Novel outpatient antibiotic prescribing report of respiratory infections in a pediatric health system's emergency departments and urgent care clinics

2020 ◽  
Author(s):  
Rana E. El Feghaly ◽  
Alaina Burns ◽  
Jennifer L. Goldman ◽  
Angela Myers ◽  
Amol V. Purandare ◽  
...  
Keyword(s):  
Emergency Departments ◽  
Respiratory Infections ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Pediatric Health

Evaluation of antibiotic prescribing in emergency departments and urgent care centers across the Veterans’ Health Administration

2020 ◽  
pp. 1-8
Author(s):  
James L. Lowery ◽  
Bruce Alexander ◽  
Rajeshwari Nair ◽  
Brett H. Heintz ◽  
Daniel J. Livorsi
Keyword(s):  
Emergency Departments ◽  
Respiratory Infections ◽  
Antibiotic Use ◽  
Veterans Health Administration ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Veterans Health ◽  
Health Administration ◽  
Urgent Care Centers ◽  
Exacerbation Of Copd

Abstract Objective: Assessments of antibiotic prescribing in ambulatory care have largely focused on viral acute respiratory infections (ARIs). It is unclear whether antibiotic prescribing for bacterial ARIs should also be a target for antibiotic stewardship efforts. In this study, we evaluated antibiotic prescribing for viral and potentially bacterial ARIs in patients seen at emergency departments (EDs) and urgent care centers (UCCs). Design: This retrospective cohort included all ED and UCC visits by patients who were not hospitalized and were seen during weekday, daytime hours during 2016–2018 in the Veterans Health Administration (VHA). Guideline concordance was evaluated for viral ARIs and for 3 potentially bacterial ARIs: acute exacerbation of COPD, pneumonia, and sinusitis. Results: There were 3,182,926 patient visits across 129 sites: 80.7% in EDs and 19.3% in UCCs. Mean patient age was 60.2 years, 89.4% were male, and 65.6% were white. Antibiotics were prescribed during 608,289 (19.1%) visits, including 42.7% with an inappropriate indication. For potentially bacterial ARIs, guideline-concordant management varied across clinicians (median, 36.2%; IQR, 26.0–52.7) and sites (median, 38.2%; IQR, 31.7–49.4). For viral ARIs, guideline-concordant management also varied across clinicians (median, 46.2%; IQR, 24.1–68.6) and sites (median, 40.0%; IQR, 30.4–59.3). At the clinician and site levels, we detected weak correlations between guideline-concordant management for viral ARIs and potentially bacterial ARIs: clinicians (r = 0.35; P = .0001) and sites (r = 0.44; P < .0001). Conclusions: Our findings suggest that, across EDs and UCCs within VHA, there are major opportunities to improve management of both viral and potentially bacterial ARIs. Some clinicians and sites are more frequently adhering to ARI guideline recommendations on antibiotic use.

scholarly journals 143. Initial Impact of COVID-19 on Ambulatory Antibiotic Prescribing for Respiratory Viral Infections

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S82-S82
Author(s):  
Zahra Kassamali Escobar ◽  
Todd Bouchard ◽  
Jose Mari Lansang ◽  
Scott Thomassen ◽  
Joanne Huang ◽  
...  
Keyword(s):  
Primary Care ◽  
Viral Infections ◽  
Respiratory Infections ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Specific Rate ◽  
Inclusion Criteria ◽  
Diagnosis Codes ◽  
Control And Prevention ◽  
Viral Respiratory Infections

