scholarly journals Decreased Overall and Inappropriate Antibiotic Prescribing in a Veterans Affairs Hospital Emergency Department following a Peer Comparison-Based Stewardship Intervention

2020 ◽  
Vol 65 (1) ◽  
pp. e01660-20
Author(s):  
Deanna J. Buehrle ◽  
Rameez H. Phulputo ◽  
Marilyn M. Wagener ◽  
Cornelius J. Clancy ◽  
Brooke K. Decker
Keyword(s):  
Interrupted Time Series ◽  
Antibiotic Use ◽  
Baseline Period ◽  
Veterans Affairs ◽  
Antibiotic Prescribing ◽  
Oral Antibiotic ◽  
Intervention Period ◽  
Time Series Regression ◽  
Amoxicillin Clavulanate ◽  
Ed Visits

ABSTRACTAntibiotic prescribing is very common in emergency departments (EDs). Optimal stewardship intervention strategies in EDs are not well defined. We conducted a prospective, observational cohort study in a Veterans Affairs ED in which clinician education and monthly e-mail-based peer comparisons were directed against all oral antibiotic prescribing for discharged patients. Oral antibiotic prescriptions were compared in baseline (June 2016 to December 2017) and intervention (January to June 2018) periods using an interrupted time series regression model. Prescribing appropriateness was compared during January to June 2017 and the intervention period. During the intervention period, antibiotic prescriptions decreased monthly by 10.4 prescriptions per 1,000 ED visits (P = 0.07 [95% confidence interval {CI}, −21.7 to 1.0]). The relative decrease in the trend of antibiotic prescriptions during the intervention period compared to baseline was 9.9 prescriptions per 1,000 ED visits per month (P = 0.07 [95% CI, −20.9 to 1.0]). The intervention was associated with a significant decrease and increase in amoxicillin-clavulanate and cephalexin prescriptions, respectively (P < 0.001, P = 0.004). Decreasing trends in ciprofloxacin prescriptions during the baseline period were maintained during the intervention. Unnecessary antibiotic prescribing (i.e., antibiotic not indicated) decreased from 55.6% to 38.7% during the intervention (30.4% decrease, P = 0.003). Optimal antibiotic prescribing (i.e., antibiotics were indicated, and a guideline-concordant agent was prescribed for guideline-concordant duration) increased by 36% (21.6% to 29.3%, P = 0.12). A peer comparison-based stewardship intervention directed at ED clinicians was associated with reductions in overall and unnecessary oral antibiotic prescribing. There is potential to further improve antibiotic use as suboptimal prescribing remained common.

scholarly journals 150. Using audit-and-feedback to improve antibiotic-prescribing in Emergency Departments: a quasi-experimental study across 4 sites in the Veterans Health Administration

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S85-S85
Author(s):  
Daniel J Livorsi ◽  
Rajeshwari Nair ◽  
Andrew Dysangco ◽  
Andrea Aylward ◽  
Bruce Alexander ◽  
...  
Keyword(s):  
Experimental Study ◽  
Emergency Departments ◽  
Antibiotic Use ◽  
Audit And Feedback ◽  
Series Data ◽  
Antibiotic Prescribing ◽  
Intervention Period ◽  
Quasi Experimental ◽  
Ed Visits ◽  
Research Grant

