Inappropriate prescribing in outpatient healthcare: an evaluation of respiratory infection visits among veterans in teaching versus non-teaching primary care clinics

Antimicrobial Prescribing in the Telehealth Setting: Framework for Stewardship During a Period of Rapid Acceleration Within Primary Care

Antibiotic resistance is a global public health threat. The use of telehealth in primary care presents unique barriers to antimicrobial stewardship, including limited physical examination and changes to the patient-provider relationship. Since the coronavirus disease 2019 (COVID-19) pandemic, there is a need to identify novel antimicrobial stewardship strategies with an explosion in the use of telehealth within primary care. Our review proposes a tailored, sustainable approach to antimicrobial prescribing in the telehealth setting based on the Centers for Disease Control and Prevention's Core Elements of Outpatient Antibiotic Stewardship: commitment, action for policy and practice; tracking and reporting; and education and expertise. The rapid growth of telehealth for all types of primary care visits (not just antibiotic use) is outpacing knowledge associated with strategies for antimicrobial stewardship. Improving antibiotic use within primary care settings is critical as telehealth will remain a priority whether the COVID-19 pandemic recedes, particularly within patient populations with limited access to healthcare.

Primary care physicians' approaches to low-value prescribing in older adults: a qualitative study

Background

Low-value prescribing may result in adverse patient outcomes and increased medical expenditures. Clinicians’ baseline strategies for navigating patient encounters involving low-value prescribing remain poorly understood, making it challenging to develop acceptable deprescribing interventions. Our objective was to characterize primary care physicians’ (PCPs) approaches to reduce low-value prescribing in older adults through qualitative analysis of clinical scenarios.

Methods

As part of an overarching qualitative study on low-value prescribing, we presented two clinical scenarios involving potential low-value prescribing during semi-structured interviews of 16 academic and community PCPs from general internal medicine, family medicine and geriatrics who care for patients aged greater than or equal to 65. We conducted a qualitative analysis of their responses to identify salient themes related to their approaches to prescribing, deprescribing, and meeting patients’ expectations surrounding low-value prescribing.

Results

We identified three key themes. First, when deprescribing, PCPs were motivated by their desire to mitigate patient harms and follow medication safety and deprescribing guidelines. Second, PCPs emphasized good communication with patients when navigating patient encounters related to low-value prescribing; and third, while physicians emphasized the importance of shared decision-making, they prioritized patients’ well-being over satisfying their expectations.

Conclusions

When presented with real-life clinical scenarios, PCPs in our cohort sought to reduce low-value prescribing in a guideline-concordant fashion while maintaining good communication with their patients. This was driven primarily by a desire to minimize the potential for harm. This suggests that barriers other than clinician knowledge may be driving ongoing use of low-value medications in clinical practice.

Improving urinary tract infection treatment through a multifaceted antimicrobial stewardship intervention in the emergency department

BACKGROUND

Urinary tract infection (UTI) is frequently encountered in the emergency department (ED). We assessed an antibiotic stewardship intervention tailored for the ED. The primary objective was improving overall adherence to agent choice and treatment duration. The secondary objective was a decrease in fluoroquinolone prescription.

METHODS

This pre-post study included patients discharged from the ED with a UTI diagnosis. The intensive intervention period lasted three months and involved dissemination of guidelines, short lectures, incorporation of order sets into electronic ED charts and weekly personal audit and feedback. The following 11-month phase was a booster period consisting of monthly text messages of the treatment protocol. Assessment of adherence to the protocol was compared between the three-month pre-intervention period and the last two months of the intensive intervention period, as well as with the last two months of the booster period.

RESULTS

A total of 177 patients were included in the pre-intervention period, 156 in the intervention period, and 94 in the late follow-up assessing the booster period. Median age was 49 (18-94) years, 78.2% were female, 84.8% had cystitis. During the intervention period, protocol adherence with antibiotic selection and duration increased from 41% to 84% (p < 0.001). Adherence remained high in the late follow-up period (73.4% vs. 41%, p < 0.001). Fluoroquinolone use decreased from 19.1% pre-intervention, to 5% in the intervention and 7.4% in the late follow-up periods (p < 0.001).

CONCLUSIONS

An antibiotic stewardship intervention in a busy ED resulted in adherence to treatment protocols, including a decrease in fluoroquinolone use. A monthly reminder preserved most of the effect for a year.

