142. Implementing an Antimicrobial Stewardship Program in the Outpatient Setting

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

Download Full-text

1879. A 20/20 Vision: Successful Integration of a Prescribing Dashboard for Outpatient Antimicrobial Stewardship to Target 20% Reduction by the Year 2020

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz359.109 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S49-S49

Author(s):

Erin Gentry ◽

Marc Kowalkowski ◽

Ryan Burns ◽

Chloe Sweeney ◽

Cliff Collins ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Urgent Care ◽

Ambulatory Setting ◽

Initial Increase ◽

Relative Reduction ◽

Antibiotic Prescribing ◽

Post Intervention ◽

Awareness Campaign ◽

Stewardship Program ◽

Rate Ratios

Abstract Background At least 30% of antibiotics prescribed in the ambulatory setting are unnecessary, including high rates of overuse for acute respiratory infections (ARI). We designed and evaluated whether a multifaceted outpatient stewardship program leveraging multidisciplinary stakeholder engagement, education tools, and an innovative prescribing dashboard decreased antibiotic prescribing in ARI. Methods In November 2017, the Carolinas HealthCare Outpatient Antimicrobial Stewardship Empowerment Network (CHOSEN) launched an antibiotic awareness campaign in over 150 ambulatory practices in the Charlotte metropolitan area, reaching over one million patients. The campaign included online and in-person tools for patients and providers, targeted education at meetings, and social and mass media exposure. In March 2018, a provider level prescribing dashboard was introduced to target inappropriate antibiotic prescribing in ARI (acute sinusitis, nonsuppurative otitis media, nonbacterial pharyngitis, URI, cough, allergy, and influenza). Data were collected for family medicine (FM), internal medicine (IM), urgent care (UC) and pediatric medicine (PM); 10% and 20% relative reduction targets (years 2019 and 2020, respectively) were set for each service line. We compared pre (April 2016–March 2018) vs. post (April 2018–March 2019) intervention prescribing rates (calculated as the number of encounters with antibiotics vs. total) as rate ratios and used segmented regression models to assess change over time. Results There were 1,001,335 pre and 448,390 post-intervention encounters. Postintervention prescribing rates (antibiotics per 100 encounters) decreased for all service lines, FM (49.4 to 39.3), IM (49.7 to 41.2), UC (49.8 to 44.4), and PM (40.6 to 36.1) vs. pre-intervention (all rate ratios, P ≤ 0.01). All service lines met the target 2019 10% reduction goals. Post-implementation, FM and IM showed immediate decreases in prescribing (figure). After an initial increase, UC showed a significant month-to-month decrease (figure). Conclusion Integration of a prescribing dashboard within a multifaceted antibiotic awareness campaign reduced inappropriate outpatient antibiotic prescribing for ARI and achieved interim targets consistent with 2020 reduction goals. Disclosures All Authors: No reported Disclosures.

Download Full-text

Appropriateness of Antibiotic Prescribing in United States Children’s Hospitals: A National Point Prevalence Survey

Clinical Infectious Diseases ◽

10.1093/cid/ciaa036 ◽

2020 ◽

Vol 71 (8) ◽

pp. e226-e234 ◽

Cited By ~ 1

Author(s):

Alison C Tribble ◽

Brian R Lee ◽

Kelly B Flett ◽

Lori K Handy ◽

Jeffrey S Gerber ◽

...

Keyword(s):

United States ◽

Antimicrobial Stewardship ◽

Inappropriate Prescribing ◽

The United States ◽

Antibiotic Prescribing ◽

Hospitalized Children ◽

Prescribing Practices ◽

Children's Hospitals ◽

Stewardship Program ◽

Children’S Hospitals

Abstract Background Studies estimate that 30%–50% of antibiotics prescribed for hospitalized patients are inappropriate, but pediatric data are limited. Characterization of inappropriate prescribing practices for children is needed to guide pediatric antimicrobial stewardship. Methods Cross-sectional analysis of antibiotic prescribing at 32 children’s hospitals in the United States. Subjects included hospitalized children with ≥ 1 antibiotic order at 8:00 am on 1 day per calendar quarter, over 6 quarters (quarter 3 2016–quarter 4 2017). Antimicrobial stewardship program (ASP) physicians and/or pharmacists used a standardized survey to collect data on antibiotic orders and evaluate appropriateness. The primary outcome was the percentage of antibiotics prescribed for infectious use that were classified as suboptimal, defined as inappropriate or needing modification. Results Of 34 927 children hospitalized on survey days, 12 213 (35.0%) had ≥ 1 active antibiotic order. Among 11 784 patients receiving antibiotics for infectious use, 25.9% were prescribed ≥ 1 suboptimal antibiotic. Of the 17 110 antibiotic orders prescribed for infectious use, 21.0% were considered suboptimal. Most common reasons for inappropriate use were bug–drug mismatch (27.7%), surgical prophylaxis > 24 hours (17.7%), overly broad empiric therapy (11.2%), and unnecessary treatment (11.0%). The majority of recommended modifications were to stop (44.7%) or narrow (19.7%) the drug. ASPs would not have routinely reviewed 46.1% of suboptimal orders. Conclusions Across 32 children’s hospitals, approximately 1 in 3 hospitalized children are receiving 1 or more antibiotics at any given time. One-quarter of these children are receiving suboptimal therapy, and nearly half of suboptimal use is not captured by current ASP practices.