Abstract Background Between 15–50% of patients seen in ambulatory settings are prescribed an antibiotic. At least one third of this usage is considered unnecessary. In 2019, our institution implemented the MITIGATE Toolkit, endorsed by the Centers for Disease Control and Prevention to reduce inappropriate antibiotic prescribing for viral respiratory infections in emergency and urgent care settings. In February 2020 we identified our first hospitalized patient with SARS-CoV(2). In March, efforts to limit person-to-person contact led to shelter in place orders and substantial reorganization of our healthcare system. During this time we continued to track rates of unnecessary antibiotic prescribing. Methods This was a single center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. We provided monthly individual feedback to urgent care prescribers, (Sep 2019-Mar 2020), primary care, and ED providers (Jan 2020 – Mar 2020) notifying them of their specific rate of unnecessary antibiotic prescribing and labeling them as a top performer or not a top performer compared to their peers. The primary outcome was rate of inappropriate antibiotic prescribing. Results Pre toolkit intervention, 14,398 patient visits met MITIGATE inclusion criteria and 12% received an antibiotic unnecessarily in Jan-April 2019. Post-toolkit intervention, 12,328 patient visits met inclusion criteria and 7% received an antibiotic unnecessarily in Jan-April 2020. In April 2020, patient visits dropped to 10–50% of what they were in March 2020 and April 2019. During this time the unnecessary antibiotic prescribing rate doubled in urgent care to 7.8% from 3.6% the previous month and stayed stable in primary care and the ED at 3.2% and 11.8% respectively in April compared to 4.6% and 10.4% in the previous month. Conclusion Rates of inappropriate antibiotic prescribing were reduced nearly in half from 2019 to 2020 across 3 ambulatory care settings. The increase in prescribing in April seen in urgent care and after providers stopped receiving their monthly feedback is concerning. Many factors may have contributed to this increase, but it raises concerns for increased inappropriate antibacterial usage as a side effect of the SARS-CoV(2) pandemic. Disclosures All Authors: No reported disclosures

scholarly journals 2568. Variability in Pediatric Antibiotic Prescribing for Upper Respiratory Illnesses by Provider Specialty

2018 ◽  
Vol 5 (suppl_1) ◽  
pp. S73-S74
Author(s):  
Holly M Frost ◽  
Huong McLean ◽  
Brian Chow
Keyword(s):  
Respiratory Infections ◽  
Group A Streptococcus ◽  
Acute Otitis Media ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Respiratory Illnesses ◽  
Upper Respiratory Infection ◽  
Medical Diagnoses ◽  
Group A ◽  
Upper Respiratory

Abstract Background Antibiotic prescribing varies among providers, contributing to antibiotic resistance and adverse drug reactions. Objective. To evaluate variation in antibiotic prescribing between pediatric and nonpediatric providers for common upper respiratory illnesses. Methods Patient encounters for children aged &lt;18 years from a regional healthcare system were identified. Electronic medical records from 2011 to 2016 were extracted for diagnoses of upper respiratory infection (URI), pharyngitis, acute otitis media (AOM), and sinusitis. Encounters with competing medical diagnoses, recent hospitalization, and antibiotic prescriptions within 30 days were excluded. Adherence to antibiotic guidelines was assessed by provider training (pediatric, nonpediatric physicians, and advance practice providers [APP]). Additional factors assessed included clinic or urgent care setting, calendar year, and patient’s age, gender, insurance status, and number of sick visits in the prior year. Results Across 6 years, 141,361 visits were examined: 43,914 for URI, 43,701 for pharyngitis, 43,925 for AOM, and 9,821 for sinusitis. Pediatricians were more likely than APPs and nonpediatric providers to have guideline-concordant prescribing for pharyngitis (pediatricians 66.7 (54.5, 77.0)%, nonpediatricians 49.1 (36.3, 62.0)%, APPs 52.2(39.4, 64.7)%, P &lt; 0.0001) and sinusitis (pediatricians 70.8(53.8, 83.4)%, nonpediatricians 63.3(46.8, 77.2)%, APPs 62.1(45.1, 76.5)%, P = 0.48) and to withhold antibiotics for URI than APPs and nonpediatric providers (pediatricians 86.6(81.2, 90.6)%, nonpediatricians 80.8(73.0, 86.8)%, APPs 76.8(68.4, 83.5)%, P &lt; 0.0001). Pediatricians were less likely to prescribe antibiotics for pharyngitis without a positive Group A Streptococcus test than APPs and nonpediatric providers (pediatricians 15.1(10.4, 21.6)%, nonpediatricians 29.4(20.8, 39.6)%, APPs 27.2(19.3, 36.9)%, P &lt; 0.0001). First-line antibiotic prescribing for pharyngitis and AOM did not differ between provider specialties. A trend toward more guideline-concordant prescribing was seen for pharyngitis and sinusitis over the study period. Conclusion Pediatricians were more likely to adhere to guidelines for pediatric acute respiratory infections. Pediatric antibiotic stewardship efforts should also target non-pediatricians. Disclosures All authors: No reported disclosures.