Antibiotic prescribing patterns for adult urinary tract infections within emergency department and urgent care settings

Urinary tract infections (UTI) are a common reason for emergency department (ED) and urgent care (UC) visits. Fluoroquinolones (FQ) are frequently prescribed for treatment of UTI in the outpatient setting; however, data evaluating prescribing patterns after FDA safety warnings is limited, especially in UC. The study goal was to investigate and compare antimicrobial prescribing for UTIs in a single-site ED and an off-site UC in an urban, academic health system. This retrospective study included patients presenting with a UTI to the ED or UC between January and June 2018. Those 18 years or older with uncomplicated, complicated UTI, or pyelonephritis were included. Exclusion criteria were catheter-related UTI, urinary tract abnormalities, immunocompromised, or hospitalization. Primary outcome was FQ prescribing rate for all UTI in the ED and UC. Secondary outcomes were rates of non-FQ prescribing, re-presentation, bug-drug mismatch, and treatment durations. 184 patients were included. FQ prescribing rate was similar in ED and UC (21.2% vs. 16.3%, p = 0.4). Non-FQs prescribed in ED and UC were nitrofurantoin (20.2% vs 53.6%), beta-lactams (46.1% vs 22.6%), and trimethoprim/sulfamethoxazole (12.5% vs. 5%). A longer than recommended duration was identified in 46.3% UC patients compared to 21.2% ED patients. Thirty-day re-presentation with persistent UTI symptoms occurred more frequently in the ED compared to UC (13.5% vs. 7.5%). Predictors of FQ prescribing on logistic regression were male, recurrent UTI, and malignancy. FQ prescribing rate for UTI treatment was low with no difference between ED and UC. Opportunity exists to improve treatment duration and antimicrobial choice.

Barriers and facilitators to the uptake of an antimicrobial stewardship program in primary care: A qualitative study

The overuse of antimicrobials in primary care can be linked to an increased risk of antimicrobial-resistant bacteria for individual patients. Although there are promising signs of the benefits associated with Antimicrobial Stewardship Programs (ASPs) in hospitals and long-term care settings, there is limited knowledge in primary care settings and how to implement ASPs in these settings is unclear. In this context, a qualitative study was undertaken to explore the perceptions of primary care prescribers of the usefulness, feasibility, and experiences associated with the implementation of a pilot community-focused ASP intervention in three primary care clinics. Qualitative interviews were conducted with primary care clinicians, including local ASP champions, prescribers, and other primary health care team members, while they participated in an ASP initiative within one of three primary care clinics. An iterative conventional content analyses approach was used to analyze the transcribed interviews. Themes emerged around the key enablers and barriers associated with ASP implementation. Study findings point to key insights relevant to the scalability of community ASP activities with primary care providers.

Outpatient antibiotic prescribing patterns in pediatric academic and community practices

Little is known about antibiotic prescribing differences between academic and community outpatient settings. This retrospective, cross-sectional chart review compares compliance with Infectious Diseases Society of America and American Academy of Pediatrics prescribing guidelines for otitis media, sinusitis, and pharyngitis in academic and affiliated community practices. The study results for correct antibiotic prescribing rate in the academic setting (67%) compared with the community setting (21%) demonstrate the urgent need for stewardship in community outpatient clinics.

Antibiotic stewardship targets in the outpatient setting

BACKGROUND

Outpatient prescriptions comprise 60% of antibiotic use. This study prospectively identified inappropriate antibiotic use enabling a focused approach to outpatient antimicrobial stewardship.

METHODS

Outpatients at the Veterans Affairs Western New York Healthcare System were identified via an electronic antibiotic alert from June 2017 to September 2017. Descriptive statistics and multivariable logistic regression identified stewardship targets.

RESULTS

Of the 1,063 patients, 40% of antibiotic prescriptions were not indicated. Urinary tract infections (21%), bronchitis (20%), skin structure infections (17%), and sinusitis (10%) were common causes of inappropriate antibiotic use. Azithromycin (37%) was prescribed unnecessarily most often, followed by ciprofloxacin (16%), amoxicillin/clavulanate (13%), and cephalexin (12%). The correct drug was chosen in 52%, dose in 81%, and duration in 75% of patients. When the antibiotic was indicated, the correct drug was 2.9 times more likely to be prescribed and 2 times more likely to have the correct duration and receive care in the emergency room.

DISCUSSION

Focusing on 4 drugs; amoxicillin/clavulanate, azithromycin, ciprofloxacin, and cephalexin accounted for 80% of unnecessary drug use. This study provides a guide to concentrate efforts during implementation of an outpatient stewardship program.

