Evaluating an urgent care antibiotic stewardship intervention: a multi-network collaborative effort.

The protocol of improving safe antibiotic prescribing in telehealth: A randomized trial

Impact of an Educational Intervention to Improve Antibiotic Prescribing for Nurse Practitioners in a Pediatric Urgent Care Center

BackgroundBetween 15–50% of patients seen in ambulatory settings are prescribed an antibiotic. At least one third of this usage is considered unnecessary. In 2019, our institution implemented the MITIGATE Toolkit, endorsed by the Centers for Disease Control and Prevention to reduce inappropriate antibiotic prescribing for viral respiratory infections in emergency and urgent care settings. In February 2020 we identified our first hospitalized patient with SARS-CoV(2). In March, efforts to limit person-to-person contact led to shelter in place orders and substantial reorganization of our healthcare system. During this time we continued to track rates of unnecessary antibiotic prescribing.MethodsThis was a single center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. We provided monthly individual feedback to urgent care prescribers, (Sep 2019-Mar 2020), primary care, and ED providers (Jan 2020 – Mar 2020) notifying them of their specific rate of unnecessary antibiotic prescribing and labeling them as a top performer or not a top performer compared to their peers. The primary outcome was rate of inappropriate antibiotic prescribing.ResultsPre toolkit intervention, 14,398 patient visits met MITIGATE inclusion criteria and 12% received an antibiotic unnecessarily in Jan-April 2019. Post-toolkit intervention, 12,328 patient visits met inclusion criteria and 7% received an antibiotic unnecessarily in Jan-April 2020. In April 2020, patient visits dropped to 10–50% of what they were in March 2020 and April 2019. During this time the unnecessary antibiotic prescribing rate doubled in urgent care to 7.8% from 3.6% the previous month and stayed stable in primary care and the ED at 3.2% and 11.8% respectively in April compared to 4.6% and 10.4% in the previous month.ConclusionRates of inappropriate antibiotic prescribing were reduced nearly in half from 2019 to 2020 across 3 ambulatory care settings. The increase in prescribing in April seen in urgent care and after providers stopped receiving their monthly feedback is concerning. Many factors may have contributed to this increase, but it raises concerns for increased inappropriate antibacterial usage as a side effect of the SARS-CoV(2) pandemic.DisclosuresAll Authors: No reported disclosures

Objective:To compare demographic patterns, diagnosis distribution, and prescribing trends between urgent care and non-urgent care clinics for infectious disease encounters across age groups.Design:Retrospective cross-sectional study.Setting:Outpatient encounters from 93 facilities (7 urgent care, 86 non-urgent clinics) in a single Michigan health system, from January 2021 to December 2024.Participants:A total of 161,328 outpatient encounters involving an antibiotic prescription. Data were stratified by age group, sex, race, insurance type, and care setting.Methods:Antibiotic prescription and ICD-10 diagnosis data were extracted from the CHARM database and compared across settings using χ2, Fisher’s exact, and Mann-Whitney tests.Results:Urgent care encounters involved younger patients (median age 45 vs 55 yr, p < .001), with more visits among children aged 0–5 years (9.0% vs 5.3%, p < .001). Non-urgent care encounters had more patients aged ≥ 60 years (43.8% vs 34.1%, p < .001). Upper respiratory tract infections (URTIs), including acute pharyngitis and otitis media, were more frequent in urgent care (15.0% and 11.9% vs 6.7% and 7.6%, p < .001). Urinary tract infections (UTIs) were more common in non-urgent care (15.2% vs 13.8%, p < .001). Amoxicillin was the most prescribed antibiotic in urgent care (17.4% vs 11.4%, p < .001), while cephalexin led in non-urgent care (13.5% vs 11.5%, p < .001).Conclusions:Comparatively, a larger proportion of urgent care visits were for patients under the age of 18 and for patients with URTIs. Meanwhile, a greater proportion of non-urgent care encounters were for patients over the age of 60 years old and patients with unspecified UTI.