Download Full-text

1084. A Pre- and Post-Intervention Study to Implement a Successful Antimicrobial Stewardship Program at an Urban Chronic Hemodialysis Center

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.948 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S385-S385

Author(s):

Jenny Park ◽

Mohamed Nakeshbandi ◽

Subodh Saggi ◽

Roopali Sharma

Keyword(s):

Vascular Access ◽

Antimicrobial Stewardship ◽

Positive Impact ◽

Inappropriate Prescribing ◽

Chronic Hemodialysis ◽

Therapeutic Drug ◽

Antimicrobial Stewardship Program ◽

Post Intervention ◽

Implementation Phase ◽

Stewardship Program

Abstract Background Patients receiving chronic outpatient hemodialysis (CHD) are at high risk for bloodstream and vascular access infections due to the immune-compromised status of patients and repeated vascular access. CHD patients are especially vulnerable to multidrug-resistant organisms due to extensive exposure to antibiotics (ABX). It is estimated that more than 40% of CHD patients receive ≥1 ABX course each year. As data characterizing ABX use and reasons for inappropriate prescribing is still scarce in CHD patients, our objective was to assess ABX use pre- and post-implementation of antimicrobial stewardship program (ASP). Methods A retrospective cohort study to analyze appropriate ABX use from 2015–2018 in CHD patients was conducted. Starting January 15, 2019, ASP was established at the hemodialysis center and tracked all ABX doses including appropriate indication, dosage, frequency, route, therapeutic drug monitoring (TDM) and duration of therapy. All results are presented as descriptive statistics. Results Of the 250 accounts of antibiotics that were assessed retrospectively in all patients from ages 12 to 95 years old, 50% of antibiotics ordered were inappropriately prescribed. The following were the reasons for inappropriateness: indication (59%), duration (14%), culture susceptibility (7%), dose (12%), narrow-spectrum warranted (2%), TDM (6%). Twenty-three accounts were assessed post-implementation phase. ASP implementation led to 100% compliance with regards to the appropriateness of ABX usage (indication, dose, and duration). Additional, ASP interventions included recommendations to obtain blood cultures and conduct TDM in 47% of patients. Conclusion This study identified inappropriateness of antibiotic usage without an established ASP in CHD patients. Implementation of ASP was associated with a positive impact on all ABX doses prescribed and this can have a significant outcome on optimizing ABX use in CHD patients. Disclosures All authors: No reported disclosures.

Download Full-text

Successful Implementation of an Antibiotic Stewardship Program in an Academic Dental Practice

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz067 ◽

2019 ◽

Vol 6 (3) ◽

Cited By ~ 17

Author(s):

Alan E Gross ◽

Danny Hanna ◽

Susan A Rowan ◽

Susan C Bleasdale ◽

Katie J Suda

Keyword(s):

Antibiotic Stewardship ◽

Guideline Development ◽

The United States ◽

Outpatient Setting ◽

Urgent Care ◽

Antibiotic Prescribing ◽

Successful Implementation ◽

Provider Education ◽

Multimodal Intervention ◽

Stewardship Program

AbstractBackgroundMost antibiotic use in the United States occurs in the outpatient setting, and 10% of these prescriptions are generated by dentists. The development of comprehensive antibiotic stewardship programs (ASPs) in the dental setting is nascent, and therefore we describe the implementation of a dental ASP.MethodsA collaborative team of dentist, pharmacist, and physician leaders conducted a baseline needs assessment and literature evaluation to identify opportunities to improve antibiotic prescribing by dentists within Illinois’ largest oral health care provider for Medicaid recipients. A multimodal intervention was implemented that included patient and provider education, clinical guideline development, and an assessment of the antibiotic prescribing rate per urgent care visit before and after the educational interventions.ResultsWe identified multiple needs, including standardization of antibiotic prescribing practices for patients with acute oral infections in the urgent care clinics. A 72.9% decrease in antibiotic prescribing was observed in urgent care visits after implementation of our multimodal intervention (preintervention urgent care prescribing rate, 8.5% [24/283]; postintervention, 2.3% [8/352]; P < .001).ConclusionsWe report the successful implementation of a dental ASP that is concordant with the Centers for Disease Control and Prevention Core Elements of Antibiotic Stewardship in the Outpatient Setting. Our approach may be adapted to other dental practices to improve antibiotic prescribing.

Download Full-text

The Implementation of a Unit-Based Antimicrobial Stewardship Program Using a Consultative Approach to Improve Antibiotic Prescribing Practices

American Journal of Infection Control ◽

10.1016/j.ajic.2017.04.039 ◽

2017 ◽

Vol 45 (6) ◽

pp. S19-S20

Author(s):

Frances Edwards ◽

Jodi Galaydick ◽

Bernard Nash ◽

Michael McDonough ◽

James Parrott ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Antibiotic Prescribing ◽

Antimicrobial Stewardship Program ◽

Prescribing Practices ◽

Stewardship Program

Download Full-text

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.

