Appropriateness of Antibiotic Prescribing in Patients Discharged From a Community Hospital Emergency Department

IMPORTANCE: Every year, thousands of emergency department (ED) visits result in patients being discharged with oral antibiotic prescriptions. Published studies that assess the appropriateness of these antibiotic regimens are limited. PURPOSE: The purpose of this study was to examine the appropriateness of antibiotic prescriptions written for patients discharged from a community hospital’s ED. ENDPOINTS: The primary objective was to determine the overall percent of appropriate antibiotic prescriptions for patients discharged from the ED. Secondary objectives included the following: identify reasons for inappropriateness categorized by antibiotic selection, dose, duration, and allergies; identify the most common antibiotics prescribed inappropriately as well as the most common disease states that led to inappropriate prescribing of antibiotics; and analyze prescribing trends based on provider type and time of day the prescription was written. STUDY DESIGN AND METHODS: Patients eligible for inclusion were adults age 18 and older who presented to the ED during four chosen weeks in 2019 and who were discharged with oral antibiotics. Extracted electronic health record data was reviewed to identify the discharge diagnosis for each patient that meets the inclusion criteria. Pertinent information gathered from the patients’ medical records along with a validated antimicrobial assessment tool were utilized to determine the level of appropriateness of the prescribed antibiotic regimens. RESULTS: A total of 76% of the prescribed antibiotics were appropriate, 16% were inappropriate, and the remaining 8% were not assessable. Duration was the most common reason for a regimen to not be optimal. The most frequently inappropriately prescribed antibiotics included cephalexin (but it is noted cephalexin was included in almost half of the antibiotic regimens in this study), clindamycin, and azithromycin. Infections that were most frequently treated inappropriately were skin and soft tissue infections, dental infections, and sinusitis. Overall, medical residents prescribed the highest percent of appropriate regimens, and the time of day that had the highest percent of appropriate prescriptions was third shift (11 p.m. to 7 a.m.). CONCLUSION AND RELEVANCE: Almost half of all the nonoptimal antibiotic regimens had an excessive duration. Targeted local education efforts and future clinical decision support can facilitate appropriate prescribing of discharge antibiotics from the ED, ultimately improving antimicrobial stewardship within the community.

Antimicrobial Usage and Resistance in Makkah Region Hospitals: A Regional Point Prevalence Survey of Public Hospitals

(1) Background: Inappropriate use of antimicrobials and subsequently rise of antimicrobial resistance (AMR) remains a major public health priority. Over-prescribing of broad-spectrum antibiotics is one of the main contributing factors for the emergence of AMR. We sought to describe antimicrobial prescribing trends among patients in public hospitals in Makkah hospitals. (2) Method: We undertook a point prevalence survey (PPS) in six hospitals in Makkah, Saudi Arabia, from January 2019 to July 2019. The survey included all the inpatients receiving antimicrobials on the day of PPS. Data was collected using the Global point prevalence survey (PPS) tool developed by the University of Antwerp, Belgium. (3) Results: Of 710 hospitalized patients, 447 patients (61.9%) were treated with one or more antimicrobials during the study period. The average bed occupancy among six hospitals was 74.4%. The majority of patients received antimicrobials parenterally (90.3%). Of the total prescribed antimicrobials, 415 (53.7%) antimicrobials were used in medical departments, 183 (23.7%) in surgical departments, and 175 (22.6%) in ICUs. Pneumonia (17.3%), skin and soft tissue infections (10.9%), and sepsis (6.6.%) were three common clinical indications. Ceftriaxones were the most commonly used antibiotics that were prescribed in 116 (15%) of patients, followed by piperacillin, with an enzyme inhibitor in 84 (10.9%). (4) Conclusion: There was a high prevalence of antibiotic use in the hospitals of Makkah, which could be a potential risk factor for the incidence of resistant strains, particularly MRSA infection. Public health decision-makers should take these findings into consideration to update national policies for antibiotic use in order to reduce the risks of further increases of AMR.

Inappropriate antibiotic use for respiratory infections in outpatient settings

Background: Overuse of antibiotics is a significant problem in low- and middle-income countries where recommended treatment guidelines are not routinely practiced, resulting in antimicrobial resistance. Acute respiratory tract infections, mostly viral in origin, remain the clinical category for most commonly prescribed antibiotics. Due to the lack of local evidence about antibiotic prescribing trends in such infections, this study was conducted to evaluate the prescribing patterns in general and antibiotic prescribing trends specifically in prescriptions with the diagnosis of acute respiratory infections in district Mirpur of Azad Kashmir. Patients and methods: A prospective cross-sectional study carried out in the Department of Pharmacology and Therapeutics, Army Medical College, Rawalpindi, and outpatient departments of public health facilities in district Mirpur, Kashmir, from Aug to Oct 2020. Data were collected from 10 different public health facilities in District Mirpur, Kashmir including, three rural health centers (RHC) and five basic health units (BHU). Prescribing pattern analysis by objective observations of the prescriptions after patient-physician encounter against the World Health Organization defined core prescribing indicators. The appropriateness of antibiotic use was analyzed against clinical practice guidelines. IBM SPSS Statistics for Windows, Version 26 was used for data analysis. Descriptive analysis was done to find frequencies and percentages for categorical data and means and standard deviation for continuous data. Results: Total number of prescriptions evaluated was 144. Number of prescriptions containing antibiotics was 118 (82%) (standard, 20 - 26.8%). Inappropriate use of antibiotics was seen in 78% of cases where no antibiotics were indicated. The average number of medicines per prescription was 3.11 (standard, 2.1), whereas 79% of medicines prescribed were from the national essential medicine list (standard, 100%). Only 2.5% (standard, 100%) of the medications were prescribed with generic names. Conclusion: This study shows an inappropriate and overuse of antibiotics for acute respiratory tract infections, indicating a lack of adherence to core prescribing indicators and clinical guidelines by the physicians in outpatient clinics of Mirpur.

