Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Infections in the Veteran Population: A Cross-sectional Study

Factors contributing to the variation in antibiotic prescribing among primary health care physicians: a systematic review

BACKGROUND

Antibiotic resistance is growing globally. The practice of health professionals when prescribing antibiotics in primary health care settings significantly impacts antibiotic resistance. Antibiotic prescription is a complex process influenced by various internal and external factors. This systematic review aims to summarize the available evidence regarding factors contributing to the variation in antibiotic prescribing among physicians in primary healthcare settings.

METHODS

This systematic review was conducted based on PRISMA guidelines. We included qualitative, quantitative and mixed methods studies that examined factors influencing prescription practice and variability among primary healthcare physicians. We excluded editorials, opinions, systematic reviews and studies published in languages other than English. We searched studies from electronic databases: PubMed, ProQuest Health and Medicine, Web Science, and Scopus. The quality of the included studies was appraised using the Mixed Methods Appraisal Tool (Version 2018). Narrative synthesis was employed to synthesize the result and incorporate quantitative studies.

RESULTS

Of the 1816 identified studies, 49 studies spanning 2000-2023 were eligible for review. The factors influencing antibiotic prescription practice and variability were grouped into physician-related, patient-related, and healthcare system-related factors. Clinical guidelines, previous patient experience, physician experience, colleagues' prescribing practice, pharmaceutical pressure, time pressure, and financial considerations were found to be influencing factors of antibiotic prescribing practice. In addition, individual practice patterns, practice volume, and relationship with patients were also other factors for the variability of antibiotic prescription, especially for intra-physician prescription variability.

CONCLUSION

Antibiotic prescription practice in primary health care is a complex practice, influenced by a combination of different factors and this may account for the variation. To address the factors that influence the variability of antibiotic prescription (intra- and inter-physician), interventions should aim to reduce diagnostic uncertainty and provide continuous medical education and training to promote patient-centred care.

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.

Decisions regarding antibiotic prescribing for acute sinusitis in Norwegian general practice. A qualitative focus group study

BACKGROUND

Acute sinusitis is a frequent reason for primary care visits. Most patients recover within two weeks without antibiotic treatment. Despite this, about 50% of patients with acute sinusitis in Norwegian general practice are still prescribed antibiotics. We do not know the reason behind this discrepancy.

AIM

To explore the clinical decision-making process and reasons for treatment with antibiotics for acute sinusitis among Norwegian general practitioners (GPs).

METHODS

Five focus group interviews were conducted (N = 25) in different parts of Norway, including GPs of various age, gender, and experience. The interviews were analysed using Systematic Text Condensation.

RESULTS

The results showed a very diverse management of acute sinusitis among GPs, with decisions regarding antibiotics not always aligning with guideline recommendations. Many of the GPs did not agree with the Norwegian guidelines for antibiotics and chose something other than phenoxymethylpenicillin as their first choice. Clinical predictors emphasized in decision-making were pain complaints and patient exhaustion. Pragmatic factors such as weekday, travel plans, or a full waiting room could also influence the decision.

CONCLUSION

GPs found it difficult to identify when patients would benefit from antibiotic treatment for acute sinusitis, and different strategies were used to make prescribing decisions. For several GPs the degree of pain was one of the decisive reasons for antibiotic prescribing, however the guidelines for antibiotics do not give sufficient advice regarding pain treatment. These results suggest a need for revaluation of guideline contents and the way they are communicated to GPs.

Common antibiotics, azithromycin and amoxicillin, affect gut metagenomics within a household

BACKGROUND

The microbiome of the human gut serves a role in a number of physiological processes, but can be altered through effects of age, diet, and disturbances such as antibiotics. Several studies have demonstrated that commonly used antibiotics can have sustained impacts on the diversity and the composition of the gut microbiome. The impact of the two most overused antibiotics, azithromycin, and amoxicillin, in the human microbiome has not been thoroughly described. In this study, we recruited a group of individuals and unrelated controls to decipher the effects of the commonly used antibiotics amoxicillin and azithromycin on their gut microbiomes.

RESULTS

We characterized the gut microbiomes by metagenomic sequencing followed by characterization of the resulting microbial communities. We found that there were clear and sustained effects of the antibiotics on the gut microbial community with significant alterations in the representations of Bifidobacterium species in response to azithromycin (macrolide antibiotic). These results were supported by significant increases identified in putative antibiotic resistance genes associated with macrolide resistance. Importantly, we did not identify these trends in the unrelated control individuals. There were no significant changes observed in other members of the microbial community.

CONCLUSIONS

As we continue to focus on the role that the gut microbiome plays and how disturbances induced by antibiotics might affect our overall health, elucidating members of the community most affected by their use is of critical importance to understanding the impacts of common antibiotics on those who take them. Clinical Trial Registration Number NCT05169255. This trial was retrospectively registered on 23-12-2021.

Best practice guidance for antibiotic audit and feedback interventions in primary care: a modified Delphi study from the Joint Programming Initiative on Antimicrobial resistance: Primary Care Antibiotic Audit and Feedback Network (JPIAMR-PAAN)

BACKGROUND

Primary care is a critical partner for antimicrobial stewardship efforts given its high human antibiotic usage. Peer comparison audit and feedback (A&F) is often used to reduce inappropriate antibiotic prescribing. The design and implementation of A&F may impact its effectiveness. There are no best practice guidelines for peer comparison A&F in antibiotic prescribing in primary care.

OBJECTIVE

To develop best practice guidelines for peer comparison A&F for antibiotic prescribing in primary care in high income countries by leveraging international expertise via the Joint Programming Initiative on Antimicrobial Resistance-Primary Care Antibiotic Audit and Feedback Network.

METHODS

We used a modified Delphi process to achieve convergence of expert opinions on best practice statements for peer comparison A&F based on existing evidence and theory. Three rounds were performed, each with online surveys and virtual meetings to enable discussion and rating of each best practice statement. A five-point Likert scale was used to rate consensus with a median threshold score of 4 to indicate a consensus statement.

RESULTS

The final set of guidelines include 13 best practice statements in four categories: general considerations (n = 3), selecting feedback recipients (n = 1), data and indicator selection (n = 4), and feedback delivery (n = 5).

CONCLUSION

We report an expert-derived best practice recommendations for designing and evaluating peer comparison A&F for antibiotic prescribing in primary care. These 13 statements can be used by A&F designers to optimize the impact of their quality improvement interventions, and improve antibiotic prescribing in primary care.

Acute Respiratory Infection Incidence and Outpatient Antibiotic Prescription Patterns in People With or Without Human Immunodeficiency Virus Infection: A Virtual Cohort Study

Background

Inappropriate antibiotic use in acute respiratory infections (ARIs) is a major public health concern; however, data for people with human immunodeficiency virus (PWH) are limited.

Methods

The HIV Virtual Cohort Study is a retrospective cohort of adult Department of Defense beneficiaries. Male PWH cases (n = 2413) were matched 1:2 to controls without HIV (n = 4826) by age, gender, race/ethnicity, and beneficiary status. Acute respiratory infection encounters between 2016 and 2020 and corresponding antibiotic prescriptions were characterized as always, sometimes, or never appropriate based on International Classification of Diseases, Tenth Revision coding. Incidence of ARI encounters and antibiotic appropriateness were compared between PWH and controls. Subgroup analyses were assessed by CD4 count and viral load suppression on antiretroviral therapy.

Results

Mean rates of ARI encounters were similar for PWH (1066 per 1000 person-years) and controls (1010 per 1000 person-years); however, the rate was double among PWH without viral load (VL) suppression (2018 per 1000 person-years). Antibiotics were prescribed in 26% of encounters among PWH compared to 34% for controls (P ≤ .01); antibiotic use was "never" appropriate in 38% of encounters with PWH and 36% in controls. Compared to controls, PWH received more sulfonamides (5.5% vs 2.7%; P = .001), and variation existed among HIV subgroups in the prescription of sulfonamides, fluoroquinolones, and β-lactams.

Discussion

Acute respiratory infection encounters were similar for PWH and those without HIV; however, PWH with lower CD4 counts and/or nonsuppressed VL had more frequent ARI visits. Inappropriate antibiotic use for ARIs was high in both populations, and focused interventions to improve antibiotic appropriateness for prescribers caring for PWH should be pursued.

Implementation and outcomes of a clinician-directed intervention to improve antibiotic prescribing for acute respiratory tract infections within the Veterans' Affairs Healthcare System

OBJECTIVE

To determine whether a clinician-directed acute respiratory tract infection (ARI) intervention was associated with improved antibiotic prescribing and patient outcomes across a large US healthcare system.

DESIGN

Multicenter retrospective quasi-experimental analysis of outpatient visits with a diagnosis of uncomplicated ARI over a 7-year period.

PARTICIPANTS

Outpatients with ARI diagnoses: sinusitis, pharyngitis, bronchitis, and unspecified upper respiratory tract infection (URI-NOS). Outpatients with concurrent infection or select comorbid conditions were excluded.

INTERVENTION(S)

Audit and feedback with peer comparison of antibiotic prescribing rates and academic detailing of clinicians with frequent ARI visits. Antimicrobial stewards and academic detailing personnel delivered the intervention; facility and clinician participation were voluntary.

MEASURE(S)

We calculated the probability to receive antibiotics for an ARI before and after implementation. Secondary outcomes included probability for a return clinic visits or infection-related hospitalization, before and after implementation. Intervention effects were assessed with logistic generalized estimating equation models. Facility participation was tracked, and results were stratified by quartile of facility intervention intensity.

RESULTS

We reviewed 1,003,509 and 323,023 uncomplicated ARI visits before and after the implementation of the intervention, respectively. The probability to receive antibiotics for ARI decreased after implementation (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.78-0.86). Facilities with the highest quartile of intervention intensity demonstrated larger reductions in antibiotic prescribing (OR, 0.69; 95% CI, 0.59-0.80) compared to nonparticipating facilities (OR, 0.89; 95% CI, 0.73-1.09). Return visits (OR, 1.00; 95% CI, 0.94-1.07) and infection-related hospitalizations (OR, 1.21; 95% CI, 0.92-1.59) were not different before and after implementation within facilities that performed intensive implementation.

