic stewardship for direct-to-consumer telemedicine encounters.

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A model for improving and assessing outpatient stewardship initiatives for acute respiratory infection

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2019.206 ◽

2019 ◽

Vol 40 (10) ◽

pp. 1198-1200 ◽

Cited By ~ 1

Author(s):

Joan Guzik ◽

Pooja Kothari ◽

Misha Sharp ◽

Belinda Ostrowsky ◽

Gopi Patel ◽

...

Keyword(s):

Healthcare System ◽

Respiratory Infection ◽

Antibiotic Stewardship ◽

Acute Respiratory Infection ◽

Respiratory Infections ◽

Acute Respiratory Infections ◽

New Yorker ◽

Stage 1

Many hospitals have established inpatient antibiotic stewardship programs (ASPs), but outpatient activities remain limited. In 2016, the United Hospital Fund (UHF), an independent nonprofit working to build a more effective healthcare system for every New Yorker, launched a 2-stage grant-funded initiative to evaluate outpatient antibiotic stewardship, focusing on adults with acute respiratory infections (ARIs). Conclusions from stage 1 included few outpatient antibiotic stewardship activities, variation in prescribing, macrolides as the most commonly prescribed antibiotic, and provider interest in improving prescribing.1

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Antibiotic prescribing for acute respiratory infections in New York City: A model for collaboration

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2018.227 ◽

2018 ◽

Vol 39 (11) ◽

pp. 1360-1366 ◽

Cited By ~ 3

Author(s):

Joan Guzik ◽

Gopi Patel ◽

Pooja Kothari ◽

Misha Sharp ◽

Belinda Ostrowsky ◽

...

Keyword(s):

New York ◽

New York City ◽

Collaborative Learning ◽

York City ◽

Antibiotic Stewardship ◽

Respiratory Infections ◽

Antibiotic Prescribing ◽

Acute Respiratory Infections ◽

Prescribing Practices ◽

The Status

AbstractObjectiveTo assess the status of antibiotic prescribing in the ambulatory setting for adult patients with acute respiratory infections (ARIs) and to identify opportunities and barriers for outpatient antibiotic stewardship programs (ASPs).DesignMixed methods including point prevalence using chart reviews, surveys, and collaborative learning.SettingHospital-owned clinics in the New York City area.Participants/PatientsIn total, 31 hospital-owned clinics from 9 hospitals and health systems participated in the study to assess ARI prescribing practices for patients >18 years old.InterventionsEach clinic performed a survey of current stewardship practices, retrospective chart reviews of prescribing in 30 randomly selected ARI patients from October 2015 to March 2016, and surveys of provider characteristics and knowledge. Clinics participated in collaborative learning with peers and experts in antibiotic stewardship and collected data from June 2016 to August 2016. Sites received data reports by individual clinic, aggregated by hospital, and were compared among participating clinics.ResultsFew sites had outpatient stewardship activities. The retrospective review of 1,004 ARI patients revealed that 37.3% of ARI patients received antibiotics, with significant variation in prescribing practices among sites (17.4%–71.0%; P<.001). Macrolides were the most commonly prescribed antibiotics. Most of the 302 respondents recognized the need for tools to assist in prescribing.ConclusionsThis collaborative study establishes a baseline assessment of the status of outpatient ASPs in New York City. It provides hospitals, health systems, and individual clinics with specific data to inform their development of stewardship interventions targeting ARIs.

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Topical (local) antibiotics for respiratory infections with sore throat: An antibiotic stewardship perspective

Journal of Clinical Pharmacy and Therapeutics ◽

10.1111/jcpt.13012 ◽

2019 ◽

Vol 44 (6) ◽

pp. 829-837 ◽

Cited By ~ 3

Author(s):

Sabiha Essack ◽

John Bell ◽

Douglas S. Burgoyne ◽

Martin Duerden ◽

Adrian Shephard

Keyword(s):

Sore Throat ◽

Antibiotic Stewardship ◽

Respiratory Infections ◽

Local Antibiotics

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Outpatient Antibiotic Stewardship: A Growing Frontier—Combining Myxovirus Resistance Protein A With Other Biomarkers to Improve Antibiotic Use

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy024 ◽

2018 ◽

Vol 5 (2) ◽

Cited By ~ 6

Author(s):

Patrick Joseph ◽

Eliot Godofsky

Keyword(s):

Respiratory Infection ◽

Antibiotic Stewardship ◽

Respiratory Infections ◽

Protein A ◽

Care Facility ◽

Urgent Care ◽

Cochrane Library ◽

Specific Marker ◽

Term Care ◽

Resistance Protein

Abstract Background The majority of oral antibiotics are prescribed in outpatient primary and urgent care clinics for acute respiratory infections. Effective antibiotic stewardship must include proper prescribing for outpatients as well as for those in a hospital or long-term care facility. Methods Major databases, including MEDLINE and the Cochrane Library, were searched for prospective human clinical studies, including children and/or adults published between January 1966 and November 2017 that evaluated Myxovirus resistance protein A (MxA) as a biomarker for diagnosing viral infections as well as both C-reactive protein (CRP) and procalcitonin (PCT) as potential biomarkers for identifying and differentiating true bacterial upper respiratory infection (URI) from colonization. Results Ten prospective human studies, totaling 1683 patients, were identified that evaluated MxA as a viral biomarker in children and/or adults. Both systematic review articles, meta-analyses, and randomized controlled clinical trials that examined CRP and/or PCT as a biomarker for identifying clinically significant bacterial infections and supporting antibiotic stewardship were identified. Conclusions Quick and accurate differentiation between a viral and bacterial respiratory infection is critical to effectively combat antibiotic misuse. MxA expression in peripheral blood is a highly specific marker for viral infection. Combining MxA with other inflammatory biomarkers to test for respiratory infections offers enhanced sensitivity and specificity, forming an excellent tool for antibiotic stewardship in the outpatient setting.