Long-acting injectable antipsychotic (LAI) prescribing trends during COVID-19 restrictions in Canada: a retrospective observational study

Background The COVID-19 pandemic has had significant impacts on how mental health services are delivered to patients throughout Canada. The reduction of in-person healthcare services have created unique challenges for individuals with psychotic disorders that require regular clinic visits to administer and monitor long-acting injectable antipsychotic medications. Methods To better understand how LAI usage was impacted, national and provincial patient-level longitudinal prescribing data from Canadian retail pharmacies were used to examine LAI prescribing practices during the pandemic. Prescribing data on new starts of medication, discontinuations of medications, switches between medications, antipsychotic name, concomitant medications, payer plan, gender and age were collected from January 2019 to December 2020 for individuals ≥18-years of age, and examined by month, as well as by distinct pandemic related epochs characterized by varying degrees of public awareness, incidence of COVID-19 infections and public health restrictions. Results National, and provincial level data revealed that rates of LAI prescribing including new starts, discontinuations and switches between LAI products remained highly stable (i.e., no statistically significant differences) throughout the study period. Conclusions Equal numbers of LAI new starts and discontinuations prior to and during the pandemic suggests prescribing of LAI antipsychotics, for those already in care, continued unchanged throughout the pandemic. The observed consistency of LAI prescribing contrasts with other areas of healthcare, such as cardiovascular and diabetes care, which experienced decreases in medication prescribing during the COVID-19 pandemic.

Changes in diabetes prescription patterns following Affordable Care Act Medicaid expansion

IntroductionMost patients with diabetes mellitus are prescribed medications to control their blood glucose. The implementation of the Affordable Care Act (ACA) led to improved access to healthcare for patients with diabetes. However, impact of the ACA on prescribing trends by diabetes drug category is less clear. This study aims to assess if long-acting insulin and novel agents were prescribed more frequently following the ACA in states that expanded Medicaid compared with non-expansion states.Research design and methodsIn this analysis of a natural experiment, prescriptions reimbursed by Medicaid (US public insurance) for long-acting insulins, metformin, and novel agent medications (DPP4 inhibitors, sodium/glucose cotransporter 2 inhibitor antagonists, and glucagon-like peptide-1 receptor agonists) from 2012 to 2017 were obtained from public records. For each medication category, we performed difference-in-differences (DID) analysis modeling change in rate level from pre-ACA to post-ACA in Medicaid expansion states relative to Medicaid non-expansion states.ResultsExpansion and non-expansion states saw a decline in both metformin and long-acting insulin prescriptions per 100 enrollees from pre-ACA to post-ACA. These decreases were larger in non-expansion states relative to expansion states (metformin: absolute DID = +0.33, 95% CI=0.323 to 0.344) and long-acting insulin (absolute DID: +0.11; 95% CI=0.098 to 0.113). Novel agent prescriptions in expansion states (+0.08 per 100 enrollees) saw a higher absolute increase per 100 Medicaid enrollees than in non-expansion states (absolute DID= +0.08, 95% CI=0.079 to 0.086).ConclusionsThere was a greater absolute increase for prescriptions of novel agents in expansion states relative to non-expansion states after accounting for number of enrollees. Reducing administrative barriers and improving the ability of providers to prescribe such newer therapies will be critical for caring for patients with diabetes—particularly in Medicaid non-expansion states.

Trends in Prescribing Patterns and Drug Related Problems of Kidney Disease Patients

Objective: The aim of the study was the evaluation of drug-related problems, including drug-drug interactions, dose error, use of nephrotoxic drugs and polypharmacy with special emphasis on kidney disease patients. Methods: Descriptive cross-sectional study from January to April 2019 was carried out in nephrology ward of Ayub teaching hospital, Abbottabad, Pakistan to review patient’s medication orders for evaluation of drug-related problems. Doses of medicine and drug-drug interactions were evaluated by comparing it with standard protocols given in BNF and Lexicomp software. Prescriptions were also evaluated for polypharmacy and use of nephrotoxic drugs. Results: Out of 131 patients, majority were males 72 (55%). Drug-drug interactions were found in 69 (52.7%) patients among which the highest percentage was of the moderate drug-drug interaction (48.1%) followed by major and minor drug-drug interaction (29.8% and 20.6% respectively). Incidence of polypharmacy (51.9%) and use of nephrotoxic drug (77%) was high while dose error was low up to 10.7%. All the drug-related problems were present with a high percentage in patients with CKD as compare to other kidney diseases. There was significant association of CKD stages with DDIs, polypharmacy, dose error and prescribing drugs. There was significant positive correlation among DDIs-polypharmacy and prescribing drugs was noted in the study. Conclusion: The higher incidence of drug-related problems in our study setting reflects irrational prescribing trends and deficiency of professional staff dealing kidney disease patients. Key Words: kidney disease, drug-drug interactions, polypharmacy, nephrotoxic drugs, dose error. Continuous...