CONCLUSIONS

Implementation of a nationwide ARI management intervention (ie, audit and feedback with academic detailing) was associated with improved ARI management in an intervention intensity-dependent manner. No impact on ARI-related clinical outcomes was observed.

Antibiotic Prescribing in Outpatient Settings: Rural Patients Are More Likely to Receive Fluoroquinolones and Longer Antibiotic Courses

Suboptimal antibiotic prescribing may be more common in patients living in rural versus urban areas due to various factors such as decreased access to care and diagnostic testing equipment. Prior work demonstrated a rural health disparity of overprescribing antibiotics and longer durations of antibiotic therapy in the United States; however, large-scale evaluations are limited. We evaluated the association of rural residence with suboptimal outpatient antibiotic use in the national Veterans Affairs (VA) system. Outpatient antibiotic dispensing was assessed for the veterans diagnosed with an upper respiratory tract infection (URI), pneumonia (PNA), urinary tract infection (UTI), or skin and soft tissue infection (SSTI) in 2010-2020. Rural-urban status was determined using rural-urban commuting area codes. Suboptimal antibiotic use was defined as (1) outpatient fluoroquinolone dispensing and (2) longer antibiotic courses (>ten days). Geographic variation in suboptimal antibiotic use was mapped. Time trends in suboptimal antibiotic use were assessed with Joinpoint regression. While controlling for confounding, the association of rurality and suboptimal antibiotic use was assessed with generalized linear mixed models with a binary distribution and logit link, accounting for clustering by region and year. Of the 1,405,642 veterans diagnosed with a URI, PNA, UTI, or SSTI and dispensed an outpatient antibiotic, 22.8% were rural-residing. In 2010-2020, in the rural- and urban-residing veterans, the proportion of dispensed fluoroquinolones declined by 9.9% and 10.6% per year, respectively. The rural-residing veterans were more likely to be prescribed fluoroquinolones (19.0% vs. 17.5%; adjusted odds ratio (aOR), 1.03; 95% confidence interval (CI), 1.02-1.04) and longer antibiotic courses (53.8% vs. 48.5%; aOR, 1.19, 95% CI, 1.18-1.20) than the urban-residing veterans. Among a large national cohort of veterans diagnosed with URIs, PNA, UTIs, and SSTIs, fluoroquinolone use and longer antibiotic courses were disproportionally more common among rural- as compared to urban-residing veterans. Outpatient antibiotic prescribing must be improved, particularly for rural-residing patients. There are many possible solutions, of which antibiotic stewardship interventions are but one.

A retrospective review of antibiotic use for acute respiratory infections in urgent-care patients

Objective

We examined the use of antibiotics for acute respiratory infections in an urgent-care setting.

Design

Retrospective database review.

Setting

The study was conducted in 2 urgent-care clinics staffed by academic emergency physicians in San Diego, California.

Patients

Visits for acute respiratory infections were identified based on presenting complaints.

Methods

The primary outcome was a discharge prescription for an antibiotic. The patient and provider characteristics that predicted this outcome were analyzed using logistic regression. The variation in antibiotic prescriptions between providers was also analyzed.

Results

In total, 15,160 visits were analyzed. The patient characteristics were not predictive of antibiotic treatment. Physicians were more likely than advanced practice practitioners to prescribe antibiotics (1.31; 95% confidence interval [CI], 1.21-1.42). For every year of seniority, a provider was 1.03 (95% CI, 1.02-1.03) more likely to prescribe an antibiotic. Although the providers saw similar patients, we detected significant variation in the antibiotic prescription rate between providers: the mean antibiotic prescription rate within the top quartile was 54.3% and the mean rate in the bottom quartile was 21.7%.

Conclusions

The patient and provider characteristics we examined were either not predictive or were only weakly predictive of receiving an antibiotic prescription for acute respiratory infection. However, we detected a marked variation between providers in the rate of antibiotic prescription. Provider differences, not patient differences, drive variations in antibiotic prescriptions. Stewardship efforts may be more effective if directed at providers rather than patients.

Evaluation of the Clinical Outcome and Cost Analysis of Antibiotics in the Treatment of Acute Respiratory Tract Infections in the Emergency Department in Saudi Arabia

This study aims to assess the prevalence and antibiotic-treatment patterns of respiratory tract infections (RTIs), prevalence and types of antibiotic-prescribing errors, and the cost of inappropriate antibiotic use among emergency department (ED) patients. A cross-sectional study was conducted at the ED in King Abdulaziz Medical City, Riyadh, Saudi Arabia. Patient characteristics (age, sex, weight, allergies, diagnostic tests (CX-Ray), cultures, microorganism types, and prescription characteristics) were studied. During the study, 3185 cases were diagnosed with RTIs: adults (>15 years) 55% and pediatrics (<15 years) 44%. The overall prevalence of RTIs was 21%, differentiated by upper respiratory tract infections (URTI) and lower respiratory tract infections (LRTI) (URTI 13.4%; LRTI 8.4%), of total visits. Three main antibiotics (ATB) categories were prescribed in both age groups: penicillin (pediatrics 43%; adults 26%), cephalosporin (pediatrics 29%; adults 19%), and macrolide (pediatrics 26%; adults 38%). The prevalence of inappropriate ATB prescriptions was 53% (pediatrics 35%; adults 67%). Errors in ATB included selection (3.3%), dosage (22%), frequency (3%), and duration (32%). There is a compelling need to create antimicrobial stewardship (AMS) programs to improve antibiotic use due to the high number of prescriptions in the ED deemed as inappropriate. This will help to prevent unwanted consequences on the patients and the community associated with antibiotic use.

Antibiotic stewardship to reduce inappropriate antibiotic prescribing in integrated academic health-system urgent care clinics

Objective:

To develop and implement antibiotic stewardship activities in urgent care targeting non–antibiotic-appropriate acute respiratory tract infections (ARIs) that also reduces overall antibiotic prescribing and maintains patient satisfaction.

Patients and setting:

Patients and clinicians at the urgent care clinics of an integrated academic health system.

Intervention and methods:

The stewardship activities started in fiscal 2020 and included measure development, comparative feedback, and clinician and patient education. We measured antibiotic prescribing in fiscal years 2019, 2020, and 2021 for the stewardship targets, potential diagnosis-shifting visits, and overall. We also collected patient satisfaction data for ARI visits.

Results:

From FY19 to FY21, 576,609 patients made 1,358,816 visits to 17 urgent care clinics, including 105,781 visits for which stewardship measures were applied and 149,691 visits for which diagnosis shifting measures were applied. The antibiotic prescribing rate decreased for stewardship-measure visits from 34% in FY19 to 12% in FY21 (absolute change, −22%; 95% confidence interval [CI], −23% to −22%). The antibiotic prescribing rate decreased for diagnosis-shifting visits from 63% to 35% (−28%; 95% CI, −28% to −27%), and the antibiotic prescribing rate decreased overall from 30% to 10% (−20%; 95% CI, −20% to −20%). The patient satisfaction rate increased from 83% in FY19 to 89% in FY20 and FY21. There was no significant association between antibiotic prescribing rates of individual clinicians and ARI visit patient satisfaction.

Conclusions:

Although it was affected by the COVID-19 pandemic, an ambulatory antimicrobial stewardship program that focused on improving non–antibiotic-appropriate ARI prescribing was associated with decreased prescribing for (1) the stewardship target, (2) a diagnosis shifting measure, and (3) overall antibiotic prescribing. Patient satisfaction at ARI visits increased over time and was not associated with clinicians’ antibiotic prescribing rates.

Antibiotic Prescribing Practices for Upper Respiratory Tract Infections Among Primary Care Providers: A Descriptive Study

Background

Most antibiotics are prescribed in the ambulatory setting with estimates that up to 50% of use is inappropriate. Understanding factors associated with antibiotic misuse is essential to advancing better stewardship in this setting. We sought to assess the frequency of unnecessary antibiotic use for upper respiratory infections (URIs) among primary care providers and identify patient and provider characteristics associated with misuse.

Methods

Unnecessary antibiotic prescribing was assessed in a descriptive study by using adults ≥18 years seen for common URIs in a large, Upper Midwest, integrated health system, electronic medical records from June 2017 through May 2018. Individual provider rates of unnecessary prescribing were compared for primary care providers practicing in the departments of internal medicine, family medicine, or urgent care. Patient and provider characteristics associated with unnecessary prescribing were identified with a logistic regression model.

Results

A total of 49 463 patient encounters were included. Overall, antibiotics were prescribed unnecessarily for 42.2% (95% confidence interval [CI], 41.7–42.6) of the encounters. Patients with acute bronchitis received unnecessary antibiotics most frequently (74.2%; 95% CI, 73.4–75.0). Males and older patients were more likely to have an unnecessary antibiotic prescription. Provider characteristics associated with higher rates of unnecessary prescribing included being in a rural practice, having more years in practice, and being in higher volume practices such as an urgent care setting. Fifteen percent of providers accounted for half of all unnecessary antibiotic prescriptions.

Conclusions

Although higher-volume practices, a rural setting, or longer time in practice were predictors, unnecessary prescribing was common among all providers.

Antibiotic prescribing patterns and guideline-concordant management of acute respiratory tract infections in virtual urgent care settings

BACKGROUND

Antibiotic overprescribing for acute respiratory tract infections (ARTIs) commonly occurs and can lead to higher medical costs, antibiotic resistance, and health complications. Inappropriate prescribing of antibiotics for ARTIs has been shown to occur more frequently in urgent care than other outpatient settings. It is not clear whether antibiotic overprescribing varies between virtual and in-person urgent care.