Download Full-text

Decreased Outpatient Fluoroquinolone Prescribing Using a Multimodal Antimicrobial Stewardship Initiative

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa182 ◽

2020 ◽

Vol 7 (6) ◽

Author(s):

Kevin Lin ◽

Yorgo Zahlanie ◽

Jessica K Ortwine ◽

Norman S Mang ◽

Wenjing Wei ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Inappropriate Prescribing ◽

Multidrug Resistant ◽

Outpatient Setting ◽

Urgent Care ◽

Hospital System ◽

Inappropriate Use ◽

History Of ◽

Outpatient Settings ◽

The Impact

Abstract Background Fluoroquinolones are antibiotics prescribed in the outpatient setting, though they have serious side effects. This study evaluates the impact of stewardship interventions on total and inappropriate prescribing of fluoroquinolones in outpatient settings in a large county hospital and health system. Methods In an effort to decrease inappropriate outpatient fluoroquinolone usage, a multimodal antimicrobial stewardship initiative was implemented in November 2016. Education regarding the risks, benefits, and appropriate uses of fluoroquinolones was provided to providers in different outpatient settings, Food and Drug Administration warnings were added to all oral fluoroquinolone orders, an outpatient order set for cystitis treatment was created, and fluoroquinolone susceptibilities were suppressed when appropriate. Charts from October 2016, 2017, and 2018 were retrospectively reviewed if the patient encounter occurred in primary care clinics, emergency departments, or urgent care centers within Parkland Health & Hospital System and a fluoroquinolone was prescribed. Inappropriate use was defined as a fluoroquinolone prescription for cystitis, bronchitis, or sinusitis in a patient without a history of Pseudomonas aeruginosa or multidrug-resistant organisms and without drug allergies that precluded use of other oral antibiotics. Results Total fluoroquinolone prescriptions per 1000 patient visits decreased significantly by 39% (P < .01), and inappropriate fluoroquinolone use decreased from 53% to 34% (P < .01). More than 90% of inappropriate fluoroquinolone prescriptions were given for cystitis, while bronchitis and sinusitis accounted for only 4.4% and 1.6% of inappropriate indications, respectively. Conclusion A multimodal stewardship initiative appears to effectively reduce both total and inappropriate outpatient fluoroquinolone prescriptions.

Download Full-text

Risks of use and non-use of antibiotics in primary care. Qualitative study of prescribers’ views

10.1101/2020.03.26.20044107 ◽

2020 ◽

Author(s):

Olga Boiko ◽

Caroline Burgess ◽

Robin Fox ◽

Mark Ashworth ◽

Martin C Gulliford

Keyword(s):

Risk Assessment ◽

Primary Care ◽

Qualitative Study ◽

Antimicrobial Stewardship ◽

Inappropriate Prescribing ◽

Warning Signs ◽

Antibiotic Prescribing ◽

List Type ◽

Structured Interviews ◽

Trade Offs

ABSTRACTPurposeThe emergence of antimicrobial resistance has led to increasing efforts to reduce unnecessary use of antibiotics in primary care, but potential hazards from bacterial infection continue to cause concern. This study investigated how primary care prescribers evaluate the risks of reduced antibiotic prescribing.MethodsQualitative study using semi-structured interviews conducted with primary care prescribers from 10 general practices in an urban area and a shire town in England. A thematic analysis was conducted.ResultsThirty participants were recruited, including 23 general practitioners, 5 nurses and 2 pharmacists. Three main themes were identified: risk assessment; balancing treatment risks; and negotiating decisions and risks. Respondents indicated that their decisions were grounded in clinical risk assessment, but this was informed by different approaches to antibiotic use, with most leaning towards reduced prescribing. Prescribers’ perceptions of risk included the consequences of both inappropriate prescribing and inappropriate withholding of antibiotics. Sepsis was viewed as the most concerning potential outcome of non-prescribing, leading to possible patient harm and potential litigation. Risks of antibiotic prescribing included antibiotic resistant and C. difficile infections, as well as side effects, such as rashes, that might lead to possible mislabelling as antibiotic allergy. Prescribers elicited patient preferences for use or avoidance of antibiotics to inform management strategies, which included educational advice, advice on self-management including warning signs, use of delayed prescriptions, and safety netting.ConclusionsAttitudes towards antibiotic prescribing are evolving, with reduced antibiotic prescribing now being approached more systematically. The safety trade-offs associated with either use or non-use of antibiotics present difficulties especially when prescribing decisions are inconsistent with patients’ expectations.Strengths and limitations of this studyThe study provides an investigation of primary care prescribers’ perceptions, emphasising safety perspectives in the context of antimicrobial stewardship.The main themes identified may inform the basis for future improvement and antimicrobial stewardship programs.The study is based on interviews with prescribers and may be susceptible to the limitations associated with qualitative interview studiesThe diverse sample of participants provide a good spread of opinions that are of a high validity and rigorously analysed.The study may lack generalisability beyond high-income countries.

Download Full-text