Abstract Background Antibiotic-prescribing in Emergency Departments (EDs) is often inappropriate. In this study, we evaluated whether audit-and-feedback could improve antibiotic use in EDs. Figure 1. Comparison of antibiotic-prescribing between the pretest and intervention periods at 2 intervention EDs and 2 control EDs Methods We pilot tested an audit-and-feedback intervention using a quasi-experimental study design at 2 intervention and 2 matched-control EDs with a 12-month pretest and a 12-month intervention period. At intervention sites, 27 of 31 (87.1%) clinicians were enrolled; at baseline, they received 1) one-on-one education about antibiotic-prescribing and 2) individualized feedback with comparisons to local peers. Feedback included personalized antibiotic-prescribing data for all ED visits and specifically for viral acute respiratory infections (ARIs); feedback was updated quarterly. The primary outcome was the antibiotic-prescribing rate for ED visits not resulting in hospitalization, and it was assessed using a segmented regression analysis of monthly time series data. Manual chart reviews were performed to assess guideline-concordant management (i.e. prescribing an antibiotic when indicated and not prescribing when not indicated) for 5 ARIs plus cystitis. Results In the pre-test and intervention periods, intervention sites had 28,146 and 27,396 visits compared to 31,439 and 32,295 visits at control sites. After implementation started, intervention sites saw an immediate decrease in antibiotic use (-10.3%, p=0.15) compared to a 1.5% increase (p=0.88) at control sites. By the end of the intervention period, there was an 8.9% decrease in antibiotic use at intervention sites compared to a 3.4% decrease at control sites [relative risk ratio (RRR) -3.3% (95% CI, -8.4 to +1.7), Figure 1]. Guideline-concordant management improved from 52.1% to 72.2% (p&lt; 0.01) at intervention sites compared to 51.3% to 58.2% (p=0.13) at control sites. Intervention and control sites had similar changes in 30-day outcomes, including late antibiotic prescriptions and hospitalizations. Conclusion After the implementation of audit-and-feedback at 2 EDs, antibiotic use did not significantly decrease compared to 2 control EDs but guideline-concordant management improved. Future studies should include more study sites to improve statistical power and also evaluate the effectiveness of more frequent and specific feedback. Disclosures Daniel J. Livorsi, MD, MSc, Merck and Company, Inc (Research Grant or Support) Rajeshwari Nair, PhD, Merck and Company, Inc. (Research Grant or Support)

scholarly journals Improving the quality of care for patients with or at risk of atrial fibrillation: an improvement initiative in UK general practices

Open Heart ◽  
2019 ◽  
Vol 6 (2) ◽  
pp. e001086
Author(s):  
Yewande Adeleke ◽  
Dionne Matthew ◽  
Bradley Porter ◽  
Thomas Woodcock ◽  
Jayne Yap ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Interrupted Time Series ◽  
Baseline Period ◽  
Risk Scores ◽  
Intervention Period ◽  
Time Series Regression ◽  
Statistical Process ◽  
Diagnosis And Management ◽  
Cardiovascular Morbidity And Mortality ◽  
General Practices

ObjectiveAtrial fibrillation (AF) is a growing problem internationally and a recognised cause of cardiovascular morbidity and mortality. The London borough of Hounslow has a lower than expected prevalence of AF, suggesting poor detection and associated undertreatment. To improve AF diagnosis and management, a quality improvement (QI) initiative was set up in 48 general practices in Hounslow. We aimed to study whether there was evidence of a change in AF diagnosis and management in Hounslow following implementation of interventions in this QI initiative.MethodsUsing the general practice information system (SystmOne), data were retrospectively collected for 415 626 patients, who were actively registered at a Hounslow practice between 1 January 2011 and 31 August 2018. Process, outcome and balancing measures were analysed using statistical process control and interrupted time series regression methods. The baseline period was from 1 January 2011 to 30 September 2014 and the intervention period was from 1 October 2014 to 31 August 2018.ResultsWhen comparing the baseline to the intervention period, (1) the rate of new AF diagnoses increased by 27% (relative risk 1.27; 95% CI 1.05 to 1.52; p<0.01); (2) ECG tests done for patients aged 60 and above increased; (3) CHA2DS2-VASc and HAS-BLED risk assessments within 30 days of AF diagnosis increased from 1.7% to 19% and 0.2% to 8.1%, respectively; (4) among those at higher risk of stroke, anticoagulation prescription within 30 days of AF diagnosis increased from 31% to 63% while prescription of antiplatelet monotherapy within the same time period decreased from 17% to 7.1%; and (5) average CHA2DS2-VASc and HAS-BLED risk scores did not change.ConclusionImplementation of interventions in the Hounslow QI initiative coincided with improved AF diagnosis and management. Areas with perceived underdetection of AF should consider similar interventions and methodology.

scholarly journals 144. Little evidence of same-day, oral antibiotic prescribing at ambulatory surgery centers