OBJECTIVES

Summarize published primary scientific literature on antibiotic prescribing patterns for ARTIs among adults in virtual urgent care settings.

DATA SOURCES

We conducted a systematic review to compare antibiotic prescribing for ARTIs between virtual and in-person urgent care. Our review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. We assessed risk of bias using the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) assessment tool. We summarized study results from seven included retrospective cohort studies.

CONCLUSIONS

Antibiotic prescribing frequency may be similar between virtual urgent care and in-person care for adult patients treated for ARTIs. However, variability existed in intervention characteristics, settings, and outcome measures. Additional studies are needed to better understand the conditions in which virtual care may be most effective.

IMPLICATIONS FOR PRACTICE

Evidence suggests that giving providers direct access to evidence-based guidelines and electronic health records within the virtual visit may support diagnosis and management. Furthermore, practices that use telemedicine platforms for virtual urgent care visits should consider how to potentially improve diagnosis and management of conditions through the use of home-based point-of-care testing or accessory "e-tools."

Outpatient Antibiotic Prescriptions in France: Patients and Providers Characteristics and Impact of the COVID-19 Pandemic

In France, despite several successive plans to control antimicrobial resistance, antibiotic use remains high in the outpatient setting. This study aims to better understand outpatient antibiotic use and prescription in order to identify tailored targets for future public health actions. Using data from the French National Health Data System, we described and compared the individual characteristics of patients with and without an antibiotic prescription. The prescribed antibiotics (ATC-J01) were detailed and compared between 2019 and 2020. Antibiotic prescribing indicators that take prescriber activity into account were estimated and compared. Patients who were female, advanced age, and the presence of comorbidities were associated with antibiotic prescriptions. The overall prescription rate was estimated at 134 per 1000 consultations and 326 per 1000 patients seen in 2019. General practitioners (GPs), dentists and paediatricians were associated with 78.0%, 12.2% and 2.2% of antibiotic prescriptions, respectively, with high prescription rates (391, 447, and 313 p. 1000 patients seen, respectively). In comparison with 2019, this rate decreased in 2020 for paediatricians (−30.4%) and GPs (−17.9%) whereas it increased among dentists (+17.9%). The reduction was twice as high among the male prescribers than among their female counterparts (−26.6 and −12.0, respectively). The reduction in prescriptions observed in 2020 (−18.2%) was more marked in children (−35.8%) but less so among individuals ≥65 years (−13.1%) and those with comorbidities (−12.5%). The decrease in penicillin prescriptions represents 67.3% of the overall reduction observed in 2020. The heterogeneous decrease in prescriptions by age and antibiotic class could be explained by the impact of COVID-19 control measures on the spread of respiratory viruses; thus, a substantial proportion of the prescriptions avoided in 2020 is likely inappropriate, particularly among children. In order to keep the rate of prescriptions comparable to that observed in 2020, male prescribers, paediatricians and GPs should be encouraged to maintain that level, while a campaign to raise awareness of the appropriate use of antibiotics should be aimed at dentists in particular.

Population-based assessment of factors influencing antibiotic prescribing for adults with dengue infection in Taiwan

Background

Antibiotic treatment for dengue is likely considerable and potentially avoidable but has not been well characterized. This study aimed to assess antibiotic prescribing for confirmed dengue cases in outpatient and inpatient settings and to identify associated patient, physician and contextual factors.

Methods

57,301 adult dengue cases reported in Taiwan between 2008–2015 were analyzed. We assessed both outpatient and inpatient claims data of dengue patients from a week before to a week after their dengue infections were confirmed under Taiwan’s National Health Insurance program. A multivariable logistic regression with generalized estimating equations was used to estimate the probability of antibiotic prescribing in dengue patients.

Results

Overall, 24.6% of dengue patients were prescribed an antibiotic during the 14 day-assessment period. Antibiotics were prescribed in 6.1% and 30.1% of outpatient visits and inpatient admissions, respectively. Antibiotic prescriptions were reduced by ~50% in epidemic years. Among inpatients, advanced age, females, and major comorbidities were risk factors for receipt of an antibiotic; antibiotics were used in 26.0% of inpatients after dengue was diagnosed. Significant differences in antibiotic prescribing practices were observed among physicians in outpatient settings but not in inpatient settings.

Conclusions

In addition to patient and physician demographic characteristics, contextual factors such as care setting and during epidemics significantly influenced prescription of antibiotics. Characterization of prescribing patterns should help direct programs to curb antibiotic prescribing.

Antimicrobial resistance is a growing global public health threat. The non-specific clinical manifestations of dengue overlap with signs and symptoms of other febrile illnesses common to tropical and subtropical zones making differential diagnosis between dengue and bacterial infections difficult, hence, leading to potentially unnecessary antibiotic prescribing. However, our understanding of factors underlying antibiotic prescribing for dengue is rather limited. Taiwan has experienced periodic dengue outbreaks and has a comprehensive national health insurance database including reliable infectious diseases surveillance and prescribing records. The findings in Taiwan show that other than commonly known patient characteristics, provider and contextual factors play a significant role. Physician’s age and practice setting were significant factors influencing the decision to prescribe antibiotics, particularly in outpatient visits. The likelihood of prescribing an antibiotic to dengue patients was reduced by more than 50% in medical visits occurring after the dengue infection was confirmed. Understanding patient, provider and contextual factors in antibiotics prescription for dengue infections can provide insights for improved antibiotic stewardship and unnecessary antibiotic treatment for dengue.

Optimizing responsiveness to feedback about antibiotic prescribing in primary care: protocol for two interrelated randomized implementation trials with embedded process evaluations

Background

Audit and feedback (A&F) that shows how health professionals compare to those of their peers, can be an effective intervention to reduce unnecessary antibiotic prescribing among family physicians. However, the most impactful design approach to A&F to achieve this aim is uncertain. We will test three design modifications of antibiotic A&F that could be readily scaled and sustained if shown to be effective: (1) inclusion of case-mix-adjusted peer comparator versus a crude comparator, (2) emphasizing harms, rather than lack of benefits, and (3) providing a viral prescription pad.

Methods

We will conduct two interrelated pragmatic randomized trials in January 2021. One trial will include family physicians in Ontario who have signed up to receive their MyPractice: Primary Care report from Ontario Health (“OH Trial”). These physicians will be cluster-randomized by practice, 1:1 to intervention or control. The intervention group will also receive a Viral Prescription Pad mailed to their office as well as added emphasis in their report on use of the pad. Ontario family physicians who have not signed up to receive their MyPractice: Primary Care report will be included in the other trial administered by Public Health Ontario (“PHO Trial”). These physicians will be allocated 4:1 to intervention or control. The intervention group will be further randomized by two factors: case-mix adjusted versus unadjusted comparator and emphasis or not on harms of antibiotics. Physicians in the intervention arm of this trial will receive one of four versions of a personalized antibiotic A&F letter from PHO. For both trials, the primary outcome is the antibiotic prescribing rate per 1000 patient visits, measured at 6 months post-randomization, the primary analysis will use Poisson regression and we will follow the intention to treat principle. A mixed-methods process evaluation will use surveys and interviews with family physicians to explore potential mechanisms underlying the observed effects, exploring targeted constructs including intention, self-efficacy, outcome expectancies, descriptive norms, and goal prioritization.

Discussion

This protocol describes the rationale and methodology of two interrelated pragmatic trials testing variations of theory-informed components of an audit and feedback intervention to determine how to optimize A&F interventions for antibiotic prescribing in primary care.

Trial registration

NCT04594200, NCT05044052. CIHR Grant ID: 398514

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01194-8.

Identifying Higher-Volume Antibiotic Outpatient Prescribers Using Publicly Available Medicare Part D Data - United States, 2019

Antibiotic prescribing can lead to adverse drug events and antibiotic resistance, which pose ongoing urgent public health threats (1). Adults aged ≥65 years (older adults) are recipients of the highest rates of outpatient antibiotic prescribing and are at increased risk for antibiotic-related adverse events, including Clostridioides difficile and antibiotic-resistant infections and related deaths (1). Variation in antibiotic prescribing quality is primarily driven by prescribing patterns of individual health care providers, independent of patients' underlying comorbidities and diagnoses (2). Engaging higher-volume prescribers (the top 10% of prescribers by antibiotic volume) in antibiotic stewardship interventions, such as peer comparison audit and feedback in which health care providers receive data on their prescribing performance compared with that of other health care providers, has been effective in reducing antibiotic prescribing in outpatient settings and can be implemented on a large scale (3-5). This study analyzed data from the Centers for Medicare & Medicaid Services (CMS) Part D Prescriber Public Use Files (PUFs)* to describe higher-volume antibiotic prescribers in outpatient settings compared with lower-volume prescribers (the lower 90% of prescribers by antibiotic volume). Among the 59.4 million antibiotic prescriptions during 2019, 41% (24.4 million) were prescribed by the top 10% of prescribers (69,835). The antibiotic prescribing rate of these higher-volume prescribers (680 prescriptions per 1,000 beneficiaries) was 60% higher than that of lower-volume prescribers (426 prescriptions per 1,000 beneficiaries). Identifying health care providers responsible for a higher volume of antibiotic prescribing could provide a basis for additional assessment of appropriateness and outreach. Public health organizations and health care systems can use publicly available data to guide focused interventions to optimize antibiotic prescribing to limit the emergence of antibiotic resistance and improve patient outcomes.

Interprovincial variation in antibiotic use in Canada, 2019: a retrospective cross-sectional study

BACKGROUND

Geographic trends in antibiotic prescribing show regional variation in antibiotic overuse and antimicrobial resistance, posing a threat to global health care systems. This study's objective was to examine interprovincial variation in outpatient antibiotic dispensing in Canada in 2019.

METHODS

We conducted a cross-sectional study of antibiotic prescriptions dispensed in Canadian provinces in 2019, leveraging the IQVIA Geographic Prescription Monitor database. We report annual rates of overall antibiotic dispensing, broad-spectrum antibiotic dispensing and age-specific antibiotic dispensing as prescriptions per 1000 population in each province and nationally.

