From concept to reality: Building an ambulatory antimicrobial stewardship program

It takes a village: decreasing inappropriate antibiotic prescribing for upper respiratory tract infections

Objective

Prescribing of antibiotics for viral upper respiratory infections (URIs) remains a pressing public health problem. We sought to reduce inappropriate prescribing of antibiotics for URIs in Mayo Clinic Arizona.

Design

Single-center, quasi-experimental, and retrospective cohort study.

Setting

Emergency medicine and all primary care departments.

Methods

The interventions included sharing baseline prescribing data, education, resources, and quarterly peer comparison reports. Encounters with diagnostic codes for respiratory infections commonly caused by viruses were categorized as Tier 3 (ie, never appropriate to prescribe antibiotics). Our goal was to reduce inappropriate prescribing for Tier 3 encounters by 22% in 2022.

Results

Department education was completed by June 2022. The annual antibiotic prescribing rate for Tier 3 encounters was reduced by 29%, from a baseline rate of 23.6% in 2021 to 16.4% in 2022 (P < .001). The posteducation prescribing rate was 13.1%. Repeat respiratory-related healthcare contact within 14 days of Tier 3 encounters did not differ between patients prescribed and not prescribed an antibiotic in all of 2022 (4.7% antibiotic vs 4.2% no antibiotic, P = .595) or during the posteducation period (3.7% vs 4.6%, P = .604).

Conclusion

A multi-faceted intervention, which included baseline education, syndrome-specific order panels, resources for symptomatic management, and peer comparison reports, resulted in significant reduction of inappropriate antibiotic prescribing for URIs.

Evaluation of Multisite Programmatic Bundle to Reduce Unnecessary Antibiotic Prescribing for Respiratory Infections: A Retrospective Cohort Study

Background

The aim of this study was to evaluate the frequency of unnecessary antibiotic prescribing for Tier 3 upper respiratory infection (URI) syndromes across the Mayo Clinic Enterprise before and after a multifaceted antimicrobial stewardship intervention, and to determine ongoing factors associated with antibiotic prescribing and repeat respiratory healthcare contact in the postintervention period.

Methods

This was a quasi-experimental, pre/post, retrospective cohort study from 1 January 2019 through 31 December 2022, with 12-month washout during implementation from 1 July 2020 through 30 June 2021. All outpatient encounters, adult and pediatric, from primary care, urgent care, and emergency medicine specialties with a Tier 3 URI diagnosis were included. The intervention was a multifaceted outpatient antibiotic stewardship bundle. The primary outcome was the rate of antibiotic prescribing in Tier 3 encounters. Secondary outcomes included 14-day repeat healthcare contact for respiratory indications and factors associated with persistent unnecessary prescribing.

Results

A total of 165 658 Tier 3 encounters, 96 125 in the preintervention and 69 533 in the postintervention period, were included. Following intervention, the prescribing rate for Tier 3 encounters decreased from 21.7% to 11.2% (P < .001). Repeat 14-day respiratory healthcare contact in the no antibiotic group was lower postintervention (9.9.% vs 9.4%; P = .004). Multivariable models indicated that increasing patient age, Charlson comorbidity index, and primary diagnosis selected were the most important factors associated with persistent unnecessary antibiotic prescribing.

Conclusions

Outpatient antibiotic stewardship initiatives can reduce unnecessary antibiotic prescribing for Tier 3 URIs without increasing repeat respiratory healthcare contact. Advancing age and number of comorbidities remain risk factors for persistent unnecessary antibiotic prescribing.

Identification of priority targets for intervention in outpatient antimicrobial stewardship

A multimodal antimicrobial stewardship intervention was associated with a decrease in antibiotic prescribing for targeted non-coronavirus disease 2019 (COVID-19) upper respiratory infections from 27.6% in 2019 to 7.6% in 2021. We describe our approach to prioritizing departments for 3 levels of interventions in the setting of limited stewardship personnel.