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 2073. Apples and Oranges: Comparing Toolkits to Track Antimicrobial Prescribing in Ambulatory Care Settings

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S699-S699
Author(s):  
Zahra Kassamali ◽  
Chloe Bryson-Cahn ◽  
Todd Bouchard ◽  
Kyung Min Lee ◽  
Jose Mari G. Lansang ◽  
...  
Keyword(s):  
Primary Care ◽  
Local Level ◽  
Inappropriate Prescribing ◽  
Careful Consideration ◽  
Specialty Care ◽  
Choosing Wisely ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Inclusion Criteria ◽  
Technical Specifications

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. Multiple tools have emerged to evaluate antibiotic prescribing in ambulatory settings. The toolkits, MITIGATE and Choosing Wisely, have been funded by the Centers for Disease Control and Prevention and promoted by the American Board of Internal Medicine, respectively, but use different reporting criteria. Notably, the target rate of antibiotic prescribing in the MITIGATE framework is zero, whereas the target rate for Choosing Wisely is not zero because it includes diagnoses for which an antibiotic may be appropriate. We compared both to evaluate prescribing in primary care and specialty clinics, urgent care, and the emergency department. Methods This was a single-center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. The primary outcome was rate of inappropriate antibiotic prescribing overall and in each of the individual settings. Results Between March 2018 and April 2019, 42,650 patient visits met MITIGATE inclusion criteria and 11% received an antibiotic unnecessarily. In the same time-period, 23,366 patient visits met Choosing Wisely inclusion criteria and 17% received an antibiotic unnecessarily. Within the MITIGATE framework, inappropriate prescribing was highest in the ED (17%), followed by primary care (12%), urgent care (10%), and specialty care (5%). Choosing Wisely, inappropriate prescribing was highest in primary care (23%), followed by urgent care (15%), and specialty care (8%). The ED was not included in the Choosing Wisely technical specifications. The top coded diagnosis in both frameworks was acute respiratory infection, unspecified. Conclusion Rates of inappropriate antibiotic prescribing varied widely depending upon the toolkit used. Inappropriate antibiotic prescribing in primary care by Choosing Wisely framework was double that of MITIGATE. Careful consideration of the differences and goals of using these toolkits is needed both on the local level for individual provider feedback and more broadly, when comparing prescribing rates between institutions. Disclosures All authors: No reported disclosures.

scholarly journals 131. Antimicrobial Usage for Respiratory Infections in Urgent Care Settings within the University of Washington Medicine Network

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S77-S77
Author(s):  
Joanne Huang ◽  
Zahra Kassamali Escobar ◽  
Rupali Jain ◽  
Jeannie D Chan ◽  
John B Lynch ◽  
...  
Keyword(s):  
Adverse Drug Events ◽  
Respiratory Infections ◽  
Inappropriate Prescribing ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Prescribing Practices ◽  
University Of Washington ◽  
Tract Infections ◽  
Viral Respiratory Infections ◽  
Viral Respiratory

Abstract Background In an effort to combat antimicrobial resistance and adverse drug events, The Joint Commission mandated expansion of antimicrobial stewardship programs into ambulatory healthcare settings Jan 2020. The most common diagnoses resulting in inappropriate antimicrobial prescribing are respiratory infections. This study aimed to assess the rate of antibiotic prescribing for viral respiratory tract infections within six urgent care clinics affiliated with University of Washington Medicine health system in Seattle, WA. Methods This was a retrospective observational study from Jan 2019-Feb 2020. We used the MITIGATE toolkit; a resource that meets CDC’s core elements for outpatient stewardship. Patients were identified based upon pre-specified ICD-10 codes for viral respiratory infections. The primary outcome was the rate of unnecessary antimicrobial prescriptions for acute viral respiratory infections. Secondary outcomes evaluated inappropriate prescribing practices based on antibiotic selection, diagnosis, and age. Results Of 7,313 patients (6078 adults and 1235 pediatric) included, 23% were inappropriately prescribed antibiotics. The most common antibiotics inappropriately prescribed were azithromycin (62%), amoxicillin (13%), and doxycycline (13%). Fluoroquinolone (FQ) utilization was low (2%). Bronchitis (61%) and nonsuppurative otitis media (NSOM) (24%) were the most common viral diagnoses for which antibiotics were prescribed. Overall, unnecessary prescribing was lower in pediatrics than adults at 13% and 25%, respectively (p< 0.001). Adults were more often prescribed antibiotics inappropriately for bronchitis and NSOM compared to pediatrics (p=0.0013). Conclusion Inappropriate prescribing practices across six urgent care clinics varied based upon age and diagnosis. Azithromycin is most often inappropriately prescribed but the low rate of FQ prescribing is encouraging. The lower rate of unnecessary prescribing in pediatrics is promising although there is room for improvement as 1 in 8 children were unnecessarily prescribed antibiotics. These findings support the need for antibiotic stewardship in the outpatient setting, targeting areas for azithromycin use and therapeutic management of bronchitis. Disclosures All Authors: No reported disclosures

scholarly journals 145. Monthly Antibiotic Prescribing Peer Comparison Combined with In-person Education Decreases Antibiotic Prescribing for Acute Respiratory Infections