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S82-S83
Author(s):  
Laura M King ◽  
Lauri Hicks ◽  
Sarah Kabbani; Sharon Tsay ◽  
Katherine E Fleming-Dutra
Keyword(s):  
Surgical Procedures ◽  
Ambulatory Surgery ◽  
Antibiotic Use ◽  
Antibiotic Prescribing ◽  
Oral Antibiotic ◽  
Chi Square ◽  
Convenience Sample ◽  
Ambulatory Surgery Centers ◽  
National Public Health ◽  
Course Length

Abstract Background The objective of our study was to describe oral antibiotic prescriptions associated with procedures in ambulatory surgery centers (ASC) to evaluate if there are major national opportunities to improve antibiotic use in this setting. Methods We identified surgical procedures in ASCs and oral antibiotic prescriptions in the IBM® MarketScan® Commercial 2018 database, a large convenience sample of privately-insured individuals aged &lt; 65 years. We excluded visits with same-day hospitalizations and those with infectious diagnoses that may warrant antibiotic treatment. We included only antibiotic prescriptions dispensed on the same day as an ASC visit. We calculated the number of visits and oral antibiotic prescriptions and the percent of visits with oral antibiotic prescriptions overall, and by patient age group (&lt; 18 and 18–64 years), antibiotic class, and procedure type. We also calculated median antibiotic course length. Across-group comparisons were evaluated using chi-square tests. Results In 2018, 918,127 ASC visits with surgical procedure codes were captured, of which 37,032 (4.0%) were associated with same-day oral antibiotic prescriptions. The percent of visits with antibiotic prescriptions was significantly higher among children compared to adults (9.4% vs 3.8%; p&lt; 0.01); however, adults accounted for 89% of prescriptions. Respiratory/nasal and urinary tract system procedures were most frequently associated with antibiotic prescriptions (Figure). Median course length was 5 (interquartile range 3–7) days. The most common antibiotic class was cephalosporins (49.6% of prescriptions), followed by penicillins (12.6%) and fluoroquinolones (10.9%). Figure. Percent of ambulatory surgery center visits with same-day antibiotic prescriptions by procedure category, IBM® MarketScan® Commercial Database, 2018 Conclusion Only 4% of ASC procedures were associated with same-day oral antibiotic prescriptions, suggesting antibiotics are not commonly prescribed in ASCs on the day of surgical procedures. Additionally, the observed 5-day median duration may suggest that some of these courses are intended for treatment rather than prophylaxis. Our estimates represent lower bounds for oral antibiotic prescriptions in this setting, as we only captured same-day prescriptions. However, our findings suggest that ASC facilities may not be high-impact targets for national, public health antibiotic stewardship efforts. Disclosures All Authors: No reported disclosures

scholarly journals Antibiotic Use Metrics to Guide Antibiotic Stewardship Priorities: Dental Antibiotic Prescribing in the U.S. Veterans Affairs (VA) System

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S252-S253
Author(s):  
Kj Suda ◽  
Margaret Fitzpatrick ◽  
Gretchen Gibson ◽  
Marianne Jurasic ◽  
Scott Miskevics ◽  
...  
Keyword(s):  
Antibiotic Stewardship ◽  
Antibiotic Use ◽  
Veterans Affairs ◽  
Antibiotic Prescribing ◽  
The U.S

scholarly journals Impact of a pilot multimodal intervention to decrease antibiotic use for respiratory infections in a geriatric clinic

2022 ◽  
Vol 2 (1) ◽  
Author(s):  
Lakshmi R. Chauhan ◽  
Misha Huang ◽  
Mona Abdo ◽  
Skotti Church ◽  
Danielle Fixen ◽  
...  
Keyword(s):  
Respiratory Infections ◽  
Low Cost ◽  
Action Plan ◽  
Antibiotic Use ◽  
Outpatient Setting ◽  
Quality Improvement Initiative ◽  
Antibiotic Prescribing ◽  
Clostridioides Difficile ◽  
Before And After ◽  
Amoxicillin Clavulanate

