Pharmacist-Driven Implementation of Outpatient Antibiotic Prescribing Algorithms Improves Guideline Adherence in the Emergency Department

2020 ◽  
pp. 089719002093097
Author(s):  
Kristin Stoll ◽  
Erik Feltz ◽  
Steven Ebert
Keyword(s):  
Emergency Department ◽  
Clinical Practice ◽  
Guideline Adherence ◽  
Inappropriate Prescribing ◽  
Community Acquired Pneumonia ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Duration Of Therapy ◽  
Tract Infections ◽  
Selection Of

Background: Inappropriate prescribing of antibiotics has been identified as the most important modifiable risk factor for antimicrobial resistance. Objective: The purpose of this project was to improve guideline adherence and promote optimal use of outpatient antibiotics in the emergency department (ED). Methods: Prescribing algorithms for community-acquired pneumonia (CAP), skin and soft tissue infections (SSTI), and urinary tract infections (UTI) were developed to integrate clinical practice guideline recommendations with local ED antibiogram data. Outcomes were evaluated through chart review of patients prescribed outpatient antibiotics by ED providers. The primary outcome was adherence to clinical practice guidelines, defined as the selection of an appropriate antibiotic agent, dose, and duration of therapy for each patient discharged. Results: When compared to patients discharged from the ED prior to algorithm implementation (N = 325), the post-implementation group (N = 353) received more antibiotic prescriptions that were completely guideline adherent (61.5% vs 11.7%, P < .00001). Post-implementation discharge orders demonstrated improvement in the selection of an appropriate agent (87.3% vs 45.5%, P < .00001), dose (91.5% vs 77.2%, P < .00001), and duration of therapy (71.1% vs 39.1%, P < .01). Additionally, fluoroquinolone prescribing rates were reduced (2.3% vs 12.3%, P < .00001). A reduction in all-cause 30-day returns to the ED or urgent care was observed (15.3% vs 21.5%, P = .036). Conclusion: Pharmacist-driven implementation of antibiotic prescribing algorithms improved guideline adherence in the outpatient treatment of CAP, SSTI, and UTI.

scholarly journals 2066. Development and Implementation of Prescribing Algorithms for Antibiotics on Discharge from the Emergency Department

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S696-S696 ◽  
Author(s):  
Kristin Stoll ◽  
Erik Feltz ◽  
Steven C Ebert
Keyword(s):  
Emergency Department ◽  
Clinical Practice ◽  
Guideline Adherence ◽  
Community Acquired Pneumonia ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Duration Of Therapy ◽  
Tract Infections ◽  
Algorithm Implementation ◽  
Selection Of

Abstract Background In the emergency department (ED), rapid decision-making and frequent distractions are often challenging to implementing effective antimicrobial stewardship. The purpose of this project is to improve guideline adherence and promote optimal use of outpatient antibiotic therapy for community-acquired infections. Methods Prescribing algorithms were developed to integrate clinical practice guideline recommendations with emergency department-specific antibiogram data. Algorithms for treating community-acquired pneumonia (CAP), skin and soft-tissue infections (SSTI), and urinary tract infections (UTI) were made available throughout the ED. Outcomes were evaluated through a chart review of patients prescribed empiric outpatient antibiotics for CAP, SSTI, or UTI by ED providers. Patients were excluded if they were <18 years old, pregnant, or taking antibiotics prior to arrival. The primary outcome was rate of adherence to clinical practice guidelines, defined as the selection of an appropriate antibiotic agent, dose, and duration of therapy for each patient discharged. Secondary outcomes included the rate of fluoroquinolone use, as well as all-cause 30-day returns to the ED or urgent care. Results When compared with patients discharged from the ED prior to algorithm implementation (N = 325), the post-implementation group (N = 172) received more antibiotic prescriptions that were completely guideline adherent (57.0% vs. 11.7%, P < 0.01). Post-implementation discharge orders demonstrated improvement in the selection of an appropriate agent (86.6% vs. 45.5%, P < 0.01), dose (89.0% vs. 77.2%, P < 0.01), and duration of therapy (63.4% vs. 39.1%, P < 0.01). Additionally, fluoroquinolone prescribing rates in this population were reduced (2.9% vs. 12.3%, P < 0.01). In the post-implementation patients who presented at least 30 days prior to analysis (N = 124), a reduction in all-cause 30-day returns to the ED or urgent care was observed (12.9% vs. 21.5%, P < 0.05). Conclusion Implementation of antibiotic prescribing algorithms improved guideline adherence in the outpatient treatment of CAP, SSTI, and UTI. By developing prescribing algorithms, pharmacists may reduce the unnecessary use of broad-spectrum antibiotics and prevent patient returns to the ED. Disclosures All authors: No reported disclosures.