CONCLUSIONS

Poor antibiotic prescribing was found in the outpatient setting. This study identifies areas for improvement via stewardship.

Impact of the 10-valent pneumococcal conjugate vaccine on antimicrobial prescriptions in young children: a whole population study

Background

Antimicrobial resistance is a public-health threat and antimicrobial consumption is the main contributor. The ten-valent pneumococcal conjugate vaccine (PHiD-CV10) was introduced into the Icelandic vaccination program in 2011.

The aim was to estimate the vaccine impact of PHiD-CV10 on outpatient antimicrobial prescriptions in children.

Methods

Eleven Icelandic birth-cohorts (2005–2015) were followed from birth until three years of age or to the end of the study period (December 31, 2016). Birth-cohorts were grouped as vaccine non-eligible (VNEC, 2005–2010) or vaccine eligible (VEC, 2011–2015). Data on primary care visits for respiratory infections and antimicrobial prescriptions were extracted from two national registers. Using national identification numbers, prescriptions were linked to physician visits if filled within three days of the visit. Incidence rates and incidence rate ratios between VNEC and VEC were calculated. An Andersen-Gill model was used to model the individual level data, accounting for repeated events and censoring. Vaccine impact was calculated as (1 – Hazard Ratio) × 100%.

Results

Included were 53,510 children who contributed 151,992 person-years of follow-up and filled 231,660 antimicrobial prescriptions. The incidence rate was significantly lower in the VEC compared to the VNEC, 144.5 and 157.2 prescriptions per 100 person-years respectively (IRR 0.92, 95%CI 0.91–0.93). Children in VEC were more likely to have filled zero (IRR 1.16 (95%CI 1.10–1.23) and 1–4 (IRR 1.08 95%CI 1.06–1.11) prescriptions compared to children in VNEC. The vaccine impact of PHiD-CV10 against all-cause antimicrobial prescriptions was 5.8% (95%CI 1.6–9.8%).When only considering acute otitis media-associated prescriptions, the vaccine impact was 21.8% (95%CI 11.5–30.9%).

Conclusion

The introduction of PHiD-CV10 lead to reduced antimicrobial use in children, mainly by reducing acute otitis media episodes. This intervention therefore reduces both disease burden and could slow the spread of antimicrobial resistance.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3416-y) contains supplementary material, which is available to authorized users.

Assessments of Opportunities to Improve Antibiotic Prescribing in an Emergency Department: A Period Prevalence Survey

Introduction

Approximately 30% of all outpatient antimicrobials are inappropriately prescribed. Currently, antimicrobial prescribing patterns in emergency departments (ED) are not well described. Determining inappropriate antimicrobial prescribing patterns and opportunities for interventions by antimicrobial stewardship programs (ASP) are needed.

Methods

A retrospective chart review was performed among a random sample of non-admitted, adult patients who received an antimicrobial prescription in the ED from January 1 to December 31, 2015. Appropriateness was measured using the Medication Appropriateness Index, and was based on provider adherence to local guidelines. Additional information collected included patient characteristics, initial diagnoses, and other chronic medication use.

Results

Of 1579 ED antibiotic prescriptions in 2015, we reviewed a total of 159 (10.1%) prescription records. The most frequently prescribed antimicrobial classes included penicillins (22.6%), macrolides (20.8%), cephalosporins (17.6%), and fluoroquinolones (17.0%). The most common indications for antibiotics were bronchitis or upper respiratory tract infection (URTI) (35.1%), followed by skin and soft tissue infection (SSTI) (25.0%), both of which were the most common reason for unnecessary prescribing (28.9% of bronchitis/URTIs, 25.6% of SSTIs). Of the antimicrobial prescriptions reviewed, 39% met criteria for inappropriateness. Among 78 prescriptions with a consensus on appropriate indications, 13.8% had inappropriate dosing, duration, or expense.

Conclusion

Consistent with national outpatient prescribing, inappropriate antibiotic prescribing in the ED occurred in 39% of cases with the highest rates observed among patients with bronchitis, URTI, and SSTI. Antimicrobial stewardship programs may benefit by focusing on initiatives for these conditions among ED patients. Moreover, creation of local guideline pocketbooks for these and other conditions may serve to improve prescribing practices and meet the Core Elements of Outpatient Stewardship recommended by the Centers for Disease Control and Prevention.