Introducing antimicrobial stewardship to the outpatient clinics of a suburban academic health system

Abstract Objective: To establish an antimicrobial stewardship program in the outpatient setting. Design: Prescribers of antimicrobials were asked to complete a survey regarding antimicrobial stewardship. We also monitored their compliance with appropriate prescribing practices, which were shared in monthly quality improvement reports. Setting: The study was performed at Loyola University Health System, an academic teaching healthcare system in a metropolitan suburban environment. Participants: Prescribers of antimicrobials across 19 primary care and 3 immediate- and urgent-care clinics. Methods: The voluntary survey was developed using SurveyMonkeyand was distributed via e-mail. Data were collected anonymously. Rates of compliance with appropriate prescribing practices were abstracted from electronic health records and assessed by 3 metrics: (1) avoidance of antibiotics in adult acute bronchitis and appropriate antibiotic treatment in (2) patients tested for pharyngitis and (3) children with upper respiratory tract infections. Results: Prescribers were highly knowledgeable about what constitutes appropriate prescribing; verified compliance rates were highly concordant with self-reported rates. Nearly all prescribers were concerned about resistance, but fewer than half believed antibiotics were overprescribed in their office. Among respondents, 74% reported intense pressure from patients to prescribe antimicrobials inappropriately. Immediate- and urgent-care prescribers had higher rates of compliance than primary-care prescribers, and the latter group responded well to monthly reports and online educational resources. Conclusions: Intense pressure from patients to prescribe antimicrobials when they are not indicated leads to overprescribing, an effect compounded by the importance of patient satisfaction scores. Compliance reporting improved the number of appropriate antibiotics prescribed in the primary care setting.

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142. Implementing an Antimicrobial Stewardship Program in the Outpatient Setting

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.187 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S82-S82

Author(s):

Travis B Nielsen ◽

Maressa Santarossa ◽

Beatrice D Probst ◽

Laurie Labuszewski ◽

Jenna Lopez ◽

...

Keyword(s):

Primary Care ◽

Antimicrobial Stewardship ◽

Inappropriate Prescribing ◽

The United States ◽

Outpatient Setting ◽

Urgent Care ◽

Antibiotic Prescribing ◽

Antimicrobial Stewardship Program ◽

Post Intervention ◽

Stewardship Program

Abstract Background Antimicrobial-resistant infections lead to increased morbidity, mortality, and healthcare costs. Among the most facile modifiable risk factors for developing resistance is inappropriate prescribing. The CDC estimates that 47 million (or ≥30% of) outpatient antibiotic prescriptions in the United States are unnecessary. This has provided impetus for expanding our antimicrobial stewardship program (ASP) into the outpatient setting. Initial goals included the following: continuous evaluation and reporting of antibiotic prescribing compliance; minimize underuse of antibiotics from delayed diagnoses and misdiagnoses; ensure proper drug, dose, and duration; improve the percentage of appropriate prescriptions. Methods To achieve these goals, we first sent a baseline survey to outpatient prescribers, assessing their understanding of stewardship and antimicrobial resistance. Questions were modeled from the Illinois Department of Public Health (IDPH) Precious Drugs & Scary Bugs Campaign. The survey was sent to prescribers at 19 primary care and three immediate/urgent care clinics. Compliance rates for prescribing habits were subsequently tracked via electronic health records and reported to prescribers in accordance with IRB approval. Results Prescribers were highly knowledgeable about what constitutes appropriate prescribing, with verified compliance rates highly concordant with self-reported rates. However, 74% of respondents reported intense pressure from patients to inappropriately prescribe antimicrobials. Compliance rates have been tracked since December 2018 and comparing pre- with post-intervention rates shows improvement in primary care since reporting rates to prescribers in August 2019. Conclusion Reporting compliance rates has been helpful in avoiding inappropriate antimicrobial therapy. However, the survey data reinforce the importance of behavioral interventions to bolster ASP efficacy in the outpatient setting. Going forward, posters modeled off of the IDPH template will be conspicuously exhibited in exam rooms, indicating institutional commitment to the enumerated ASP guidelines. Future studies will allow for comparison of pre- and post-intervention knowledge and prescriber compliance. Disclosures All Authors: No reported disclosures