scholarly journals 1633. A Multifaceted Intervention to Improve Prescribing for Acute Respiratory Infection in Adults and Children in Emergency Department and Urgent Care Settings (MITIGATE Trial)

2018 ◽  
Vol 5 (suppl_1) ◽  
pp. S43-S43 ◽  
Author(s):  
Kabir Yadav ◽  
Daniella Meeker ◽  
Rakesh Mistry ◽  
Jason Doctor ◽  
Katherine Fleming-Dutra ◽  
...  
Keyword(s):  
Emergency Department ◽  
Health System ◽  
Respiratory Infection ◽  
Acute Respiratory Infection ◽  
Inappropriate Prescribing ◽  
Antibiotic Use ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Adults And Children ◽  
Specific Implementation

Abstract Background Antibiotics are prescribed in approximately half of emergency department (ED) and urgent care center (UCC) visits for antibiotic inappropriate or presumed viral acute respiratory infection (ARI). Unnecessary antibiotic use increases adverse events, antibiotic resistance, and healthcare costs. Antibiotic stewardship in the ED and UCC requires specific implementation tailored to these unique settings. Objective. To evaluate the comparative effectiveness of patient and provider education adapted for the acute care setting (adapted intervention) to an intervention with behavioral nudges and individual peer comparisons (enhanced intervention), on reducing inappropriate antibiotic use for ARI in EDs and UCCs. Methods Pragmatic, cluster randomized clinical trial conducted in 3 academic health systems (1 pediatric-only, 2 serving adults and children) that included 5 adult and pediatric EDs and 4 UCCs. Sites were block randomized by health system, and providers at each site assigned to receive the adapted or enhanced intervention. Implementation science strategies were employed to tailor interventions at each site. The main outcome was the proportion of antibiotic inappropriate ARI diagnosis visits that received an antibiotic. We estimated a hierarchical mixed effects logistic regression model for visits that occurred between November and February for 2016–2017 (baseline) and 2017–2018 (intervention), controlling for organization and provider fixed effects. Results Across all sites, there were 45,160 ARI visits among 534 providers, with overall antibiotic prescribing at 2.6%; the pediatric-only system had a lower baseline rate (1.6%) compared with the other 2 systems (5.0% and 7.1%), P &lt; 0.001). Despite the unusually low rate, we found a significant reduction in inappropriate prescribing after adjusting for health-system and provider-level effects from 2.6% to 1.4 % (odds ratio 0.52; 0.38–0.72). Reductions in prescribing between the 2 interventions were in the expected direction, but not significantly different (P &lt; 0.062). Conclusion Implementation of antimicrobial stewardship for ARI is feasible and effective in the ED and UCC settings. The enhanced behavioral nudging methods were not more effective in high-performance settings. Disclosures All authors: No reported disclosures.

scholarly journals Utilizing Behavioral Science to Improve Antibiotic Prescribing in Rural Urgent Care Settings

2020 ◽  
Vol 7 (7) ◽  
Author(s):  
Patricia L Cummings ◽  
Rita Alajajian ◽  
Larissa S May ◽  
Russel Grant ◽  
Hailey Greer ◽  
...  
Keyword(s):  
Behavioral Interventions ◽  
Inappropriate Prescribing ◽  
The United States ◽  
Urgent Care ◽  
Resistant Bacteria ◽  
Antibiotic Prescribing ◽  
Intervention Period ◽  
Its Analysis ◽  
Tract Infections ◽  
Inappropriate Prescriptions