RESULTS

A total of 23 406 640 antibiotic prescriptions were dispensed nationally in 2019, at a rate of 627.3 prescriptions per 1000 population. Overall antibiotic dispensing rates in Newfoundland and Labrador (920.5 prescriptions per 1000 population) and Saskatchewan (713.7 prescriptions per 1000 population) significantly exceeded the national rate, whereas the rate in British Columbia (543.3 prescriptions per 1000 population) was significantly below the national rate. We observed additional variation when provincial rates of antibiotic dispensing were stratified by drug class and age group.

INTERPRETATION

We identified interprovincial variation in antibiotic use in Canadian provinces in 2019. These findings highlight the need for provincial targets for antibiotic use to reduce overuse and antimicrobial resistance.

Antibiotic prescribing patterns for acute respiratory infections in a free clinic network: A pooled cross-sectional study

In the United States, overprescribing of antibiotics for viral respiratory infections and antimicrobial resistance continue to be public health concerns. To date, no literature has focused on antibiotic prescribing patterns from free clinics. To address this gap, we used patient-level data from a student-run free clinic network of four primary care clinics to assess factors associated with inappropriate antibiotic prescribing for viral respiratory infections. Treatment plans were deemed inappropriate if any type of antibiotic was prescribed. We used unpaired t-tests and chi-square tests to assess for differences in receiving an inappropriate antibiotic prescription by patient-level factors (i.e., age, race/ethnicity, sex, educational attainment, preferred language, insurance status). Of 298 visits, 22.5% did not meet treatment guidelines. No patient-level factors studied were associated with inappropriate antibiotic prescribing. Our findings suggest other factors, beyond patient-level, may be drivers of variation in antibiotic prescribing in free clinics.

Estimating variations in the use of antibiotics in primary care: Insights from the Tuscany region, Italy

BACKGROUND

Practice variation is a well-known phenomenon that affects all aspects of healthcare delivery and leads to suboptimal health outcomes as well as poor resource allocation. Given the global rise of antimicrobial resistance, practice variation is of particular concern when it comes to the prescription of antibiotics. A growing number of healthcare systems are tackling this issue at all levels of healthcare governance.

AIMS AND OBJECTIVES

This study sought to estimate the variation in antibiotic use across different levels of Tuscany's primary care, and assess the extent to which the organization of primary care delivery is responsible for this variation.

METHODS

We analysed the performance and variation for seven indicators related to the use of antibiotics at three levels of healthcare governance: (i) the clinician level (2619 general practitioners [GPs]); (ii) the peer-group level (all 116 GP group practices) and (iii) the institutional level (all 26 health districts). For the statistical analysis, we built three-level mixed effects models that were fitted with 2619 GPs, 116 GP group practices and 26 health districts.

RESULTS

The multi-level models suggested that the grand majority of the variation in antibiotic use was located at the GP level (75% to 97%). However, the percentage of variation associated with GP group practices and health districts ranged from 3% to 25%, depending on the type of indicator analysed.

CONCLUSION

While the variation was found to be in large part due to differences between GPs themselves, the influence exerted by peer groups and institutional mechanisms does have a significant impact as well. Further research needs to be conducted regarding the institutional and contextual factors that prompt GPs to harmonize their prescribing behaviour in line with best practices and lead to not only improved patient outcomes but also large cost-savings.

Non-Visit-Based and Non-Infection-Related Antibiotic Use in the US: A Cohort Study of Privately Insured Patients During 2016-2018

BACKGROUND

Ambulatory antibiotic prescriptions without a clinic visit or without documentation of infection could represent overuse and contribute to adverse outcomes. We aim to describe US ambulatory antibiotic prescribing, including those without an associated visit or infection diagnosis.

METHODS

We conducted an observational cohort study using data of all patients receiving antibacterial, antibiotic prescriptions from 04/01/2016 to 06/30/2018 in a large US private health insurance plan. We identified outpatient antibiotic prescriptions as (1) associated with a clinician visit and an infection-related diagnosis; (2) associated with a clinician visit but no infection-related diagnosis; or (3) not associated with an in-person clinician visit in the 7 days before the prescription (non-visit-based). We then assessed whether non-visit-based antibiotic prescriptions (NVBAPs) differed from visit-based antibiotics by patient, clinician, or antibiotic characteristics using multivariable models.

RESULTS

The cohort included 8.6M enrollees who filled 22.3M antibiotic prescriptions. NVBAP accounted for 31% (6.9M) of fills, and non-infection-related prescribing accounted for 22% (4.9M). NVBAP rates were lower for children than for adults (0-17 years old, 16%; 18-64 years old, 33%; >65 years old, 34%). Among most commonly prescribed antibiotic classes, NVBAP was highest for penicillins (36%) and lowest for cephalosporins (25%) and macrolides (25%). Specialist physicians had the highest rate of NVBAP (38%), followed by internists (28%), family medicine (20%), and pediatricians (10%). In multivariable models, NVBAP was associated with increasing age, and NVBAP was less likely for patients in the South, those with more baseline clinical visits, or those with chronic lung disease.

CONCLUSIONS

Over half of ambulatory antibiotic use was either non-visit-based or non-infection-related. Particularly given health care changes due to the coronavirus disease 2019 pandemic, efforts to improve antibiotic prescribing must account for non-visit-based and non-infection-related prescribing.

Operationalising outpatient antimicrobial stewardship to reduce system-wide antibiotics for acute bronchitis

BACKGROUND

Antibiotics are not recommended for treatment of acute uncomplicated bronchitis (AUB), but are often prescribed (85% of AUB visits within the Veterans Affairs nationally). This quality improvement project aimed to decrease antibiotic prescribing for AUB in community-based outpatient centres from 65% to <32% by April 2020.

METHODS

From January to December 2018, community-based outpatient clinics' 6 months' average of prescribed antibiotics for AUB and upper respiratory infections was 63% (667 of 1054) and 64.6% (314 of 486) when reviewing the last 6 months. Seven plan-do-study-act (PDSA) cycles were implemented by an interprofessional antimicrobial stewardship team between January 2019 and March 2020. Balancing measures were a return patient phone call or visit within 4 weeks for the same complaint. Χ² tests and statistical process control charts using Western Electric rules were used to analyse intervention data.

RESULTS

The AUB antibiotic prescribing rate decreased from 64.6% (314 of 486) in the 6 months prior to the intervention to 36.8% (154 of 418) in the final 6 months of the intervention. No change was seen in balancing measures. The largest reduction in antibiotic prescribing was seen after implementation of PDSA 6 in which 14 high prescribers were identified and targeted for individualised reviews of encounters of patients with AUB with an antimicrobial steward.

CONCLUSIONS

Operational implementation of successful stewardship interventions is challenging and differs from the traditional implementation study environment. As a nascent outpatient stewardship programme with limited resources and no additional intervention funding, we successfully reduced antibiotic prescribing from 64.6% to 36.8%, a reduction of 43% from baseline. The most success was seen with targeted education of high prescribers.

Comparative effectiveness of amoxicillin versus amoxicillin-clavulanate among adults with acute sinusitis in emergency department and urgent care settings

OBJECTIVE

To compare the effectiveness of amoxicillin-clavulanate versus amoxicillin for adults diagnosed with acute sinusitis (AS). A secondary objective compared antibiotic effectiveness in patients meeting risk criteria for treatment failure.

METHODS

A retrospective cohort study of adults diagnosed with AS prescribed amoxicillin ± clavulanate within Veterans Affairs emergency departments from 2012-2019 was conducted. The primary outcome was sinusitis-related return visits for amoxicillin versus amoxicillin-clavulanate. Secondary outcomes included 30-day infectious complications, gastrointestinal-related adverse events (AEs), and hospitalizations. Propensity-score matching and logistic regression models adjusted for potential confounders.

RESULTS

A total of 89,627 AS patient visits were identified: 18,576 prescribed amoxicillin and 71,051 amoxicillin-clavulanate. Most patients were male (75,604; 84.4%) and afebrile (80,624; 91.7%). The propensity score-matched cohort comprised 17,929 amoxicillin and 42,294 amoxicillin-clavulanate patient visits. There was no difference in sinusitis-related return visits between amoxicillin (4.9%) and amoxicillin-clavulanate (5.1%) (adjusted odds ratio [OR], 0.96; 95% confidence interval [CI], 0.88, 1.04; P = 0.317). Infectious complications (amoxicillin [0.3%] vs amoxicillin-clavulanate [0.4%]); (adjusted OR, 0.78; 95% CI, 0.57, 1.07; P = 0.124) and hospitalization (amoxicillin [2.0%] vs amoxicillin-clavulanate [2.4%]); (adjusted OR, 0.92; 95% CI, 0.81, 1.04; P = 0.173) were not different. Gastrointestinal-related AEs were lower with amoxicillin (0.5%) relative to amoxicillin-clavulanate (0.7%); (adjusted OR, 0.67; 95% CI, 0.53, 0.86; P = 0.002). Comorbidity was the only guideline-recommended risk factor that was a significant predictor of infectious complications with respect to treatment (amoxicillin vs amoxicillin-clavulanate, OR, 0.63; 95% CI, 0.40 to 0.94; P = 0.022).

CONCLUSION

Amoxicillin demonstrated similar efficacy to amoxicillin-clavulanate for AS with fewer gastrointestinal-related AEs. Amoxicillin is a viable option in adults with AS meeting criteria for antibiotic therapy.

The Association Between High and Unnecessary Antibiotic Prescribing: A Cohort Study Using Family Physician Electronic Medical Records

BACKGROUND

Approximately 25% of outpatient antibiotic prescriptions are unnecessary among family physicians in Canada. Minimizing unnecessary antibiotics is key for community antibiotic stewardship. However, unnecessary antibiotic prescribing is much harder to measure than total antibiotic prescribing. We investigated the association between total and unnecessary antibiotic use by family physicians and evaluated inter-physician variability in unnecessary antibiotic prescribing.