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Reducing Unnecessary Antibiotic Treatment for Acute Bronchitis Using Virtual Primary Care

Telehealth and Medicine Today ◽

10.30953/tmt.v6.272 ◽

2021 ◽

Author(s):

David McCune ◽

James Pellegrin ◽

Anshul Sachdeva ◽

Roxana Cham ◽

Jessica Sollaccio ◽

...

Keyword(s):

Primary Care ◽

Acute Bronchitis ◽

High Rate ◽

Urgent Care ◽

National Committee ◽

Prescribing Practices ◽

National Guidelines ◽

Antibiotic Overuse ◽

Patients Âgés ◽

Systemic Antibiotics

Objective: Reducing antibiotic overuse is a point of emphasis of the Centers for Disease Control and Prevention (CDC). Despite this, both telemedicine and traditional in-person medical care struggle to meet national guidelines. This study evaluates antibiotic prescribing practices at 98point6, a Seattle-based provider of virtual primary care. This paper reviews a novel combination of machine learning with a physician-led virtual platform and smartphone interface to exceed published benchmarks for the avoidance of antibiotics in the treatment of bronchitis. Design: This retrospective cohort study looks at patients ages 18–64 who presented to 98point6 with “acute bronchitis/bronchiolitis” diagnosed between December 1, 2019 and November 30, 2020. Visits were categorized by whether systemic antibiotics were or were not given. Cases in which systemic antibiotics were given were categorized as “broad spectrum” or “narrow spectrum”. The results are presented as descriptive statistics with demographic information and compared to published reports of antibiotic use for the treatment of bronchitis. Results: Of the 1,238 visits with a bronchitis/bronchiolitis diagnosis, 99 (8.0%) were treated with prescribed systemic antibiotics. The rate of antibiotic avoidance of 92.0% compares favorably with published benchmarks from the National Committee for Quality Assurance and is significantly lower than rates in previously published samples for telemedicine, primary care and urgent care. Conclusion: Virtual primary care administered by 98point6 resulted in a high rate of adherence to the established standard for the treatment of bronchitis, greatly exceeding benchmarks and published results from both telemedicine and in-person medical practice.

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

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1275 ◽

2020 ◽

pp. 1-7

Author(s):

Lindsey R. Westerhof ◽

Lisa E. Dumkow ◽

Tarajo L. Hanrahan ◽

Samantha V. McPharlin ◽

Nnaemeka E. Egwuatu

Keyword(s):

