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

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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Knowledge, Attitudes, and Reported Practices Among Obstetrician-Gynecologists in the USA Regarding Antibiotic Prescribing for Upper Respiratory Tract Infections

Infectious Diseases in Obstetrics and Gynecology ◽

10.1155/2005/405868 ◽

2005 ◽

Vol 13 (1) ◽

pp. 17-24 ◽

Cited By ~ 14

Author(s):

Shadi Chamany ◽

Jay Schulkin ◽

Charles E. Rose ◽

Laura E. Riley ◽

Richard E. Besser

Keyword(s):

Primary Care ◽

Respiratory Tract Infections ◽

Antibiotic Use ◽

Upper Respiratory Tract Infections ◽

Antibiotic Prescribing ◽

Upper Respiratory Tract ◽

Office Visits ◽

The Common ◽

Upper Respiratory ◽

Tract Infections

Background:Knowledge, attitudes, and practices regarding antibiotic prescribing for upper respiratory tract infections (URIs) have not been well described among obstetrician-gynecologists (OB/GYNs). This information is useful for determining whether an OB/GYN-specific program promoting appropriate antibiotic use would significantly contribute to the efforts to decrease inappropriate antibiotic use among primary care providers.Methods:An anonymous questionnaire asking about the treatment of URIs was sent to 1031 obstetrician-gynecologists.Results:The overall response rate was 46%. The majority of respondents (92%) were aware of the relationship between antibiotic use and antibiotic resistance, and respondents estimated that 5% of their patients had URI symptoms at their office visits. Overall, 56% of respondents reported that they would prescribe an antibiotic for uncomplicated bronchitis and 43% for the common cold. OB/GYNs with the fewest years of experience were less likely than those with the most years of experience to report prescribing for uncomplicated bronchitis (Odds ratio (OR) 0.46, 95% confidence interval (CI) 0.23 to 0.91) or the common cold (OR 0.44, CI 0.22 to 0.89). The majority of respondents (60%) believed that most patients wanted an antibiotic for URI symptoms, with male OB/GYNs being more likely than female OB/GYNs (OR 2.1, CI 1.2 to 3.8) to hold this belief. Both male OB/GYNs (OR 1.9, CI 1.1 to 3.4) and rural practitioners (OR 2.1, CI 1.1 to 4.0) were more likely to believe that it was hard to withhold antibiotics for URI symptoms because other physicians prescribe antibiotics for these symptoms. OB/GYNs who believed that postgraduate training prepared them well for primary care management were more likely than those who did not (OR 2.1, CI 1.1 to 4.2) to believe that they could reduce antibiotic prescribing without reducing patient satisfaction.Conclusion:Multiple demographic factors affect attitudes and reported practices regarding antibiotic prescribing. However, in view of the low proportion of office visits for URIs, an OB/GYN-specific program is not warranted.

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A collaborative primary care-based approach to managing upper respiratory tract infections as a strategy to reduce antibiotic prescribing

http://isrctn.org/> ◽

10.1186/isrctn18154381 ◽

2012 ◽

Author(s):

James McElnay

Keyword(s):

Primary Care ◽

Respiratory Tract ◽

Respiratory Tract Infections ◽

Upper Respiratory Tract Infections ◽

Antibiotic Prescribing ◽

Upper Respiratory Tract ◽

Upper Respiratory ◽

Tract Infections ◽

Collaborative Primary Care

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Determinants of antibiotic prescribing for upper respiratory tract infections in an emergency department with good primary care access: a qualitative analysis

Epidemiology and Infection ◽

10.1017/s095026881800331x ◽

2019 ◽

Vol 147 ◽

Cited By ~ 6

Author(s):

Y. Y. Chan ◽

M. A. Bin Ibrahim ◽

C. M. Wong ◽

C. K. Ooi ◽

A. Chow

Keyword(s):

Primary Care ◽

Patient Education ◽

Respiratory Tract Infections ◽

Upper Respiratory Tract Infections ◽

Antibiotic Prescribing ◽

Clinical Knowledge ◽

Upper Respiratory Tract ◽

Education And Awareness ◽

Upper Respiratory ◽

Tract Infections

AbstractUpper respiratory tract infections (URTIs) account for substantial attendances at emergency departments (EDs). There is a need to elucidate determinants of antibiotic prescribing in time-strapped EDs – popular choices for primary care despite highly accessible primary care clinics. Semi-structured in-depth interviews were conducted with purposively sampled physicians (n = 9) in an adult ED in Singapore. All interviews were analysed using thematic analysis and further interpreted using the Social Ecological Model to explain prescribing determinants. Themes included: (1) reliance on clinical knowledge and judgement, (2) patient-related factors, (3) patient–physician relationship factors, (4) perceived practice norms, (5) policies and treatment guidelines and (6) patient education and awareness. The physicians relied strongly on their clinical knowledge and judgement in managing URTI cases and seldom interfered with their peers’ clinical decisions. Despite departmental norms of not prescribing antibiotics for URTIs, physicians would prescribe antibiotics when faced with uncertainty in patients’ diagnoses, treating immunocompromised or older patients with comorbidities, and for patients demanding antibiotics, especially under time constraints. Participants had a preference for antibiotic prescribing guidelines based on local epidemiology, but viewed hospital policies on prescribing as a hindrance to clinical judgement. Participants highlighted the need for more public education and awareness on the appropriate use of antibiotics and management of URTIs. Organisational practice norms strongly influenced antibiotic prescribing decisions by physicians, who can be swayed by time pressures and patient demands. Clinical decision support tools, hospital guidelines and patient education targeting at individual, interpersonal and community levels could reduce unnecessary antibiotic use.

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