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S83-S83
Author(s):  
Shelby J Kolo ◽  
David J Taber ◽  
Ronald G Washburn ◽  
Katherine A Pleasants
Keyword(s):  
Primary Care ◽  
Respiratory Infections ◽  
Primary Care Providers ◽  
The United States ◽  
Delivery Mode ◽  
Antibiotic Prescribing ◽  
Acute Respiratory Infections ◽  
Care Providers ◽  
Intervention Period ◽  
Provider Education

Abstract Background Inappropriate antibiotic prescribing is an important modifiable risk factor for antibiotic resistance. Approximately half of all antibiotics prescribed for acute respiratory infections (ARIs) in the United States may be inappropriate or unnecessary. The purpose of this quality improvement (QI) project was to evaluate the effect of three consecutive interventions on improving antibiotic prescribing for ARIs (i.e., pharyngitis, rhinosinusitis, bronchitis, common cold). Methods This was a pre-post analysis of an antimicrobial stewardship QI initiative to improve antibiotic prescribing for ARIs in six Veterans Affairs (VA) primary care clinics. Three distinct intervention phases occurred. Educational interventions included training on appropriate antibiotic prescribing for ARIs. During the first intervention period (8/2017-1/2019), education was presented virtually to primary care providers on a single occasion. In the second intervention period (2/2019-10/2019), in-person education with peer comparison was presented on a single occasion. In the third intervention period (11/2019-4/2020), education and prescribing feedback with peer comparison was presented once in-person followed by monthly emails of prescribing feedback with peer comparison. January 2016-July 2017 was used as a pre-intervention baseline period. The primary outcome was the antibiotic prescribing rate for all classifications of ARIs. Secondary outcomes included adherence to antibiotic prescribing guidance for pharyngitis and rhinosinusitis. Descriptive statistics and interrupted time series segmented regression were used to analyze the outcomes. Results Monthly antibiotic prescribing peer comparison emails in combination with in-person education was associated with a statistically significant 12.5% reduction in the rate of antibiotic prescribing for ARIs (p=0.0019). When provider education alone was used, the reduction in antibiotic prescribing was nonsignificant. Conclusion Education alone does not significantly reduce antibiotic prescribing for ARIs, regardless of the delivery mode. In contrast, education followed by monthly prescribing feedback with peer comparison was associated with a statistically significant reduction in ARI antibiotic prescribing rates. Disclosures All Authors: No reported disclosures

scholarly journals 142. Implementing an Antimicrobial Stewardship Program in the Outpatient Setting

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

scholarly journals Neutrophils in respiratory viral infections

2021 ◽  
Author(s):  
Cecilia Johansson ◽  
Freja C. M. Kirsebom
Keyword(s):  
Viral Infections ◽  
Immune Cell ◽  
Respiratory Infections ◽  
Fungal Infections ◽  
Severe Disease ◽  
The Elderly ◽  
Viral Control ◽  
Immunological Mechanisms ◽  
Respiratory Viral Infections ◽  
Viral Respiratory Infections

AbstractViral respiratory infections are a common cause of severe disease, especially in infants, people who are immunocompromised, and in the elderly. Neutrophils, an important innate immune cell, infiltrate the lungs rapidly after an inflammatory insult. The most well-characterized effector mechanisms by which neutrophils contribute to host defense are largely extracellular and the involvement of neutrophils in protection from numerous bacterial and fungal infections is well established. However, the role of neutrophils in responses to viruses, which replicate intracellularly, has been less studied. It remains unclear whether and, by which underlying immunological mechanisms, neutrophils contribute to viral control or confer protection against an intracellular pathogen. Furthermore, neutrophils need to be tightly regulated to avoid bystander damage to host tissues. This is especially relevant in the lung where damage to delicate alveolar structures can compromise gas exchange with life-threatening consequences. It is inherently less clear how neutrophils can contribute to host immunity to viruses without causing immunopathology and/or exacerbating disease severity. In this review, we summarize and discuss the current understanding of how neutrophils in the lung direct immune responses to viruses, control viral replication and spread, and cause pathology during respiratory viral infections.

scholarly journals 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

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

scholarly journals Nasopharyngeal Type-I Interferon for Immediately Available Prophylaxis Against Emerging Respiratory Viral Infections

2021 ◽  
Vol 12 ◽  
Author(s):  
Amos C. Lee ◽  
Yunjin Jeong ◽  
Sumin Lee ◽  
Haewook Jang ◽  
Allen Zheng ◽  
...  
Keyword(s):  
Interferon Beta ◽  
Viral Infections ◽  
Respiratory Infections ◽  
Type I ◽  
Emerging Viruses ◽  
Respiratory Viral Infection ◽  
Respiratory Viral Infections ◽  
Viral Respiratory Infections ◽  
Viral Respiratory

In addition to SARS-CoV-2 and its variants, emerging viruses that cause respiratory viral infections will continue to arise. Increasing evidence suggests a delayed, possibly suppressed, type 1 interferon (IFN-I) response occurs early during COVID-19 and other viral respiratory infections such as SARS and MERS. These observations prompt considering IFN-β as a prophylactic or early intervention for respiratory viral infections. A rationale for developing and testing intranasal interferon beta (IFN-β) as an immediately available intervention for new respiratory viral infections that will arise unexpectedly in the future is presented and supported by basic and clinical trial observations. IFN-β prophylaxis could limit the spread and consequences of an emerging respiratory viral infection in at-risk individuals while specific vaccines are being developed.

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