Family Medicine ◽

Ambulatory Care ◽

Antimicrobial Stewardship ◽

Antibiotic Prescribing ◽

Antimicrobial Stewardship Program ◽

Upper Respiratory Tract ◽

Family Medicine Residency ◽

Medicine Resident ◽

Stewardship Program ◽

Tract Infections

Abstract Objective: To determine whether an ambulatory care pharmacist (AMCP)-led intervention improved outpatient antibiotic prescribing in a family medicine residency clinic (FMRC) for upper respiratory tract infections (URIs), urinary tract infections (UTIs), and skin and soft-tissue infections (SSTIs). Design: Retrospective, quasi-experimental study comparing guideline-concordant antibiotic prescribing before and after an antimicrobial stewardship program (ASP) intervention. Setting: Family medicine residency clinic affiliated with a community teaching hospital. Participants: Adult and pediatric patients prescribed antibiotics for URI, UTI, or SSTI between November 1, 2017, and April 31, 2018 (pre-ASP group), or October 1, 2018, and March 31, 2019 (ASP group), were eligible for inclusion. Methods: The health-system ASP physician and pharmacist provided live education and pocket cards to FMRC staff with local guidelines as a quick reference. Audit with feedback was delivered every other week by the clinic’s AMCP. Guideline-concordance was determined based on the institution’s outpatient ASP guidelines. Results: Overall, 525 antibiotic prescriptions were audited (pre-ASP n = 90 and ASP n = 435). Total guideline-concordant antibiotic prescribing at baseline was 38.9% (URI, 53.3%; SSTI, 16.7%; UTI, 46.7%) and improved across all 3 infection types to 57.9% (URI, 61.2%; SSTI, 57.6%; UTI, 53.5%; P = .001). Significant improvements were seen in guideline-concordant antibiotic selection (68.9% vs 80.2%; P = .018), dose (76.7% vs 86.2%; P = .023), and duration of therapy (73.3% vs 86.2%; P = .02). Conclusions: An AMCP-led outpatient ASP intervention significantly improved guideline-concordant antibiotic prescribing for common infections within a FMRC.

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Knowledge, attitudes and intentions to prescribe antibiotics: a structural equation modeling study of primary care institutions in Hubei, China

10.21203/rs.2.10397/v1 ◽

2019 ◽

Author(s):

Chenxi Liu ◽

Chaojie Liu ◽

Dan Wang ◽

xinping zhang

Keyword(s):

Primary Care ◽

Antibiotic Resistance ◽

Structural Equation ◽

Equation Modeling ◽

Upper Respiratory Tract ◽

Prescribing Practices ◽

Motivation To Change ◽

Global Issues ◽

Care Facilities ◽

Tract Infections

Abstract Background Antibiotic resistance is one of the most serious global issues, in which physician's rational prescribing plays critical role. However, the determinants of physician's antibiotic use are still inconclusive, particularly in low- and middle income countries (LMICs). This study aimed to measure physician's knowledge and five important sub-attitudes toward antibiotic prescriptions and their impacts on prescribing. Methods A questionnaire survey was conducted on 625 physicians from 67 primary care facilities in Hubei of China. Structural equation modelling (SEM) was applied to test the theoretical framework derived from the theory of Knowledge, Attitudes and Practices (KAP). The attitudes (5 subscales) and behavioral intentions (3 subscales) were measured using a five-point Likert scale ranging from -2 to +2, with a negative score indicating disapproval and a positive score indicating approval of efforts for reducing antibiotic prescriptions. Results The study participants had a low level of knowledge about antibiotic prescriptions, giving an average of 54.55% correct answers to 11 questions. Although they were generally concerned about antibiotic resistance resulting from over-prescriptions (Mean of Ignorance=1.28, SD=0.43), and were reluctant to be submissive to pressures from consumer demands for antibiotics (Mean of Complacency=1.29, SD=0.65) and the requirements of defensive practice (Mean of Fear=1.11, SD=0.63), there was a lack of motivation to change prescribing practices (Mean of Indifference=-0.29, SD=0.70). In addition, there was strong agreement that other stakeholders should take the responsibility (Mean of Responsibility Avoidance=-1.15, SD=0.45). The SEM results showed that poor knowledge was a significant predictor (p<0.001) of high intentions to prescribe antibiotics for upper respiratory tract infections and a less positive attitude toward concerns about antibiotic resistance (ignorance) which was also associated with intentions to prescribe antibiotics. However, knowledge was not connected with the negative attitude toward motivation (indifference), a significant predictor (p<0.001) of intentions to refuse to reduce antibiotic prescriptions. Conclusion Physicians in primary care facilities in Hubei have low levels of knowledge about antibiotic prescriptions. But actions for improving knowledge by itself is not enough to curb over-prescriptions of antibiotics. The lack of motivation of physicians to change prescribing practices needs to be addressed through a systems approach.