METHODS

This was a cohort study based on electronic medical records of family physicians in Ontario, Canada, between April 2011 and March 2016. We used predefined expected antibiotic prescribing rates for 23 common primary care conditions to calculate unnecessary antibiotic prescribing rates. We used multilevel Poisson regression models to evaluate the association between total antibiotic volume (number of antibiotic prescriptions per patient visit), adjusted for multiple practice- and physician-level covariates, and unnecessary antibiotic prescribing.

RESULTS

There were 499 570 physician-patient encounters resulting in 152 853 antibiotic prescriptions from 341 physicians. Substantial inter-physician variability was observed. In the fully adjusted model, we observed a significant association between total antibiotic volume and unnecessary prescribing rate (adjusted rate ratio 2.11 per 10% increase in total use; 95% CI 2.05-2.17), and none of the practice- and physician-level variables were associated with unnecessary prescribing rate.

CONCLUSIONS

We demonstrated substantial inter-physician variability in unnecessary antibiotic prescribing in this cohort of family physicians. Total antibiotic use was strongly correlated with unnecessary antibiotic prescribing. Total antibiotic volume is a reasonable surrogate for unnecessary antibiotic use. These results can inform community antimicrobial stewardship efforts.

Predictors of potentially suboptimal treatment of urinary tract infections in long-term care facilities

BACKGROUND

Suboptimal antibiotic treatment of urinary tract infection (UTI) is high in long-term care facilities (LTCFs) and likely varies between facilities. Large-scale evaluations have not been conducted.

AIM

To identify facility-level predictors of potentially suboptimal treatment of UTI in Veterans Affairs (VA) LTCFs and to quantify variation across facilities.

METHODS

This was a retrospective cohort study of 21,938 residents in 120 VA LTCFs (2013-2018) known as Community Living Centers (CLCs). Potentially suboptimal treatment was assessed from drug choice, dose frequency, and/or treatment duration. To identify facility characteristics predictive of suboptimal UTI treatment, LTCFs with higher and lower rates of suboptimal treatment (≥median, < median) were compared using unconditional logistic regression models. Joinpoint regression models were used to quantify average percentage difference across facilities. Multilevel logistic regression models were used to quantify variation across facilities.

FINDINGS

The rate of potentially suboptimal antibiotic treatment varied from 1.7 to 34.2 per 10,000 bed-days across LTCFs. The average percentage difference in rates across facilities was 2.5% (95% confidence interval (CI): 2.4-2.7). The only facility characteristic predictive of suboptimal treatment was the incident rate of UTI per 10,000 bed-days (odds ratio: 4.9; 95% CI: 2.3-10.3). Multilevel models demonstrated that 94% of the variation between facilities was unexplained after controlling for resident and CLC characteristics. The median odds ratio for the full multilevel model was 1.37.

CONCLUSION

Potentially suboptimal UTI treatment was variable across VA LTCFs. However, most of the variation across LTCFs was unexplained. Future research should continue to investigate factors that are driving suboptimal antibiotic treatment in LTCFs.

Inter-prescriber variability in the decision to prescribe antibiotics to febrile patients attending primary care in Myanmar

Background

Most antibiotic prescribing occurs in primary care. Even within the same health facility, there may be differences between prescribers in their tendency to prescribe antibiotics, which may be masked by summary data. We aimed to quantify prescriber variability in antibiotic prescription to patients with acute fever in primary care clinics in Myanmar.

Methods

We conducted a secondary analysis of prescribing data from 1090 patient consultations with 40 prescribing doctors from a trial investigating the effect of point-of-care C-reactive protein (CRP) tests on antibiotic prescription for acute fever. We used multilevel logistic regression models to assess inter-prescriber variability in the decision to prescribe antibiotics.

Results

The median odds ratio (MOR) in the unadjusted model was 1.82 (95% CI: 1.47–2.56) indicating that when two prescribers from this population are randomly selected then in half of these pairs the odds of prescription will be greater than 1.82-fold higher in one prescriber than the other. The estimated variability from this sample of prescribers corresponds to a population of prescribers where the top 25% of prescribers will prescribe antibiotics to over 41% of patients while the bottom 25% will prescribe antibiotics to less than 23% of patients. Inter-prescriber variation in antibiotic prescribing remained after adjustment for patient characteristics and CRP information (P < 0.001).

Conclusions

Despite sharing the same management guidelines, there was substantial inter-prescriber variation in antibiotic prescription to patients with acute fever. This variation should be considered when designing trials and stewardship programmes aiming to reduce inappropriate antibiotic prescribing.

Antibiotic Prescribing and Respiratory Viral Testing for Acute Upper Respiratory Infections Among Adult Patients at an Ambulatory Cancer Center

Background

Outpatient antibiotic prescribing for acute upper respiratory infections (URIs) is a high-priority target for antimicrobial stewardship that has not been described for cancer patients.

Methods

We conducted a retrospective cohort study of adult patients at an ambulatory cancer center with URI diagnoses from 1 October 2015 to 30 September 2016. We obtained antimicrobial prescribing, respiratory viral testing, and other clinical data at first encounter for the URI through day 14. We used generalized estimating equations to test associations of baseline factors with antibiotic prescribing.

Results

Of 341 charts reviewed, 251 (74%) patients were eligible for analysis. Nearly one-third (32%) of patients were prescribed antibiotics for URIs. Respiratory viruses were detected among 85 (75%) of 113 patients tested. Antibiotic prescribing (P = .001) and viral testing (P < .001) varied by clinical service. Sputum production or chest congestion was associated with higher risk of antibiotic prescribing (relative risk [RR], 2.3; 95% confidence interval [CI], 1.4–3.8; P < .001). Viral testing on day 0 was associated with lower risk of antibiotic prescribing (RR, 0.4; 95% CI 0.2–0.8; P = .01), though collinearity between viral testing and clinical service limited our ability to separate these effects on prescribing.

Conclusions

Nearly one-third of hematology–oncology outpatients were prescribed antibiotics for URIs, despite viral etiologies identified among 75% of those tested. Antibiotic prescribing was significantly lower among patients who received an initial respiratory viral test. The role of viral testing in antibiotic prescribing for URIs in outpatient oncology settings merits further study.

Accounting for variation in and overuse of antibiotics among humans

Worldwide, antibiotic use is increasing, but many infections against which antibiotics are applied are not even caused by bacteria. Over-the-counter and internet sales preclude physician oversight. Regional differences, between and within countries highlight many potential factors influencing antibiotic use. Taking a systems perspective that considers pharmaceutical commodity chains, we examine antibiotic overuse from the vantage point of both sides of the therapeutic relationship. We examine patterns and expectations of practitioners and patients, institutional policies and pressures, the business strategies of pharmaceutical companies and distributors, and cultural drivers of variation. Solutions to improve antibiotic stewardship include practitioners taking greater responsibility for their antibiotic prescribing, increasing the role of caregivers as diagnosticians rather than medicine providers, improving their communication to patients about antibiotic treatment consequences, lessening the economic influences on prescribing, and identifying antibiotic alternatives.

Systematic Review: Study of the Prescribing Pattern of Antibiotics in Outpatients and Emergency Departments in the Gulf Region

Purpose: To study the prescribing pattern of antibiotics in outpatients and emergency departments in the Gulf region. To compare the appropriateness of prescriptions and antibiotics commonly prescribed for respiratory tract infection.

Method: The search was limited to the years 2008–2020, and articles had to be in English. Articles were searched from various resources and evaluated using PRISMA. Forty-one articles were selected and screened, and in the end, 17 articles were included in the study. All articles were selected from the gulf region of six countries: UAE, Saudi Arabia, Qatar, Oman, Yemen, and Bahrain. Only primary literature were included. Inpatient and literature from other countries outside the gulf region were excluded.

Result: Penicillins, cephalosporins, and macrolides are highly useful antibiotics for respiratory tract infections. Ceftriaxone IV is recommended in acute respiratory tract infection if therapy with penicillin fails. Most of the antibiotic prescriptions in Gulf countries are inappropriate. Inappropriate antibiotic prescribing in the gulf region varies from place to place and reaches a maximum of 80%. Antibiotics may be prescribed with the wrong dosage or frequency and inappropriate guidelines. Penicillins are prescribed at about 50–60%; the most common penicillins prescribed are amoxicillin and co-amoxiclave. Cephalosporins are prescribed at about 30%, and the most common are third-generation. Macrolides are prescribed at about 17–20%, and the most common macrolides are azithromycin and clarithromycin. Fluoroquinolones are prescribed at about 10–12%, of which levofloxacin and ciprofloxacin are more commonly prescribed with metronidazole at 10%.

Conclusion: It is suggested that the antibiotic-prescribing pattern in outpatient and emergency departments in the Gulf region are highly inappropriate and need improvement through education, following guidelines, annual vaccination, and stewardship programs; the most prescribed antibiotic is amoxicillin/co-amoxiclave, and the most often encountered infection in outpatients is acute respiratory tract infection.

Evaluation of antibiotic prescribing in emergency departments and urgent care centers across the Veterans' Health Administration

OBJECTIVE

Assessments of antibiotic prescribing in ambulatory care have largely focused on viral acute respiratory infections (ARIs). It is unclear whether antibiotic prescribing for bacterial ARIs should also be a target for antibiotic stewardship efforts. In this study, we evaluated antibiotic prescribing for viral and potentially bacterial ARIs in patients seen at emergency departments (EDs) and urgent care centers (UCCs).

DESIGN

This retrospective cohort included all ED and UCC visits by patients who were not hospitalized and were seen during weekday, daytime hours during 2016-2018 in the Veterans Health Administration (VHA). Guideline concordance was evaluated for viral ARIs and for 3 potentially bacterial ARIs: acute exacerbation of COPD, pneumonia, and sinusitis.