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Interrupted Time-Series Analysis to Evaluate the Impact of a Behavioral Change Outpatient Antibiotic Stewardship Intervention

Antimicrobial Stewardship & Healthcare Epidemiology ◽

10.1017/ash.2021.28 ◽

2021 ◽

Vol 1 (S1) ◽

pp. s15-s16

Author(s):

Brittany Morgan ◽

Larissa May ◽

Haylee Bettencourt

Keyword(s):

Quality Improvement ◽

Antibiotic Stewardship ◽

Respiratory Infections ◽

Inappropriate Prescribing ◽

The United States ◽

Quality Improvement Intervention ◽

Antibiotic Prescribing ◽

The Impact ◽

Improvement Intervention ◽

Inappropriate Prescriptions

Background: The Centers for Disease Control and Prevention (CDC) estimates that outpatient settings account for 85%–90% of antibiotic prescriptions in the United States, and ~30% of those prescriptions are unnecessary. One of the most common examples of inappropriate prescribing is for viral upper respiratory infections (URIs). Up to 50% of prescriptions written for URIs are deemed inappropriate, making it an important focus for Antibiotic Stewardship programs. In this study, we evaluated the effect of a behaviorally enhanced quality improvement intervention in reducing inappropriate antibiotic prescribing for viral URIs. Methods: A quasi-experimental study assessed the effects of an Antibiotic Stewardship intervention on antibiotic prescribing for viral URIs. The outcome of interest was a change in the number of antibiotics prescribed at each participating clinic over a 1-year preimplementation period and a 2-year postimplementation period. Time trends were analyzed using segmented regression analysis, and a stepped wedge design was used to account for intervention roll-out across clinics. Results: From 2017 to 2020, there were 63,028 patient visits in 21 clinic locations. Antibiotics were prescribed an average of 11.5% and 5.8% of visits during the pre- and postimplementation periods, respectively. The most frequently prescribed antibiotic over the study period was azithromycin (n = 3,551), followed by amoxicillin (n = 924). Overall, the intervention was associated with a 46% reduction in antibiotic prescriptions or 0.54 times (P = .001) as many inappropriate antibiotics prescribed as before the intervention. There was no significant change in the month-to-month trend in inappropriate prescriptions after the intervention was implemented (P = .87). Conclusions: Our study demonstrates that a behaviorally enhanced quality improvement intervention to reduce inappropriate prescribing for URI in ambulatory care encounters was successful in reducing potentially inappropriate prescriptions for presumed viral respiratory infections.Funding: NoDisclosures: None

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115. Variable Use of Diagnostic Codes for Acute Respiratory Infections Across Emergency Departments and Urgent Care Clinics in an Integrated Healthcare System: Implications for Accuracy of Antibiotic Stewardship Metrics

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.317 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S171-S172

Author(s):

Daniel J Livorsi ◽

Rajeshwari Nair ◽

Michihiko Goto ◽

Eli N Perencevich

Keyword(s):

Healthcare System ◽

Antibiotic Stewardship ◽

Respiratory Infections ◽

Urgent Care ◽

Diagnostic Code ◽

Acute Respiratory Infections ◽

Integrated Healthcare ◽

Diagnostic Codes ◽

Facility Level ◽

Tract Infections

Abstract Background Antibiotic stewardship initiatives can leverage metrics that make peer-peer comparisons. A commonly used metric measures how frequently a clinician prescribes antibiotics for acute respiratory infections (ARIs), as defined by diagnostic codes. However, it is unclear if clinicians differ in their use of ARI diagnostic codes. In this study, we evaluated differences in how frequently clinicians code for ARIs and factors that are associated with the use of ARI diagnostic codes in Emergency Department (ED) and Urgent Care (UC) visits across an integrated healthcare system. Methods We analyzed a retrospective cohort of all ED and UC patient-visits across 129 Veterans Affairs medical centers during 2016-2018. ARI visits were identified using ICD-10 codes for acute bronchitis, influenza, pharyngitis, sinusitis, and upper respiratory tract infections for clinicians with 100 or more visits. A generalized linear mixed model with a link logit function that accounted for clustering at the clinician and facility-level was used to calculate median odds ratios (OR) and to identify factors associated with increased likelihood of entering an ARI code. Results There were 6,016,499 patient-visits, and 519,389 (8.6%) were coded as an ARI (Table 1). The mean rate of ARI diagnoses across all visits was 8.9% (SD 2.5%) at the facility-level and 7.4% (SD 4.5%) at the clinician-level (Table 2). The median OR was 2.19 (95% CI 2.18, 2.22), suggesting there was between-clinician variation in coding for ARI diagnoses. Visits were significantly more likely to be coded as ARIs if seen by an advanced practice provider (OR=2.36, 95% CI 2.19, 2.54), if a fever was recorded (OR=4.20, 95% CI 4.18, 4.29), and if the visit occurred between December-March (OR=1.97, 95% CI 1.96, 1.98). Approximately 2/5th of the variability (41.4%) in assigning an ARI diagnostic code was explained by differences across individual clinicians. Conclusion There was substantial variability in how frequently ED and UC clinicians coded a visit as an ARI, and a large proportion of the variability was explained by differences across clinicians. Unmeasured factors could include different approaches to using diagnostic codes. ARI metrics based on diagnostic codes may need to account for differences in clinicians’ coding behavior. Disclosures All Authors: No reported disclosures

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