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Stewardship in the primary care and long-term care settings

10.1093/med/9780198758792.003.0015 ◽

2016 ◽

Author(s):

Naomi Fleming

Keyword(s):

Primary Care ◽

Antimicrobial Stewardship ◽

Long Term Care ◽

Diagnostic Tools ◽

Antibiotic Prescribing ◽

Prescribing Practices ◽

Term Care ◽

Care Facilities ◽

Tract Infections

This chapter focuses on stewardship in the primary care and long-term care settings. Antibiotic prescribing in the community accounts for 80% total antibiotic prescribing and approximately 75% of this is for acute respiratory tract infections, many of which are viral. There is also significant variation in prescribing practices that is not explained by differences in presenting patients. These factors suggest that antimicrobial stewardship programmes are necessary. This chapter identifies the components of stewardship that have been successful in influencing antibiotic prescribing in primary care and shares local experiences with practical examples. The lack of UK evidence about antimicrobial stewardship in long-term care facilities is discussed, along with successful interventions from overseas. Challenges within these settings are highlighted, including patient demand, lack of access to microbiological and diagnostic tools, competing targets, time pressures, and clinical uncertainty.

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173. Identification of Inappropriate Antibiotic Orders During a Pharmacy-Supported Antimicrobial Stewardship Program in the Primary Care Setting: A Retrospective Analysis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.217 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S94-S94

Author(s):

Paula Eckardt ◽

Sheerida Hosein Mohammed ◽

Devada Singh-Franco ◽

William R Wolowich

Keyword(s):

Primary Care ◽

Antimicrobial Stewardship ◽

Care Setting ◽

Primary Care Setting ◽

Primary Care Providers ◽

Care Providers ◽

Duration Of Therapy ◽

Stewardship Program ◽

Prescribing Trends ◽

Tract Infections

Abstract Background In Florida, the number of antibiotic prescriptions has increased from 710–779 prescription/1000 population in 2012 to 748–839 prescription/1000 population in 2017. Antimicrobial stewardship in the outpatient setting is a suggested solution to combat antibiotics misuse in ambulatory practices. Methods This was a retrospective review of oral antimicrobial orders generated by primary care providers. The research protocol received approval from Memorial Healthcare System’s Institutional Review Board prior to any research related analysis being conducted. Orders from January 1-December 31, 2018 were reviewed for appropriateness by pharmacy based on IDSA guidelines. Appropriateness was assessed based on the need to prescribe the antibiotic for indication, selection, dose and duration of therapy. Descriptive statistics were used to analyze data. Results Of 2995 orders, 50.2% were inappropriate. The most common infections associated with inappropriate antibiotic use were upper/lower respiratory tract infections (URTIs (65%) and LRTIs (61%)), oral cavity infections (61%), and skin/soft tissue infections (SSTI (54%)). Inappropriately-prescribed antibiotics were penicillin (62%), cephalosporins (56%), quinolones (50%), macrolides (49%), and sulfamethoxazole/trimethoprim (46%). Penicillin use for URTIs were inappropriate (406 orders) for the following reasons: duration of therapy only 116/137 (85%); dose and duration 36/58 (62%), drug and dose 12/58 (21%) and all three (drug, dose, duration 85/93 (91%)). Conclusion Implementation of a pharmacist-driven antibiotic stewardship program in the primary care setting identified a significant proportion of orders that were inappropriate for type of antibiotic, dose, and duration of therapy in the management of patients with URTIs. These results serve as an avenue to implement the audit feedback process to promote appropriate use of antibiotics. A process improvement plan will include sharing of the findings, educating primary care physicians per IDSA guidelines and continuous review of prescribing trends. A programmatic evaluation will continue on an on-going basis to decrease the number of inappropriately prescribed antibiotics. Disclosures All Authors: No reported disclosures

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Inappropriate Azithromycin Use in Nine Primary-Care Clinics Before and After Implementation of Provider Guidance in the EMR

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.869 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s292-s293

Author(s):

Alexandria May ◽

Allison Hester ◽

Kristi Quairoli ◽

Sheetal Kandiah

Keyword(s):