Abstract Background: More than 80% of antibiotics are prescribed in the outpatient setting, of which 30% are inappropriate. The National Action Plan for Combating Antimicrobial Resistance called for a 50% decrease in outpatient antibiotic use by 2020. Inappropriate antibiotics are associated with adverse reactions and Clostridioides difficile infection, especially among older adults. Study design: Before and after study. Methods: We performed a quality improvement initiative at the University of Colorado Seniors Clinic. Providers received education on antibiotic guidelines, electronic antibiotic order sets were introduced with standardized stop dates. Antibiotic use data were collected for 6 months before and 6 months after the intervention, from December to May to avoid seasonal variation. Descriptive statistics and linear mixed-effects regression models were used for this comparison. Results: Total antibiotic prescriptions for acute respiratory conditions decreased from 137 prescriptions before the intervention (December 1, 2017, to May 31, 2018) to 112 prescriptions after the intervention (December 1, 2018, to May 31, 2019), driven primarily by decreases in antibiotic prescriptions for pneumonia, sinusitis, and bronchitis. Prescriptions for broad-spectrum antibiotics declined following the intervention including decreases in levofloxacin from 12 (9%) to 3 (3%) and amoxicillin-clavulanate from 15 (12%) to 7 (7%). We detected significant reductions in prescribed antibiotic durations (days) after the intervention for sinusitis (estimate, −2.0; 95% CI, −3.1 to −1.0; P = .0003), pharyngitis (estimate, −2.5; 95% CI, −4.6 to −0.5; P = .018), and otitis (−3.2; 95% CI, −5.2 to −1.3; P = .008). Conclusions: Low-cost interventions were initially successful in changing patterns of antibiotic use and decreasing overall antibiotic prescribing among older patients in the outpatient setting. Long-term follow-up studies are needed to determine the sustainability and clinical impact of these interventions.

scholarly journals Patterns of Oral Antibiotic Use and Excess Duration at Hospital Discharge

2020 ◽  
Vol 41 (S1) ◽  
pp. s522-s523
Author(s):  
Corey Medler ◽  
Nicholas Mercuro ◽  
Helina Misikir ◽  
Nancy MacDonald ◽  
Melinda Neuhauser ◽  
...  
Keyword(s):  
Risk Factors ◽  
Antibiotic Use ◽  
Hospitalized Patients ◽  
Guideline Recommendation ◽  
Resistant Organism ◽  
Chronic Obstructive ◽  
Antibiotic Prescribing ◽  
Oral Antibiotic ◽  
Cross Sectional ◽  
Tract Infections

Background: Antimicrobial stewardship (AMS) interventions have predominantly involved inpatient antimicrobial therapy. However, for many hospitalized patients, most antibiotic use occurs after discharge, and unnecessarily prolonged courses of therapy are common. Patient transition from hospitalization to discharge represents an important opportunity for AMS intervention. We describe patterns of antibiotic use selection and duration of therapy (DOT) for common infections including discharge antibiotics. Methods: This retrospective cross-sectional analysis was derived from an IRB-approved, multihospital, quasi-experiment at a 5-hospital health system in southeastern Michigan. The study population included patients discharged from an inpatient general and specialty practice ward on oral antibiotics from November 2018 through April 2019. Patients were included with the following diagnoses: skin and soft-tissue infections (SSTIs), community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), respiratory viral infections, acute exacerbation of chronic obstructive pulmonary disease (AECOPD), intra-abdominal infections (IAIs), and urinary tract infections (UTIs). Other diagnoses were excluded. Data were extracted from medical records including antibiotic indication, selection, and duration, as well as patient characteristics. Results: In total, 1,574 patients were screened and 800 patients were eligible for inclusion. The most common antibiotic indications were respiratory tract infections, with 487 (60.9%) patients. These included 165 AECOPD cases (20.6%) and 200 CAP cases (25%) with no multidrug resistant organism (MDRO) risk factors; 57 patients (7.1%) with MDRO risk factors; HAP in 7 patients (0.9%); and influenza in 58 patients (7.2%). Also, 205 (25.6%) patients were diagnosed with UTIs: 71 with cystitis (8.9%), 86 (10.8%) with complicated UTI (cUTI), and 48 (6%) with pyelonephritis. Furthermore, 125 patients (15.6%) were diagnosed with SSTI: 59 (7.4%) purulent and 66 (8.3%) nonpurulent. 31 (3.9%) patients had an IAI. The most commonly used antibiotics were cephalosporins in 536 patients (67%), azithromycin in 252 patients (31.5%), and fluroquinolones and tetracyclines in 231 patients (28.9%). Fluroquinolones were the most frequent antibiotic prescribed at discharge in 210 patients (26.3%). Figure 1 displays the average DOT relative to specific indications. The median duration of total antibiotic therapy exceeded institutional guideline recommendation for multiple conditions, including AECOPD (7 days vs recommended 5 days), CAP with COPD (8.3 vs 7 days ), CAP without COPD (7.7 vs 5 days), and pyelonephritis (11 vs 7–10 days). Also, 269 (33.6%) patients received unnecessary therapy; 218 (27.3%) of these were due to excess duration. Conclusions: Among a cross-section of hospitalized patients, the average DOT, including after discharge, exceeded the optimal therapy for many patients. Further understanding of patterns and influences of antibiotic prescribing is necessary to design effective AMS interventions for improvement.Funding: This work was completed under CDC contract number 200-2018-02928.Disclosures: None