scholarly journals 160. Urgent Care Prescriber Perspectives on Antibiotic Prescribing During the COVID-19 Pandemic

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S190-S191
Author(s):  
Brooke Betts ◽  
David R Ha ◽  
Marisa Holubar ◽  
Marisa Holubar ◽  
Maja Artandi ◽  
...  
Keyword(s):  
Respiratory Infections ◽  
Human Subjects ◽  
Qualitative Interviews ◽  
Antibiotic Use ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Full Time ◽  
Prescribing Practices ◽  
Stability Robustness ◽  
Trained Interviewer

Abstract Background Urgent care practices were significantly impacted by the COVID-19 pandemic. Studies conducted early in the pandemic demonstrated dramatic decreases in outpatient antibiotic prescribing, particularly amongst agents typically used for respiratory infections. We observed a 33% decline in urgent care antibiotics prescribing during the COVID-19 pandemic in our urgent care clinics. We investigated the prescriber experience to elucidate factors influencing antibiotic use for respiratory conditions during the COVID-19 pandemic at two academic urgent care clinics. Methods We employed a mix method approach, first distributing a survey to all full-time prescribers. We then followed up with qualitative interviews (12 of 22 prescribers) which was conducted by a single, trained interviewer using a standardized guide. Interviews were recorded and transcribed verbatim. Each transcription was independently reviewed and coded by two blinded investigators using standardized themes and adjudicated by a third investigator for stability, robustness, and interrater reliability. Individually, researchers identified and coded key themes and statements. These themes were then discussed as a group and combined where they shared meaning. This project was reviewed and deemed to be non-human subjects research by the Stanford University School of Medicine Panel on Human Subjects in Medical Research. Results A total of 20 of the 22 prescribers (13 MDs and 9 APPs) completed the survey (91% response rate). Notably, only 25% of prescribers agreed that COVID-19 had changed their antibiotic prescribing practices for patients with respiratory infections despite objective data that all prescribed less. In the qualitative interviews, we identified four major themes impacting the appropriateness of antibiotic prescribing practices as shown in Table 1. Conclusion Urgent care prescribers attributed a decrease in antibiotic prescribing during COVID-19 to changes in patient expectations and knowledge base, a switch to telemedicine-based encounters, and changing epidemiology. These shifts could be utilized by outpatient antimicrobial stewardship efforts to sustain low prescribing rates for conditions in which antibiotics are generally not indicated. Disclosures Marisa Holubar, MD, MS, Nothing to disclose

Impact of an electronic best-practice advisory in combination with prescriber education on antibiotic prescribing for ambulatory adults with acute, uncomplicated bronchitis within a large integrated health system

2019 ◽  
Vol 40 (12) ◽  
pp. 1348-1355 ◽  
Author(s):  
Courtney M. Pagels ◽  
Thomas J. Dilworth ◽  
Lynne Fehrenbacher ◽  
Maharaj Singh ◽  
Charles F. Brummitt
Keyword(s):  
Health System ◽  
Emergency Departments ◽  
Best Practice ◽  
Acute Bronchitis ◽  
Primary Diagnosis ◽  
Urgent Care ◽  
Absolute Difference ◽  
Antibiotic Prescribing ◽  
Practice Advisory ◽  
The Impact

