Highlights
- •Forty percent of antibiotic prescriptions were not indicated for use.
- •Azithromycin was prescribed unnecessarily most often.
- •The correct antibiotic was prescribed when the syndrome met clinical guidance.
- •ICD-10-CM codes were unreliable in identifying outpatient infections.
Background
Outpatient prescriptions comprise 60% of antibiotic use. This study prospectively
identified inappropriate antibiotic use enabling a focused approach to outpatient
antimicrobial stewardship.
Methods
Outpatients at the Veterans Affairs Western New York Healthcare System were identified
via an electronic antibiotic alert from June 2017 to September 2017. Descriptive statistics
and multivariable logistic regression identified stewardship targets.
Results
Of the 1,063 patients, 40% of antibiotic prescriptions were not indicated. Urinary
tract infections (21%), bronchitis (20%), skin structure infections (17%), and sinusitis
(10%) were common causes of inappropriate antibiotic use. Azithromycin (37%) was prescribed
unnecessarily most often, followed by ciprofloxacin (16%), amoxicillin/clavulanate
(13%), and cephalexin (12%). The correct drug was chosen in 52%, dose in 81%, and
duration in 75% of patients. When the antibiotic was indicated, the correct drug was
2.9 times more likely to be prescribed and 2 times more likely to have the correct
duration and receive care in the emergency room.
Discussion
Focusing on 4 drugs; amoxicillin/clavulanate, azithromycin, ciprofloxacin, and cephalexin
accounted for 80% of unnecessary drug use. This study provides a guide to concentrate
efforts during implementation of an outpatient stewardship program.
Conclusions
Poor antibiotic prescribing was found in the outpatient setting. This study identifies
areas for improvement via stewardship.
Key Words
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References
- Inappropriate prescribing in outpatient healthcare: an evaluation of respiratory infection visits among veterans in teaching versus non-teaching primary care clinics.Antimicrob Resist Infect Control. 2017; 6: 33
- Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011.JAMA. 2016; 315: 1864-1873
- Antibiotics for respiratory tract infections: a comparison of prescribing in an outpatient setting.Infect Control Hosp Epidemiol. 2015; 36: 153-159
- Antimicrobial stewardship 2012: science driving practice.Infect Control Hosp Epidemiol. 2012; 33: 319-321
- A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chronic Dis. 1987; 40: 373-383
- Acute uncomplicated bronchitis, on Centers for Disease Control and Prevention.(Available from:)https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/adult-treatment-rec.htmlDate: 2017Date accessed: October 18, 2017
- Acute otitis media (OAM), on Centers for Disease Control and Prevention.(Available from:)https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/pediatric-treatment-rec.htmlDate: 2017Date accessed: October 20, 2017
- Sexually transmitted diseases treatment guidelines, 2015.MMWR Recomm Rep. 2015; 64: 910-917
- Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults.Clin Infect Dis. 2007; 44: 27-72
- Developing and validating a risk score for lower-extremity amputation in patients hospitalized for a diabetic foot infection.Diabetes Care. 2011; 34: 1695-1700
- Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.Clin Infect Dis. 2012; 55: e86-102
- Treatment of bacterial prostatitis.Clin Infect Dis. 2010; 50: 1641-1652
- IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults.Clin Infect Dis. 2012; 54: e72-112
- Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America.Clin Infect Dis. 2014; 59: e10-e52
- Management of bacteriuria in veterans affairs hospitals.Clin Infect Dis. 2017; 65: 910-917
- International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases.Clin Infect Dis. 2011; 52: e103-e120
- Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults.Clin Infect Dis. 2005; 40: 643-654
- Practice guidelines for the management of infectious diarrhea.Clin Infect Dis. 2001; 32: 331-351
- Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America.Clin Infect Dis. 2010; 50: 133-164
- From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017.(Available from:)http://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd/Date: 2017Date accessed: October 18, 2017
- Antibiotic prescribing and patient satisfaction in primary care in England: cross-sectional analysis of national patient survey data and prescribing data.Br J Gen Pract. 2016; 66: e40-e46
- Why do general practitioners prescribe antibiotics for upper respiratory tract infections to meet patient expectations: a mixed methods study.BMJ Open. 2016; 6e012244
- Low-value antibiotic prescribing and clinical factors influencing patient satisfaction.Am J Manag Care. 2017; 23: 589-594
- Outpatient antibiotic stewardship: interventions and opportunities.J Am Pharm Assoc (2003). 2017; 57: 464-473
- Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09.J Antimicrob Chemother. 2014; 69: 234-240
- Antimicrobial stewardship in outpatient settings: a systematic review.Infect Control Hosp Epidemiol. 2015; 36: 142-152
Article Info
Publication History
Published online: March 09, 2019
Footnotes
Funding/support: This material is the result of work supported with resources and the use of facilities at the Veterans Affairs Western New York Healthcare System.
The contents of this manuscript are not intended to represent the views of the Department of Veterans Affairs or the US government.
Conflicts of interest: None to report.
Identification
Copyright
© 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