Abstract Background Antibiotic-inappropriate prescribing for acute respiratory tract infections (ARTI) is 45% among urgent care centers (UCCs) in the United States. Locally in our UCCs, antibiotic-inappropriate prescribing for ARTI is higher—over 70%. Methods We used a quasi-experimental design to implement 3 behavioral interventions targeting antibiotic-inappropriate/non-guideline-concordant prescribing for ARTI at 3 high-volume rural UCCs and analyzed prescribing rates pre- and post-intervention. The 3 interventions were (1) staff/patient education, (2) public commitment, and (3) peer comparison. For peer comparison, providers were sent feedback emails with their prescribing data during the intervention period and a blinded ranking email comparing them with their peers. Providers were categorized as “low prescribers” (ie,  ≤23% antibiotic-inappropriate prescriptions based off the US National Action Plan for Combating Antibiotic Resistant Bacteria 2020 goal) or “high prescribers” (ie,  ≥45%—the national average of antibiotic-inappropriate prescribing for ARTI). An interrupted time series (ITS) analysis compared prescribing for ARTI (the primary outcome) over a 16-month period before the intervention and during the 6-month intervention period, for a total of 22 months, across the 3 UCCs. Results Fewer antibiotic-inappropriate prescriptions were written during the intervention period (57.7%) compared with the pre-intervention period (72.6%) in the 3 UCCs, resulting in a 14.9% absolute decrease in percentage of antibiotic-inappropriate prescriptions. The ITS analysis revealed that the rate of antibiotic-inappropriate prescribing was statistically significantly different pre-intervention compared with the intervention period (95% confidence interval, –4.59 to –0.59; P = .014). Conclusions In this sample of rural UCCs, we reduced antibiotic-inappropriate prescribing for ARTI using 3 behavioral interventions.

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&lt; 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 Development of an Electronic Algorithm to Identify Inappropriate Antibiotic Prescribing for Pediatric Pharyngitis

2020 ◽  
Vol 41 (S1) ◽  
pp. s188-s189
Author(s):  
Jeffrey Gerber ◽  
Robert Grundmeier ◽  
Keith Hamilton ◽  
Lauri Hicks ◽  
Melinda Neuhauser ◽  
...  
Keyword(s):  
Predictive Value ◽  
Gold Standard ◽  
Antibiotic Stewardship ◽  
Chart Review ◽  
Antibiotic Use ◽  
Audit And Feedback ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Tract Infections ◽  
The Impact

Background: Antibiotic overuse contributes to antibiotic resistance and unnecessary adverse drug effects. Antibiotic stewardship interventions have primarily focused on acute-care settings. Most antibiotic use, however, occurs in outpatients with acute respiratory tract infections such as pharyngitis. The electronic health record (EHR) might provide an effective and efficient tool for outpatient antibiotic stewardship. We aimed to develop and validate an electronic algorithm to identify inappropriate antibiotic use for pediatric outpatients with pharyngitis. Methods: This study was conducted within the Children’s Hospital of Philadelphia (CHOP) Care Network, including 31 pediatric primary care practices and 3 urgent care centers with a shared EHR serving >250,000 children. We used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify encounters for pharyngitis at any CHOP practice from March 15, 2017, to March 14, 2018, excluding those with concurrent infections (eg, otitis media, sinusitis), immunocompromising conditions, or other comorbidities that might influence the need for antibiotics. We randomly selected 450 features for detailed chart abstraction assessing patient demographics as well as practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for evaluating the electronic algorithm. Criteria for appropriate use included streptococcal testing, use of penicillin or amoxicillin (absent β-lactam allergy), and a 10-day duration of therapy. Results: In 450 patients, the median age was 8.4 years (IQR, 5.5–9.0) and 54% were women. On chart review, 149 patients (33%) received an antibiotic, of whom 126 had a positive rapid strep result. Thus, based on chart review, 23 subjects (5%) diagnosed with pharyngitis received antibiotics inappropriately. Amoxicillin or penicillin was prescribed for 100 of the 126 children (79%) with a positive rapid strep test. Of the 126 children with a positive test, 114 (90%) received the correct antibiotic: amoxicillin, penicillin, or an appropriate alternative antibiotic due to b-lactam allergy. Duration of treatment was correct for all 126 children. Using the electronic algorithm, the proportion of inappropriate prescribing was 28 of 450 (6%). The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were sensitivity (99%, 422 of 427); specificity (100%, 23 of 23); positive predictive value (82%, 23 of 28); and negative predictive value (100%, 422 of 422). Conclusions: For children with pharyngitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. Future work should validate this approach in other settings and develop and evaluate the impact of an audit and feedback intervention based on this tool.Funding: NoneDisclosures: None

scholarly journals Utilizing Behavioral Science to Improve Antibiotic Prescribing in Rural Urgent Care Settings