scholarly journals Rural–urban differences in antibiotic prescribing for uncomplicated urinary tract infection

2021 ◽  
pp. 1-8
Author(s):  
Abbye W. Clark ◽  
Michael J. Durkin ◽  
Margaret A. Olsen ◽  
Matthew Keller ◽  
Yinjiao Ma ◽  
...  
Keyword(s):  
Urinary Tract Infection ◽  
Urinary Tract ◽  
Tract Infection ◽  
Rural Women ◽  
Antibiotic Use ◽  
Antibiotic Prescribing ◽  
Oral Antibiotic ◽  
Uncomplicated Urinary Tract Infection ◽  
Urban Status ◽  
To Receive

Abstract Objective: To examine rural–urban differences in temporal trends and risk of inappropriate antibiotic use by agent and duration among women with uncomplicated urinary tract infection (UTI). Design: Observational cohort study. Methods: Using the IBM MarketScan Commercial Database (2010–2015), we identified US commercially insured women aged 18–44 years coded for uncomplicated UTI and prescribed an oral antibiotic agent. We classified antibiotic agents and durations as appropriate versus inappropriate based on clinical guidelines. Rural–urban status was defined by residence in a metropolitan statistical area. We used modified Poisson regression to determine the association between rural–urban status and inappropriate antibiotic receipt, accounting for patient- and provider-level characteristics. We used multivariable logistic regression to estimate trends in antibiotic use by rural–urban status. Results: Of 670,450 women with uncomplicated UTI, a large proportion received antibiotic prescriptions for inappropriate agents (46.7%) or durations (76.1%). Compared to urban women, rural women were more likely to receive prescriptions with inappropriately long durations (adjusted risk ratio 1.10, 95% CI, 1.10–1.10), which was consistent across subgroups. From 2011 to 2015, there was slight decline in the quarterly proportion of patients who received inappropriate agents (48.5% to 43.7%) and durations (78.3% to 73.4%). Rural–urban differences varied over time by agent (duration outcome only), geographic region, and provider specialty. Conclusions: Inappropriate antibiotic prescribing is quite common for the treatment of uncomplicated UTI. Rural women are more likely to receive inappropriately long antibiotic durations. Antimicrobial stewardship interventions are needed to improve outpatient UTI antibiotic prescribing and to reduce unnecessary exposure to antibiotics, particularly in rural settings.

scholarly journals Association Between Outpatient Antibiotic Prescribing Practices and Community-Associated Clostridium difficile Infection

2015 ◽  
Vol 2 (3) ◽  
Author(s):  
Raymund Dantes ◽  
Yi Mu ◽  
Lauri A. Hicks ◽  
Jessica Cohen ◽  
Wendy Bamberg ◽  
...  
Keyword(s):  
Clostridium Difficile ◽  
Healthcare Providers ◽  
Population Level ◽  
Healthcare Facility ◽  
Antibiotic Use ◽  
Antibiotic Prescribing ◽  
Oral Antibiotic ◽  
Prescribing Practices ◽  
Active Population ◽  
Prescription Rates