AbstractObjective:To determine the impact of a passive, prescriber-directed, electronic best-practice advisory coupled with prescriber education on the rate of antibiotic prescribing for acute, uncomplicated bronchitis in ambulatory adults across a large health system.Design:This study was a quasi-experiment examining antibiotic prescribing for ambulatory adults with acute bronchitis from January 1, 2016 through December 31, 2018. The intervention was implemented in December 2016 for emergency departments and urgent care clinics followed by ambulatory clinics in September 2017.Setting:Outpatient settings across a health system, including 15 emergency departments, >30 urgent care clinics, and >150 ambulatory clinics.Participants:All adults with a primary diagnosis of acute bronchitis who were seen and discharged from a study site were included.Interventions:A passive, prescriber-directed, best-practice advisory for treatment of acute bronchitis in the electronic health record and an optional, online education module regarding acute bronchitis.Results:The study included 81,975 ambulatory adults with a primary diagnosis of acute bronchitis during the preintervention period (19.8% >65 years of age; 61.9% female) and 89,571 ambulatory adults during the postintervention period (16.5% >65 years of age; 61.1% female). Antibiotic prescribing rates decreased from 60.8% (49,877 of 81,975 patients) preintervention to 51.4% (46,018 of 89,571 patients) postintervention (absolute difference, 9.4%; P < .001). The largest reduction occurred in the emergency departments.Conclusions:An electronic best practice advisory combined with prescriber education was associated with a statistically significant reduction in antibiotic prescribing for adults with acute bronchitis. Future studies should incorporate patient education and address prescriber-reported barriers to appropriate antibiotic prescribing.

scholarly journals 969. Antibiotic Prescribing in a Large Retail Health Clinic Chain: Opportunities for Stewardship

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S32-S33
Author(s):  
Katherine E Fleming-Dutra ◽  
Laura M King ◽  
Safia Boghani ◽  
Lauri Hicks ◽  
John Hou ◽  
...  
Keyword(s):  
Urinary Tract Infection ◽  
Urinary Tract ◽  
Tract Infection ◽  
Respiratory Infections ◽  
Acute Otitis Media ◽  
Adult Patients ◽  
Urgent Care ◽  
Health Clinic ◽  
Antibiotic Prescribing ◽  
First Line

Abstract Background Retail health is a growing outpatient setting. Research using claims data found that antibiotics were linked with 46% of urgent care, 17% of medical office, and 14% of retail health visits for acute respiratory infections (ARIs) for which antibiotics are not needed. We aimed to quantify antibiotic prescribing rates to adult patients in a large retail health clinic chain using electronic health records and to identify future stewardship targets. Methods We included visits by adults ≥18 years to network retail health clinics from 2012 to 2016. We classified diagnoses by ICD codes. We calculated the percent of visits with systemic antibiotics prescribed among all visits, by individual diagnosis, and for ARIs as a group (e.g., pneumonia, sinusitis, pharyngitis, acute otitis media [AOM], bronchitis, and viral upper respiratory infections [URI]). We also assessed the percent of visits for sinusitis and pharyngitis with first-line antibiotics prescribed. Results Of 2,893,413 visits by adults during 2012–2016, 1,866,145 (66%) resulted in antibiotic prescriptions. ARIs accounted for 2,039,423 (72%) of visits and 1,475,069 (79%) of antibiotic prescriptions. The most common diagnoses regardless of antibiotic prescription were sinusitis (31% of visits), pharyngitis (15%, of which 81% were coded as streptococcal pharyngitis), urinary tract infection (9%), viral URI (8%), AOM (7%), and bronchitis (5%). Antibiotics were frequently prescribed for sinusitis, urinary tract infection, pharyngitis, and AOM but not for viral URI and bronchitis (Figure 1). First-line antibiotics were prescribed in the majority of sinusitis and pharyngitis visits (Figure 2). Conclusion ARIs are major drivers of visits by adult patients and of antibiotic prescribing to adults in this retail clinic network. Inappropriate antibiotic use was low in this setting for viral URI and bronchitis and first-line antibiotic selection was high for sinusitis and pharyngitis, although additional opportunities for improvement exist. Future antibiotic stewardship efforts may target examining adherence to guideline-recommended diagnostic criteria for sinusitis, AOM, and pharyngitis and increasing use of watchful waiting for sinusitis and AOM. Disclosures All Authors: No reported Disclosures.

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