RESULTS

There were 3,182,926 patient visits across 129 sites: 80.7% in EDs and 19.3% in UCCs. Mean patient age was 60.2 years, 89.4% were male, and 65.6% were white. Antibiotics were prescribed during 608,289 (19.1%) visits, including 42.7% with an inappropriate indication. For potentially bacterial ARIs, guideline-concordant management varied across clinicians (median, 36.2%; IQR, 26.0-52.7) and sites (median, 38.2%; IQR, 31.7-49.4). For viral ARIs, guideline-concordant management also varied across clinicians (median, 46.2%; IQR, 24.1-68.6) and sites (median, 40.0%; IQR, 30.4-59.3). At the clinician and site levels, we detected weak correlations between guideline-concordant management for viral ARIs and potentially bacterial ARIs: clinicians (r = 0.35; P = .0001) and sites (r = 0.44; P < .0001).

CONCLUSIONS

Our findings suggest that, across EDs and UCCs within VHA, there are major opportunities to improve management of both viral and potentially bacterial ARIs. Some clinicians and sites are more frequently adhering to ARI guideline recommendations on antibiotic use.

Impact of Implementation of the Core Elements of Outpatient Antibiotic Stewardship Within Veterans Health Administration Emergency Departments and Primary Care Clinics on Antibiotic Prescribing and Patient Outcomes

BACKGROUND

The Core Elements of Outpatient Antibiotic Stewardship provide a framework to improve antibiotic use. We report the impact of core elements implementation within Veterans Health Administration sites.

METHODS

In this quasiexperimental controlled study, effects of an intervention targeting antibiotic prescription for uncomplicated acute respiratory tract infections (ARIs) were assessed. Outcomes included per-visit antibiotic prescribing, treatment appropriateness, ARI revisits, hospitalization, and ARI diagnostic changes over a 3-year pre-implementation period and 1-year post-implementation period. Logistic regression adjusted for covariates (odds ratio [OR], 95% confidence interval [CI]) and a difference-in-differences analysis compared outcomes between intervention and control sites.

RESULTS

From 2014-2019, there were 16 712 and 51 275 patient visits within 10 intervention and 40 control sites, respectively. Antibiotic prescribing rates pre- and post-implementation within intervention sites were 59.7% and 41.5%, compared to 73.5% and 67.2% within control sites, respectively (difference-in-differences, P < .001). Intervention site pre- and post-implementation OR to receive appropriate therapy increased (OR, 1.67; 95% CI, 1.31-2.14), which remained unchanged within control sites (OR,1.04; 95% CI, .91-1.19). ARI-related return visits post-implementation (-1.3% vs -2.0%; difference-in-differences P = .76) were not different, but all-cause hospitalization was lower within intervention sites (-0.5% vs -0.2%; difference-in-differences P = .02). The OR to diagnose non-specific ARI compared with non-ARI diagnoses increased post-implementation forintervention (OR, 1.27; 95% CI, 1.21 -1.34) but not control (OR, 0.97; 95% CI, .94-1.01) sites.

CONCLUSIONS

Implementation of the core elements was associated with reduced antibiotic prescribing for RIs and a reduction in hospitalizations. Diagnostic coding changes were observed.

Time Trends and Factors Associated with Antibiotic Prescribing in Swiss Primary Care (2008 to 2020)

Antibiotic resistance (ABR) is a major threat to public health, and the majority of antibiotics are prescribed in the outpatient setting, especially in primary care. Monitoring antibiotic consumption is one key measure in containing ABR, but Swiss national surveillance data are limited. We conducted a retrospective cross-sectional study to characterise the patterns of antibiotic prescriptions, assess the time trends, and identify the factors associated with antibiotic prescribing in Swiss primary care. Using electronic medical records data, we analysed 206,599 antibiotic prescriptions from 112,378 patients. Based on 27,829 patient records, respiratory (52.1%), urinary (27.9%), and skin (4.8%) infections were the commonest clinical indications for antibiotic prescribing. The most frequently prescribed antibiotics were broad-spectrum penicillins (BSP) (36.5%), fluoroquinolones (16.4%), and macrolides/lincosamides (13.8%). Based on the WHO AWaRe classification, antibiotics were 57.9% Core-Access and 41.7% Watch, 69% of which were quinolones and macrolides. Between 2008 and 2020, fluoroquinolones and macrolides/lincosamides prescriptions significantly declined by 53% and 51%; BSP prescriptions significantly increased by 54%. Increasing patients' age, volume, and employment level were significantly associated with antibiotic prescribing. Our results may inform future antibiotic stewardship interventions to improve antibiotic prescribing.

Identifying Antibiotic Prescribing Patterns Through Multi-Level Latent Profile Analyses: A Cross-Sectional Survey of Primary Care Physicians

Background: Overuse of antibiotics significantly fuels the development of Antimicrobial resistance, which threating the global population health. Great variations existed in antibiotic prescribing practices among physicians, indicating improvement potential for rational use of antibiotics. This study aims to identify antibiotic prescribing patterns of primary care physicians and potential determinants. Methods: A cross-sectional survey was conducted on 551 physicians from 67 primary care facilities in Hubei selected through random cluster sampling, tapping into their knowledge, attitudes and prescribing practices toward antibiotics. Prescriptions (n = 501,072) made by the participants from 1 January to March 31, 2018 were extracted from the medical records system. Seven indicators were calculated for each prescriber: average number of medicines per prescription, average number of antibiotics per prescription, percentage of prescriptions containing antibiotics, percentage of antibiotic prescriptions containing broad-spectrum antibiotics, percentage of antibiotic prescriptions containing parenteral administered antibiotics, percentage of antibiotic prescriptions containing restricted antibiotics, and percentage of antibiotic prescriptions containing antibiotics included in the WHO "Watch and Reserve" list. Two-level latent profile analyses were performed to identify the antibiotic prescribing patterns of physicians based on those indicators. Multi-nominal logistic regression models were established to identify determinants with the antibiotic prescribing patterns. Results: On average, each primary care physician issued 909 (ranging from 100 to 11,941 with a median of 474) prescriptions over the study period. The mean percentage of prescriptions containing antibiotics issued by the physicians reached 52.19% (SD = 17.20%). Of those antibiotic prescriptions, an average of 82.29% (SD = 15.83%) contained broad-spectrum antibiotics; 71.92% (SD = 21.42%) contained parenteral administered antibiotics; 23.52% (SD = 19.12%) contained antibiotics restricted by the regional government; and 67.74% (SD = 20.98%) contained antibiotics listed in the WHO "Watch and Reserve" list. About 28.49% of the prescribers were identified as low antibiotic users, compared with 51.18% medium users and 20.33% high users. Higher use of antibiotics was associated with insufficient knowledge, indifference to changes, complacency with satisfied patients, low household income and rural location of the prescribers. Conclusion: Great variation in antibiotic prescribing patterns exists among primary care physicians in Hubei of China. High use of antibiotics is not only associated with knowledge shortfalls but also low socioeconomic status of prescribers.

Physician Prescribing Patterns and Risk of Future Long-Term Opioid Use Among Patients With Rheumatoid Arthritis: A Prospective Observational Cohort Study

OBJECTIVE

To identify the extent to which opioid prescribing rates for patients with rheumatoid arthritis (RA) vary in the US and to determine the implications of baseline opioid prescribing rates on the probability of future long-term opioid use.

METHODS

We identified patients with RA from physicians who contributed ≥10 patients within the first 12 months of participation in the Corrona RA Registry. The baseline opioid prescribing rate was calculated by dividing the number of patients with RA reporting opioid use during the first 12 months by the number of patients with RA providing data that year. To estimate odds ratios (ORs) for long-term opioid use, we used generalized linear mixed models.

RESULTS

During the follow-up period, long-term opioid use was reported by 7.0% (163 of 2,322) of patients of physicians with a very low rate of opioid prescribing (referent) compared to 6.8% (153 of 2,254) of patients of physicians with a low prescribing rate, 12.5% (294 of 2,352) of patients of physicians with a moderate prescribing rate, and 12.7% (307 of 2,409) of patients of physicians with a high prescribing rate. The OR for long-term opioid use after the baseline period was 1.16 (95% confidence interval [95% CI] 0.79-1.70) for patients of low-intensity prescribing physicians, 1.89 (95% CI 1.27-2.82) for patients of moderate-intensity prescribing physicians, and 2.01 (95% CI 1.43-2.83) for patients of high-intensity prescribing physicians, compared to very low-intensity prescribing physicians.

CONCLUSION

Rates of opioid prescriptions vary widely. Our findings indicate that baseline opioid prescribing rates are a strong predictor of whether a patient will become a long-term opioid user in the future, after controlling for patient characteristics.

Predictors and variability of antibiotic prescribing amongst family physicians

BACKGROUND

Rising rates of antimicrobial resistance are driven by overuse of antibiotics. Characterizing physician antibiotic prescribing variability can inform interventions to optimize antibiotic use.

OBJECTIVES

To describe predictors of overall antibiotic prescribing as well as the inter-physician variability in antibiotic prescribing amongst family physicians.

METHODS

We conducted a 5 year cohort study of antibiotic prescribing rates by family physicians in Ontario, Canada using a repository of electronic medical records. Using multilevel logistic regression models fitted with random intercepts for physicians, we evaluated the association of patient-, physician- and clinic-level characteristics with antibiotic prescribing rates.

RESULTS

We included 3956921 physician-patient encounters, 322129 unique patients and 313 physicians from 41 family medicine clinics. Physicians prescribed a median of 54 (interdecile range 28-95) antibiotics per 1000 encounters. Female children aged 3-5 years were most likely to receive antibiotics compared with men ≥65 years (OR 4.01, 95% CI 3.89-4.13). The only significant physician-level predictor was median daily patient visits of ≥20 compared with <10 (OR 1.28, 95% CI 1.06-1.55). The median ORs without and with patient characteristics were 1.68 and 1.69, respectively. Thus, the odds of receiving an antibiotic varied by 1.7-fold for the same patient simply by virtue of encountering two different physicians.