Abstract Background.  Antibiotic use predisposes patients to Clostridium difficile infections (CDI), and approximately 32% of these infections are community-associated (CA) CDI. The population-level impact of antibiotic use on adult CA-CDI rates is not well described. Methods.  We used 2011 active population- and laboratory-based surveillance data from 9 US geographic locations to identify adult CA-CDI cases, defined as C difficile-positive stool specimens (by toxin or molecular assay) collected from outpatients or from patients ≤3 days after hospital admission. All patients were surveillance area residents and aged ≥20 years with no positive test ≤8 weeks prior and no overnight stay in a healthcare facility ≤12 weeks prior. Outpatient oral antibiotic prescriptions dispensed in 2010 were obtained from the IMS Health Xponent database. Regression models examined the association between outpatient antibiotic prescribing and adult CA-CDI rates. Methods.  Healthcare providers prescribed 5.2 million courses of antibiotics among adults in the surveillance population in 2010, for an average of 0.73 per person. Across surveillance sites, antibiotic prescription rates (0.50–0.88 prescriptions per capita) and unadjusted CA-CDI rates (40.7–139.3 cases per 100 000 persons) varied. In regression modeling, reducing antibiotic prescribing rates by 10% among persons ≥20 years old was associated with a 17% (95% confidence interval, 6.0%–26.3%; P = .032) decrease in CA-CDI rates after adjusting for age, gender, race, and type of diagnostic assay. Reductions in prescribing penicillins and amoxicillin/clavulanic acid were associated with the greatest decreases in CA-CDI rates. Conclusions and Relevance.  Community-associated CDI prevention should include reducing unnecessary outpatient antibiotic use. A modest reduction of 10% in outpatient antibiotic prescribing can have a disproportionate impact on reducing CA-CDI rates.

scholarly journals 39. Impact of Antimicrobial Stewardship Interventions in a Community Hospital setting: An Interrupted Times Analysis

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S141-S142
Author(s):  
Jason Li ◽  
Ken Chan ◽  
Hina Parvez ◽  
Margaret Gorlin ◽  
Miriam A Smith
Keyword(s):  
Antimicrobial Stewardship ◽  
Community Hospital ◽  
Hospital Setting ◽  
Interrupted Time Series ◽  
Antibiotic Use ◽  
Antimicrobial Use ◽  
Intervention Period ◽  
Prospective Audit ◽  
Post Intervention ◽  
The Impact

Abstract Background Community hospitals have fewer resources for antimicrobial stewardship programs (ASP) compared to larger tertiary hospitals. At our 312-bed community hospital, Long Island Jewish Forest Hills/Northwell, a combination of modified preauthorization, prospective audit feedback, and ASP education was implemented starting in August 2019 (Monday through Friday 9 am to 5 pm). Methods This retrospective study evaluated the impact of ASP interventions on the rate of targeted antimicrobial use over a 7 month pre- vs 7 month post- intervention period (Aug 2018 to Feb 2019 vs Aug 2019 to Feb 2020). Targeted antimicrobials included piperacillin-tazobactam, vancomycin, daptomycin, and carbapenems. The primary outcome was the monthly mean for overall targeted antimicrobial use measured by the rate of antimicrobial days per 1000 days present. Secondary outcomes were the individual rates of antimicrobial days per 1000 days present for each of the targeted antimicrobials, and the hospital’s overall standardized antimicrobial administration ratio (SAAR). Data were analyzed as a segmented regression of interrupted time series. Results Pre-intervention, there was an increasing trend (positive slope, p&lt; 0.05) in the monthly mean, hospital SAAR, vancomycin and piperacillin-tazobactam use. Post-intervention, there was a significant change in slope for these same metrics, indicating a decrease in the mean use. Immediate impact of ASP interventions, measured by the difference in antibiotic use between the end of each intervention period, was visually evident in all cases except carbapenems (Fig. 1 through 4). The immediate impact on the overall monthly mean represented a significant reduction in the rate of antimicrobial days per 1000 days present, -12.72 (CI -21.02 to -4.42, P &lt; 0.0066). The pre- vs post- ASP gap for all measures was negative and consistent with fewer days of antibiotic use immediately following intervention. Conclusion A targeted, multifaceted ASP intervention utilizing modified preauthorization, prospective audit feedback, and education significantly reduced antibiotic use in a community hospital. Disclosures All Authors: No reported disclosures

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