1421. Empiric Fluoroquinolone Prescribing Trends for Cystitis in Primary Care

Background Understanding outpatient antibiotic prescribing practices for urinary tract infections (UTIs) is vital in guiding future stewardship initiatives. Focusing on fluoroquinolones (FQs) is of value as FQs are commonly prescribed, but not recommended as first line therapy by the Infectious Diseases Society of America (IDSA) cystitis treatment guidelines and are also associated with multiple adverse effects. Boxed warnings state FQs should be reserved for patients with no alternative treatment options, due to risk of aortic dissection, C. difficile infection, antimicrobial resistance as well as tendon, joint, muscle, and nervous system damage. Methods This descriptive study assessed rates of guideline concordant empiric FQ prescribing from March 1 to June 30, 2019. Adult women prescribed an oral FQ for acute uncomplicated cystitis at a primary care clinic were included. Men, pregnant or breastfeeding women, and patients with pyelonephritis, urologic abnormality, or antibiotic use in the past 30 days were excluded. The primary outcome was the incidence of IDSA guideline concordance among FQs empirically prescribed. Guideline concordant empiric FQ therapy was defined as correct drug, dose, duration and frequency per IDSA guidelines when no first line drug is indicated due to allergy, adverse effect, previous treatment failure or most recent previous urine culture showing bacterial resistance. Secondary outcomes were mean dose (mg), mean duration (days) and incidence of adverse effects. Results Of 95 FQ prescriptions included, none met the primary outcome definition. Rates of guideline concordance for each component of the primary outcome definition were 6% for drug selection, 38% for dose, 37% for duration, and 99% for frequency. Mean daily doses exceeded guideline recommended doses by 62% and 100% for ciprofloxacin and levofloxacin, respectively. Mean duration was 5 days, 66% longer than 3 days as recommended by IDSA guidelines. Of 66 patients with documented follow up within 30 days, 3 (5%) experienced an adverse effect, and none developed C. difficile infection. Conclusion Current outpatient FQ prescribing for acute uncomplicated cystitis does not align with IDSA guidelines. Multifaceted antimicrobial stewardship initiatives are required to improve appropriate FQ use. Disclosures All Authors: No reported disclosures

94. Implementation of Antibiotic Prescribing Scorecards in the Ambulatory Care Setting

Background Up to 56% of antibiotics prescribed in the ambulatory setting in the United States are inappropriately prescribed, with 30% of those determined to be unnecessary. In order to increase transparency and education about antibiotic prescribing in our ambulatory clinics at our institution, we implemented quarterly scorecards demonstrating antibiotic prescribing trends for primary care prescribers. Methods This pre-post interventional study analyzed the impact of prescriber scorecards on antibiotic prescribing, with the intervention consisting of real-time education and presentation of baseline data via scorecards. Prescribers were educated on the scorecard project via live meetings in Nov-Dec 2020. In Dec 2020, prescribers were sent individual emails describing their baseline antibiotic prescription rate (defined as number of prescriptions per 100 patient encounters), de-identified comparison data for other prescribers within their individual clinic, and average rate of the top 10% of prescribers with the lowest prescription rates. Baseline data was from prescriptions dated Jan-Mar 2020. The email also explained the project and shared that quarterly scorecards would be distributed in 2021. Baseline data was compared to prescription data from Jan-Mar 2021. Knowing the COVID-19 pandemic resulted in significantly fewer encounters for respiratory infections, data was also analyzed with respiratory diagnoses removed from the dataset. Results In the pre-intervention period, 11,769 antibiotics were prescribed during 92,239 encounters for a prescription rate of 12.8 (95%CI: 12.5-13.0). Of 96,449 encounters in the post-intervention period, 7,326 antibiotics were prescribed for a rate of 7.6 (95%CI: 7.4-7.8; p< 0.0001). When respiratory diagnoses were removed, prescription rates were 6.1 (95%CI: 5.9-6.2) in the pre-group, compared to 6.3 (95%CI: 6.1-6.5; p=0.0546). When analyzed by prescriber, significant decreases were seen in prescriptions by physicians (5.8 vs 5.4, p=0.0035) while increases were seen in prescriptions by advanced practice prescribers. Conclusion Antibiotic scorecards sent to prescribers may result in reduced antibiotic prescribing, but further research is needed to elucidate the impact of the scorecards in light of the COVID-19 pandemic. Disclosures All Authors: No reported disclosures