CONCLUSIONS

We observed substantial inter-physician variability in antibiotic prescribing that could not be explained by sociodemographic and clinical patient differences, suggesting that risk adjustment of antibiotic prescribing practices may not be required for audit and feedback of family physicians working in similar practice settings.

COVID-19: An Emerging Threat to Antibiotic Stewardship in the Emergency Department

While current research efforts focus primarily on identifying patient level interventions that mitigate the direct impact of COVID-19, it is important to consider the collateral effects of COVID-19 on antimicrobial resistance. Early reports suggest high rates of antibiotic utilization in COVID-19 patients despite their lack of direct activity against viral pathogens. The ongoing pandemic is exacerbating known barriers to optimal antibiotic stewardship in the ED, representing an additional direct threat to patient safety and public health. There is an urgent need for research analyzing overall and COVID-19 specific antibiotic prescribing trends in the ED. Optimizing ED stewardship during COVID-19 will likely require a combination of traditional stewardship approaches (e.g. academic detailing, provider education, care pathways) and effective implementation of host response biomarkers and rapid COVID-19 diagnostics. Antibiotic stewardship interventions with demonstrated efficacy in mitigating the impact of COVID-19 on ED prescribing should be widely disseminated and inform the ongoing pandemic response.

Corticosteroid Use for Acute Respiratory Tract Infections in Direct-to-Consumer Telemedicine

BACKGROUND

Systemic corticosteroids are not indicated for acute respiratory tract infections yet are nonetheless prescribed in outpatient care. Acute respiratory tract infections are the most common diagnosis in direct-to-consumer telemedicine. The objective of this study was to characterize use of corticosteroids for acute respiratory tract infections in this setting and to assess the association between corticosteroid receipt and patient satisfaction.

METHODS

Encounters with acute respiratory tract infection patients 18 years and older on a nationwide direct-to-consumer telemedicine platform were conducted by physicians between July 2016 and July 2018. Mixed-effects logistic regression was used to assess differences in the odds of corticosteroid prescription. A second mixed-effects model assessed differences in patient satisfaction by corticosteroid or antibiotic receipt. Adjusted prescribing rates for individual physicians were estimated. Models included diagnoses, patient age and geographic region, physician specialty and geographic region, and antibiotic prescription.

RESULTS

Of the 85,972 encounters with 465 physicians, 11% resulted in the physician prescribing corticosteroids. The median physician prescribing rate was 4.0% (range: <1%-81%). Corticosteroid receipt was associated with higher satisfaction versus receiving nothing (odds ratio: 2.54; 95% confidence interval: 2.25-2.87). Patients who received both an antibiotic and a corticosteroid reported the highest satisfaction (odd ratio: 3.91; 95% confidence interval: 3.27-4.68). There was no correlation between individual physicians' corticosteroid and antibiotic prescribing rates.

CONCLUSIONS

Corticosteroid receipt was associated with patient satisfaction. Most physicians rarely prescribed corticosteroids, yet a small number prescribed them frequently. Identification of high-prescribing physicians for educational interventions could reduce use of corticosteroids for acute respiratory tract infections.

Assessment of antibiotic use and concordance with practice guidelines within 3 diverse ambulatory clinic systems

OBJECTIVES

The objectives of this study were (1) to determine the rate of antibiotic prescribing at ambulatory clinics, and (2) to assess the concordance of antibiotic prescriptions with published guidelines and Food and Drug Administration-approved indications in terms of drug choices and dosing regimen.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Patients of all ages receiving at least 1 prescription during ambulatory visits in 2016 to 2017 were observed.

OUTCOME MEASURES

For each of the 3 clinic systems included in this study, oral antibiotic prescribing rates were estimated per patient and per ambulatory visit. Then, the concordance of oral antibiotic prescribing was assessed with respect to (1) choice of agent and (2) the dosing regimen by comparing it to the recommended therapeutic regimen (RTR).

RESULTS

A total of 284,348 patients receiving at least 1 prescription were included in the analysis. Between clinics, 17.4 to 43.7 per 100 patients received antibiotics. Of the antibiotics prescribed, 48.9% in Clinic A, 48.0% in Clinic B, and 60.7% in Clinic C were considered to be discordant in terms of drug choice. When the dosing regimen was taken into account in addition to the choice of agent, 72.6% in Clinic A, 76.7% in Clinic B, and 81.6% in Clinic C were discordant based on drug choice or dosing regimen. Of the prescriptions written with a discordant dosing regimen, 91.2% in Clinic A, 79.6% in Clinic B, and 91.0% in Clinic C were at a higher dosage than RTR.

CONCLUSION

Antibiotic prescribing rates vary by clinics, whereas discordant prescribing is consistently prevalent across clinics. More efforts should be put into ambulatory care to address antibiotic misuse problems, and our method could improve ambulatory antimicrobial stewardship programs.

Antimicrobial prescribing patterns of clinicians and clinical services at a large animal veterinary teaching hospital

OBJECTIVE

To characterize antimicrobial prescribing patterns of clinicians and clinical services at a large animal veterinary teaching hospital and identify factors associated with antimicrobial prescribing.

ANIMALS

All large animals (ie, equids, bovids, sheep, goats, camelids, swine, and cervids) evaluated at the New Bolton Center hospital at the University of Pennsylvania from 2013 through 2018.

PROCEDURES

In a cross-sectional study design, data on antimicrobial use by clinicians and clinical services were collected from administrative and billing records. Multivariable regression modeling was performed to identify factors associated with antimicrobial prescribing patterns.

RESULTS

Antimicrobials and critically important antimicrobials of the highest priority were dispensed in 42.1% (9,853/23,428) and 24.0% (2,360/9,853) of visits, respectively, and these proportions differed significantly among clinicians. Per visit, the median (interquartile [25th to 75th percentile] range) number of animal-defined daily doses dispensed was 3.6 (0.8 to 11.1) and the mean (SD) number of antimicrobial classes dispensed was 2.0 (1.3). Patient species, age, affected body system, and duration of hospitalization as well as submission of specimens for bacterial culture were significantly associated with prescribing patterns.

CONCLUSIONS AND CLINICAL RELEVANCE

The frequency and quantity of antimicrobials prescribed differed significantly among clinicians within and across services, even for animals with clinical signs affecting the same body system. Patient- and visit-level factors explained some but not all of the heterogeneity in prescribing patterns, suggesting that other clinician-specific factors drove such practices. More research is needed to better understand antimicrobial prescribing patterns of clinicians, particularly in situations for which no antimicrobial use guidelines have been established.

Frequency and Predictors of Suboptimal Prescribing Among a Cohort of Older Male Residents with Urinary Tract Infection

BACKGROUND

Unnecessary antibiotic treatment of suspected urinary tract infection (UTI) is common in long-term care facilities (LTCFs). However, less is known about the extent of suboptimal treatment, in terms of antibiotic choice, dose, and duration, after the decision to use antibiotics has been made.

METHODS

We described the frequency of potentially suboptimal treatment among residents with an incident UTI (first during the study with none in the year prior) in Veterans Affairs' (VA) Community Living Centers (CLCs, 2013-2018). Time trends were analyzed using Joinpoint regression. Residents with UTIs receiving potentially suboptimal treatment were compared to those receiving optimal treatment to identify resident characteristics predictive of suboptimal antibiotic treatment, using multivariable unconditional logistic regression models.

RESULTS

We identified 21,938 residents with an incident UTI treated in 120 VA CLCs, of which 96.0% were male. Potentially suboptimal antibiotic treatment was identified in 65.0% of residents and decreased 1.8% annually (p<0.05). Potentially suboptimal initial drug choice was identified in 45.6% of residents, suboptimal dose frequency in 28.6%, and longer than recommended duration in 12.7%. Predictors of suboptimal antibiotic treatment included: prior fluoroquinolone exposure (adjusted odds ratio [aOR] 1.38), chronic renal disease (aOR 1.19), age >85 years (aOR 1.17), prior skin infection (aOR 1.14), recent high white blood cell count (aOR 1.08), and genitourinary disorder (aOR 1.08).

CONCLUSION

Similar to findings in non-VA facilities, potentially suboptimal treatment was common but improving in CLC residents with an incident UTI. Predictors of suboptimal antibiotic treatment should be targeted with antibiotic stewardship interventions to improve UTI treatment.

Attitudes of High Versus Low Antibiotic Prescribers in the Management of Upper Respiratory Tract Infections: a Mixed Methods Study

IMPORTANCE

Inappropriate antibiotic use for upper respiratory tract infections (URTIs) is an ongoing problem in primary care. There is extreme variation in the prescribing practices of individual physicians, which cannot be explained by clinical factors.

OBJECTIVE

To identify factors associated with high and low prescriber status for management of URTIs in primary care practice.

DESIGN AND PARTICIPANTS

Exploratory sequential mixed-methods design including interviews with primary care physicians in a large health system followed by a survey. Twenty-nine physicians participated in the qualitative interviews. Interviews were followed by a survey in which 109 physicians participated.

MAIN MEASURES

Qualitative interviews were used to obtain perspectives of high and low prescribers on factors that influenced their decision making in the management of URTIs. A quantitative survey was created based on qualitative interviews and responses compared to actual prescribing rates. An assessment of self-prescribing pattern relative to their peers was also conducted.

RESULTS

Qualitative interviews identified themes such as clinical factors (patient characteristics, symptom duration, and severity), nonclinical factors (physician-patient relationship, concern for patient satisfaction, preference and expectation, time pressure), desire to follow evidence-based medicine, and concern for adverse effects to influence prescribing. In the survey, reported concern regarding antibiotic side effects and the desire to practice evidence-based medicine were associated with lower prescribing rates whereas reported concern for patient satisfaction and patient demand were associated with high prescribing rates. High prescribers were generally unaware of their high prescribing status.