2020 ◽  
Vol 41 (S1) ◽  
pp. s506-s507
Author(s):  
Patricia Cummings ◽  
Rita Alajajian ◽  
Larissa May ◽  
Russel Grant ◽  
Hailey Greer ◽  
...  
Keyword(s):  
Patient Education ◽  
Influenza Season ◽  
Action Plan ◽  
Inappropriate Prescribing ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Intervention Period ◽  
National Action Plan ◽  
Its Analysis ◽  
Urgent Care Centers

Background: The rate of inappropriate antibiotic prescribing for acute respiratory tract infections (ARTIs) is 45% among urgent care centers across the United States. To contribute to the US National Action Plan for Combating Antibiotic-Resistant Bacteria, which aims to decrease rates of inappropriate prescribing, we implemented 2 behavioral nudges using the evidence-based MITIGATE tool kit from urgent-care settings, at 3 high-volume, rural, urgent-care centers. Methods: An interrupted time series (ITS) analysis was conducted comparing a preintervention phase during the 2017–2018 influenza season (October through March) to the intervention phase during the 2018–2019 influenza season. We compared the rate of inappropriate or non–guideline-concordant antibiotic prescribing for ARTIs across 3 urgent-care locations. The 2 intervention behavioral nudges were (1) staff and patient education and (2) peer comparison. Provider education included presentations at staff meetings and grand rounds, and patient education print materials were distributed to the 3 locations coupled with news media and social media. We utilized the CDC “Be Antibiotics Aware” campaign materials, with our hospital’s logo added, and posted them in patient rooms and waiting areas. For the peer comparison behavioral intervention, providers were sent individual feedback e-mails with their prescribing data during the intervention period and a blinded ranking e-mail in which they were ranked in comparison to their peers. In the blinded ranking email, providers were placed into categories of “low prescribers,” those with a ≤23% inappropriate antibiotic prescribing rate based on the US National Action Plan for Combating Antibiotic-Resistance Bacteria 2020 goal, or “high prescribers,” those with a rate greater than the national average (45%) of inappropriate antibiotic prescribing for ARTI. Results: Our results show that fewer inappropriate antibiotic prescriptions were written during the intervention period (58.8%) than during the preintervention period (73.0%), resulting in a 14.5% absolute decrease in rates of inappropriate prescribing among urgent-care locations over a 6-month period (Fig. 1). The largest percentage decline in rates was seen in the month of April (−35.8%) when compared to April of the previous year. The ITS analysis revealed that the rate of inappropriate prescribing was statistically significantly different during the preintervention period compared to the intervention period (95% CI, −4.59 to −0.59; P = .0142). Conclusions: Using interventions outlined in the MITIGATE tool kit, we were able to reduce inappropriate antibiotic prescribing for ARTI in 3 rural, urgent-care locations.Funding: NoneDisclosures: Larissa May repo, Speaking honoraria-Cepheid Research grants-Roche Consultant-BioRad Advisory Board-Qvella Consultant-Nabriva

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 Antibiotic stewardship: ripartiamo dalla pratica clinica

2018 ◽  
Vol 85 (1_suppl) ◽  
pp. S20-S23
Author(s):  
Carlo Tascini
Keyword(s):  
Clinical Practice ◽  
Antibiotic Stewardship ◽  
Multidrug Resistant ◽  
Resistance Rate ◽  
Everyday Clinical Practice ◽  
Limited Perspective ◽  
Tract Infections ◽  
Resistance Rates ◽  
Real Challenge ◽  
Selection Of

Antibiotic stewardship: a milestone in everyday clinical practice Infectious diseases caused by multi-resistant pathogens are increasing worldwide and are challenging for clinicians, also in urological setting. The alarming situation is worsened by the limited perspective of new antibiotic developments. Several authors demonstrated that in Italy we have alarming data about resistance rates: in Campania about 58% of Escherichia coli are resistant to fluroquinolones, as 46% to sulfamethoxazole-trimethoprim. On the other hand, the resistance rate against fosfomycin is still low less than 5%. More alarming data are reported about Klebsiella pneumoniae: resistance rate to flurquinolones 65% and 58% to sulfamethoxazole-trimethoprim. A continuing uncritical, non-guideline-conform and overuse of antibiotics leads to selection of multidrug-resistant pathogens, which can colonize patients and make the treatment a real challenge. A revision of our approach to urinary tract infections at the light of antibiotic stewardiship principles are urgently required, in particular starting from the everyday clinical practice.

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