Primary Care ◽

Retrospective Chart Review ◽

Antibiotic Prescribing ◽

Upper Respiratory Tract ◽

National Guidelines ◽

Targeted Interventions ◽

Primary Care Clinics ◽

Before And After ◽

Upper Respiratory ◽

Tract Infections

Background: According to the CDC Core Elements of Outpatient Stewardship, the first step in optimizing outpatient antibiotic use the identification of high-priority conditions in which antibiotics are commonly used inappropriately. Azithromycin is a broad-spectrum antimicrobial commonly used inappropriately in clinical practice for nonspecific upper respiratory infections (URIs). In 2017, a medication use evaluation at Grady Health System (GHS) revealed that 81.4% of outpatient azithromycin prescriptions were inappropriate. In an attempt to optimize outpatient azithromycin prescribing at GHS, a tool was designed to direct the prescriber toward evidence-based therapy; it was implemented in the electronic medical record (EMR) in January 2019. Objective: We evaluated the effect of this tool on the rate of inappropriate azithromycin prescribing, with the goal of identifying where interventions to improve prescribing are most needed and to measure progress. Methods: This retrospective chart review of adult patients prescribed oral azithromycin was conducted in 9 primary care clinics at GHS between February 1, 2019, and April 30, 2019, to compare data with that already collected over a 6-month period in 2017 before implementation of the antibiotic prescribing guidance tool. The primary outcome of this study was the change in the rate of inappropriate azithromycin prescribing before and after guidance tool implementation. Appropriateness was based on GHS internal guidelines and national guidelines. Inappropriate prescriptions were classified as inappropriate indication, unnecessary prescription, excessive or insufficient treatment duration, and/or incorrect drug. Results: Of the 560 azithromycin prescriptions identified during the study period, 263 prescriptions were included in the analysis. Overall, 181 (68.8%) of azithromycin prescriptions were considered inappropriate, representing a 12.4% reduction in the primary composite outcome of inappropriate azithromycin prescriptions. Bronchitis and unspecified upper respiratory tract infections (URI) were the most common indications where azithromycin was considered inappropriate. Attending physicians prescribed more inappropriate azithromycin prescriptions (78.1%) than resident physicians (37.0%) or midlevel providers (37.0%). Also, 76% of azithromycin prescriptions from nonacademic clinics were considered inappropriate, compared with 46% from academic clinics. Conclusions: Implementation of a provider guidance tool in the EMR lead to a reduction in the percentage of inappropriate outpatient azithromycin prescriptions. Future targeted interventions and stewardship initiatives are needed to achieve the stewardship program’s goal of reducing inappropriate outpatient azithromycin prescriptions by 20% by 1 year after implementation.Funding: NoneDisclosures: None

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Finding the path of least resistance: Locally adapting the MITIGATE toolkit in emergency departments and urgent care centers

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1394 ◽

2021 ◽

pp. 1-3

Author(s):

Joanne Huang ◽

Zahra Kassamali Escobar ◽

Todd S. Bouchard ◽

Jose Mari G. Lansang ◽

Rupali Jain ◽

...

Keyword(s):

Primary Care ◽

Emergency Department ◽

Antimicrobial Stewardship ◽

Emergency Departments ◽

Urgent Care ◽

Complex Data ◽

University Of Washington ◽

Primary Care Clinics ◽

Urgent Care Centers ◽

The University

Abstract The MITIGATE toolkit was developed to assist urgent care and emergency departments in the development of antimicrobial stewardship programs. At the University of Washington, we adopted the MITIGATE toolkit in 10 urgent care centers, 9 primary care clinics, and 1 emergency department. We encountered and overcame challenges: a complex data build, choosing feasible outcomes to measure, issues with accurate coding, and maintaining positive stewardship relationships. Herein, we discuss solutions to challenges we encountered to provide guidance for those considering using this toolkit.