CONCLUSIONS AND RELEVANCE

Physicians report that nonclinical factors frequently influence their decision to prescribe antibiotics for URTI. Physician concerns regarding antibiotic side effects and patient satisfaction are important factors in the decision-making process. Changes in the health system addressing both physicians and patients may be necessary to attain desired prescribing levels.

Unnecessary antibiotic prescribing in a Canadian primary care setting: a descriptive analysis using routinely collected electronic medical record data

BACKGROUND

Unnecessary antibiotic use in the community in Canada is not well defined. Our objective was to quantify unnecessary antibiotic prescribing in a Canadian primary care setting.

METHODS

We performed a descriptive analysis in Ontario from April 2011 to March 2016 using the Electronic Medical Records Primary Care database linked to other health administrative data sets at ICES. We determined antibiotic prescribing rates (per 100 patient-physician encounters) for 23 common conditions and estimated rates of unnecessary prescribing using predefined expected prescribing rates, both stratified by condition and patient age group.

RESULTS

The study included 341 physicians, 204 313 patients and 499 570 encounters. The rate of unnecessary antibiotic prescribing for included conditions was 15.4% overall and was 17.6% for those less than 2 years of age, 18.6% for those aged 2-18, 14.5% for those aged 19-64 and 13.0% for those aged 65 or more. The highest unnecessary prescribing rates were observed for acute bronchitis (52.6%), acute sinusitis (48.4%) and acute otitis media (39.3%). The common cold, acute bronchitis, acute sinusitis and miscellaneous nonbacterial infections were responsible for 80% of the unnecessary antibiotic prescriptions. Of all antibiotics prescribed, 12.0% were for conditions for which they are never indicated, and 12.3% for conditions for which they are rarely indicated. In children, 25% of antibiotics were for conditions for which they are never indicated (e.g., common cold).

INTERPRETATION

Antibiotics were prescribed unnecessarily for 15.4% of included encounters in a Canadian primary care setting. Almost one-quarter of antibiotics were prescribed for conditions for which they are rarely or never indicated. These findings should guide safe reductions in the use of antibiotics for the common cold, bronchitis and sinusitis.

Quality Indicators for the Diagnosis and Management of Acute Bacterial Rhinosinusitis

Background

Acute bacterial rhinosinusitis (ABRS) is a highly prevalent disease that is treated by a variety of specialties, including but not limited to, family physicians, emergency physicians, otolaryngology—head and neck surgeons, infectious disease specialists, and allergy and immunologists. Unfortunately, despite high-quality guidelines, variable and substandard care continues to be demonstrated in the treatment of ABRS.

Objective

This study aimed to develop ABRS-specific quality indicators (QIs) to evaluate the diagnosis and management that reduces symptoms, improves quality of life, and prevents complications.

Methods

A guideline-based approach, proposed by Kötter et al., was used to develop QIs for ABRS. Candidate indicators (CIs) were extracted from 4 guiding documents and evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND/University of California at Los Angeles appropriateness methodology.

Results

Twenty-nine CIs were identified after literature review and evaluated by our panel. Of these, 5 CIs reached consensus as being appropriate QIs, with 1 requiring additional discussion. After a second round of evaluations, the panel selected 7 QIs as appropriate measures of high-quality care.

Conclusion

This study proposes 7 QIs for the diagnosis and management of patients with ABRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay for performance initiatives.

Evaluation of clinicians' knowledge, attitudes, and planned behaviors related to an intervention to improve acute respiratory infection management

BACKGROUND

Acute respiratory tract infections (ARIs) are commonly diagnosed and major drivers of antibiotic prescribing. Clinician-focused interventions can reduce unnecessary antibiotic prescribing for ARIs. We elicited clinician feedback to design sustainable interventions to improve ARI management by understanding the mental framework of clinicians surrounding antibiotic prescribing within Veterans' Health Administration clinics.

METHODS

We conducted one-on-one interviews with clinicians (n = 20) from clinics targeted for intervention at 5 facilities. The theory of planned behavior guided interview questions. Interviews were audio recorded and transcribed for qualitative analysis. An iterative coding approach identified 6 themes.

RESULTS

Emergent themes: (1) barriers to appropriate prescribing are multifactorial and include challenges of behavior change; (2) antibiotic prescribing decisions are perceived as autonomous yet, diagnostic uncertainty and perceptions of patient demand can make prescribing decisions difficult; (3) clinicians perceive variation in peer prescribing practices and influences; (4) clinician-focused interventions are valuable if delivered with sensitivity; (5) communication strategies for educating patients are preferred to a shared decisions process; and (6) team standardization of practice and communication are key to facilitate appropriate prescribing. Clinicians perceived audit-and-feedback with peer comparison, academic detailing, and enhanced patient communication strategies as viable approaches to improving appropriate prescribing.

CONCLUSION

Implementation strategies that enable clinicians to overcome diagnostic uncertainty, perceived patient demand, and improve patient education are desired. Implementation strategies were welcomed, and some were more readily accepted (eg, audit feedback) than others (eg, shared decision making). Implementation strategies should address clinicians' perceptions of antibiotic prescribing practices and should enhance their patient communication skills.

Evaluation of uncomplicated acute respiratory tract infection management in veterans: A national utilization review

BACKGROUND

Antibiotics are overprescribed for acute respiratory tract infections (ARIs). Guidelines provide criteria to determine which patients should receive antibiotics. We assessed congruence between documentation of ARI diagnostic and treatment practices with guideline recommendations, treatment appropriateness, and outcomes.

METHODS

A multicenter quality improvement evaluation was conducted in 28 Veterans Affairs facilities. We included visits for pharyngitis, rhinosinusitis, bronchitis, and upper respiratory tract infections (URI-NOS) that occurred during the 2015-2016 winter season. A manual record review identified complicated cases, which were excluded. Data were extracted for visits meeting criteria, followed by analysis of practice patterns, guideline congruence, and outcomes.

RESULTS

Of 5,740 visits, 4,305 met our inclusion criteria: pharyngitis (n = 558), rhinosinusitis (n = 715), bronchitis (n = 1,155), URI-NOS (n = 1,475), or mixed diagnoses (&gt;1 ARI diagnosis) (n = 402). Antibiotics were prescribed in 68% of visits: pharyngitis (69%), rhinosinusitis (89%), bronchitis (86%), URI-NOS (37%), and mixed diagnosis (86%). Streptococcal diagnostic testing was performed in 33% of pharyngitis visits; group A Streptococcus was identified in 3% of visits. Streptococcal tests were ordered less frequently for patients who received antibiotics (28%) than those who did not receive antibiotics 44%; P &lt; .01). Although 68% of visits for rhinosinusitis had documentation of symptoms, only 32% met diagnostic criteria for antibiotics. Overall, 39% of patients with uncomplicated ARIs received appropriate antibiotic management. The proportion of 30-day return visits for ARI care was similar for appropriate (11%) or inappropriate (10%) antibiotic management (P = .22).

CONCLUSIONS

Antibiotics were prescribed in most uncomplicated ARI visits, indicating substantial overuse. Practice was frequently discordant with guideline diagnostic and treatment recommendations.

Antibiotic Stewardship for Older Adults in Ambulatory Care Settings: Addressing an Unmet Challenge

Inappropriate antibiotic use is common in older adults (aged >65 y), and they are particularly vulnerable to serious antibiotic-associated adverse effects such as cardiac arrhythmias, delirium, aortic dissection, drug-drug interactions, and Clostridioides difficile. Antibiotic prescribing improvement efforts in older adults have been primarily focused on inpatient and long-term care settings. However, the ambulatory care setting is where the vast majority of antibiotic prescribing to older adults occurs. To help improve the clinical care of older adults, we review drivers of antibiotic prescribing in this population, explore systems aspects of ambulatory care that can create barriers to optimal antibiotic use, discuss existing stewardship interventions, and provide guidance on priority areas for future inquiry. J Am Geriatr Soc 68:244-249, 2020.

Diagnosis and Antibiotic Management of Otitis Media and Otitis Externa in United States Veterans

Background

Acute otitis media (AOM) and otitis media with effusion (OME) occur primarily in children, whereas acute otitis externa (AOE) occurs with similar frequency in children and adults. Data on the incidence and management of otitis in adults are limited. This study characterizes the incidence, antibiotic management, and outcomes for adults with otitis diagnoses.

Methods

A retrospective cohort of ambulatory adult veterans who presented with acute respiratory tract infection (ARI) diagnoses at 6 VA Medical Centers during 2014-2018 was created. Then, a subcohort of patients with acute otitis diagnoses was developed. Patient visits were categorized with administrative diagnostic codes for ARI (eg, sinusitis, pharyngitis) and otitis (OME, AOM, and AOE). Incidence rates for each diagnosis were calculated. Proportions of otitis visits with antibiotic prescribing, complications, and specialty referral were summarized.

Results

Of 46 634 ARI visits, 3898 (8%) included an otitis diagnosis: OME (22%), AOM (44%), AOE (31%), and multiple otitis diagnoses (3%). Incidence rates were otitis media 4.0 (95% confidence interval [CI], 3.9-4.2) and AOE 2.0 (95% CI, 1.9-2.1) diagnoses per 1000 patient-years. By comparison, the incidence rates for pharyngitis (8.4; 95% CI, 8.2-8.6) and sinusitis (15.2; 95% CI, 14.9-15.5) were higher. Systemic antibiotics were prescribed in 75%, 63%, and 21% of AOM, OME, and AOE visits, respectively. Complications for otitis visits were low irrespective of antibiotic treatment.

Conclusions

Administrative data indicated that otitis media diagnoses in adults were half as common as acute pharyngitis, and the majority received antibiotic treatment, which may be inappropriate. Prospective studies verifying diagnostic accuracy and antibiotic appropriateness are warranted.