Abstract
Background
Urinary tract infections (UTIs) are the most common outpatient indication for antibiotics and an important target for antimicrobial stewardship (AS) activities. With The Joint Commission standards now requiring outpatient AS, data supporting effective strategies are needed.
Methods
We conducted a two-phase, prospective, quasi-experimental study to estimate the effect of an outpatient AS intervention on guideline-concordant antibiotic prescribing in a primary care (PC) and urgent care (UC) clinic between August 2017 and July 2019. Phase 1 of the intervention included the development of clinic-specific antibiograms and UTI diagnosis and treatment guidelines, presented during educational sessions with clinic providers. Phase 2, consisting of routine clinic- and provider-specific feedback, began approximately twelve months after the initial education. The primary outcome was percent of encounters with first- or second-line antibiotics prescribed according to clinic-specific guidelines, and was assessed using an interrupted time series approach.
Results
Data were collected on 4,724 distinct patients seen during 6,318 UTI encounters. The percent of guideline-concordant prescribing increased by 22% (95% CI: 12% to 32%) after Phase 1 education, but decreased by 0.5% every two weeks afterwards (95% CI: -0.9% to 0%). Following routine data feedback in Phase 2, guideline concordance stabilized and significant further decline was not seen (-0.6%, 95% CI: -1.6% to 0.4%). This shift in prescribing patterns resulted in a 52% decrease in fluoroquinolone use.
Conclusions
Clinicians increased guideline-concordant prescribing, reduced UTI diagnoses, and limited use of high-collateral damage agents following this outpatient AS intervention. Routine data feedback was effective to maintain the response to the initial education.