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Impact of an Antimicrobial Stewardship Care Bundle to Improve the Management of Patients with Suspected or Confirmed Urinary Tract Infection

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2016.199 ◽

2016 ◽

Vol 37 (12) ◽

pp. 1499-1501 ◽

Cited By ~ 8

Author(s):

Curtis D. Collins ◽

Jared J. Kabara ◽

Sarah M. Michienzi ◽

Anurag N. Malani

Keyword(s):

Urinary Tract Infection ◽

Urinary Tract ◽

Tract Infection ◽

Antimicrobial Stewardship ◽

Asymptomatic Bacteriuria ◽

Care Bundle ◽

Antimicrobial Stewardship Program ◽

Stewardship Program ◽

Bundle Compliance ◽

Tract Infections

Implementation of an antimicrobial stewardship program bundle for urinary tract infections among 92 patients led to a higher rate of discontinuation of therapy for asymptomatic bacteriuria (52.4% vs 12.5%; P =.004), more appropriate durations of therapy (88.7% vs 63.6%; P =.001), and significantly higher overall bundle compliance (75% vs 38.2%; P < .001).Infect Control Hosp Epidemiol 2016;1499–1501

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Retrospective review of the management of acute infections and the indications for antibiotic prescription in primary care in northern Thailand

BMJ Open ◽

10.1136/bmjopen-2018-022250 ◽

2018 ◽

Vol 8 (7) ◽

pp. e022250 ◽

Cited By ~ 8

Author(s):

Rachel C Greer ◽

Daranee Intralawan ◽

Mavuto Mukaka ◽

Prapass Wannapinij ◽

Nicholas P J Day ◽

...

Keyword(s):

Primary Care ◽

Low Income ◽

Retrospective Review ◽

Antibiotic Prescription ◽

Multivariable Logistic Regression Analysis ◽

Upper Respiratory Tract ◽

Acute Tonsillitis ◽

Northern Thailand ◽

Acute Infections ◽

Tract Infections

IntroductionAntibiotic use in low-income and middle-income countries continues to rise despite the knowledge that antibiotic overuse can lead to antimicrobial resistance. There is a paucity of detailed data on the use of antibiotics in primary care in low-resource settings.ObjectiveTo describe the presentation of acute infections and the indications for antibiotic prescription.DesignA 2-year retrospective review of routinely collected data.SettingAll 32 primary care units in one district in northern Thailand.ParticipantsPatients attending primary care with a history of fever, documented temperature, International Statistical Classification of Diseases 10 code for infection or prescribed a systemic antibiotic. Patients attending after the initiation of a study on C-reactive protein testing in four centres were excluded.Outcome measuresThe proportion of patients prescribed an antibiotic and the frequency of clinical presentations.Results762 868 patients attended the health centres, of whom 103 196 met the inclusion criteria, 5966 were excluded resulting in 97 230 attendances consisting of 83 661 illness episodes.46.9% (39 242) of the patients were prescribed an antibiotic during their illness. Indications for antibiotic prescription in the multivariable logistic regression analysis included male sex (adjusted OR (aOR) 1.21 (95% CI 1.16 to 1.28), p<0.001), adults (aOR 1.77 (95% CI 1.57 to 2), p<0.001) and a temperature >37.5°C (aOR 1.24 (95% CI 1.03 to 1.48), p=0.020). 77.9% of the presentations were for respiratory-related problems, of which 98.6% were upper respiratory tract infections. The leading infection diagnoses were common cold (50%), acute pharyngitis (18.9%) and acute tonsillitis (5%) which were prescribed antibiotics in 10.5%, 88.7% and 87.1% of cases, respectively. Amoxicillin was the most commonly prescribed antibiotic.ConclusionsNearly half of the patients received an antibiotic, the majority of whom had a respiratory infection. The results can be used to plan interventions to improve the rational use of antibiotics. Further studies in private facilities, pharmacies and dental clinics are required.

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