Prescribing of antibiotics for viral upper respiratory infections (URIs) remains a pressing public health problem. We sought to reduce inappropriate prescribing of antibiotics for URIs in Mayo Clinic Arizona. Single-center, quasi-experimental, and retrospective cohort study. Emergency medicine and all primary care departments. The interventions included sharing baseline prescribing data, education, resources, and quarterly peer comparison reports. Encounters with diagnostic codes for respiratory infections commonly caused by viruses were categorized as Tier 3 (ie, never appropriate to prescribe antibiotics). Our goal was to reduce inappropriate prescribing for Tier 3 encounters by 22% in 2022. Department education was completed by June 2022. The annual antibiotic prescribing rate for Tier 3 encounters was reduced by 29%, from a baseline rate of 23.6% in 2021 to 16.4% in 2022 (P < .001). The posteducation prescribing rate was 13.1%. Repeat respiratory-related healthcare contact within 14 days of Tier 3 encounters did not differ between patients prescribed and not prescribed an antibiotic in all of 2022 (4.7% antibiotic vs 4.2% no antibiotic, P = .595) or during the posteducation period (3.7% vs 4.6%, P = .604). A multi-faceted intervention, which included baseline education, syndrome-specific order panels, resources for symptomatic management, and peer comparison reports, resulted in significant reduction of inappropriate antibiotic prescribing for URIs.

BackgroundAntimicrobial resistance (AMR) is currently one of the global public health threats. Increased antibiotic consumption in humans, animals, and agriculture has contributed directly to the spread of AMR. Upper respiratory tract infections (URIs) are one of the most common conditions treated by antibiotics, even if unnecessary as in cases of viral infections and self-limited conditions which represent the most cases of URIs. Investigating physicians’ knowledge, attitudes, and practice regarding antibiotic prescriptions in children with acute URIs may reflect the problem of antibiotic over prescription. This study aims to assess the problem in our community and provide information for further planning of appropriate interventions to optimize antibiotic prescriptions.MethodsThis is a cross-sectional study for all non-specialized physicians dealing with acute upper respiratory tract infections (URIs) in pediatrics sittings in Assiut district, Egypt. We used a self-administered questionnaire to assess physicians’ knowledge, attitudes, and practice. In addition, four clinical vignettes addressing different URI scenarios were included in the questionnaire to assess the patterns of antibiotic prescriptions in common cases.ResultsOur study included 153 physicians whose mean age was 32.2 ± 8.7, most of whom were pediatric residents in different health institutes in Assiut district. They had good knowledge as out of the 17 knowledge questions,the mean number of correct answers was 12.4 ± 2.9. Regarding their attitudes, mean attitude scores for inappropriate antibiotic prescribing were low. However, of those scores, the responsibility of others had the highest score (3.8 ± 0.61). Prescribing practice in special conditions of URIs showed that 80% of participants prescribed antibiotics if fever continued for more than five days and 61.4% if the child had a yellowish or greenish nasal discharge. Among 612 clinical vignettes, 326 contained antibiotic prescriptions (53.3%), and appropriate antibiotic prescriptions represented only 8.3% overall.ConclusionsPhysicians dealing with acute URIs in outpatients’ clinics in the Assiut district have good knowledge about antibiotic use and resistance and demonstrate a good attitude toward appropriate antibiotic use. Although the percentage of inappropriate prescriptions in clinical vignettes in high, more research is required to investigate the factors of antibiotic inappropriate prescribing practice and non-adherence to guidelines. Also, it is essential to set up a national antibiotic stewardship program to improve antibiotic prescribing and contain antimicrobial resistance problems.

Antibiotic overuse in China: call for consolidated efforts to develop antibiotic stewardship programmes

PAR23: DETERMINANTS OF INAPPROPRIATE ANTIBIOTIC PRESCRIBING

Behavioral Economics and Ambulatory Antibiotic Stewardship: A Narrative Review

<title>Abstract</title> Introduction: Antimicrobial resistance (AMR) poses a major global public health threat, with projected annual deaths reaching 10 million by 2050, disproportionately affecting LMICs. In Pakistan, despite adopting a National Action Plan and surveillance efforts, meaningful AMR containment actions remain limited. Primary healthcare (PHC) settings, where 80% of prescriptions contain at least one antibiotic, are critical intervention points. This study explores the existing care context and practices at rural health centres (RHC) in Punjab to inform the development of an intervention package aimed at reducing inappropriate antibiotic prescriptions for upper respiratory tract infections (URTI) and diarrhoea. Methods This study was conducted from November 2023 to May 2024 in three RHCs across Punjab, Pakistan, using a care cascade framework. The mixed-methods design included literature review, facility assessments, twelve key informant interviews, and eight focus group discussions with healthcare providers, patients, and community representatives. Data were thematically analysed using pre-defined care tasks as coding categories. Findings informed the development of an intervention package through synthesis workshops with a core expert group (CEG) and technical working group (TWG) endorsement. Results The study identified critical gaps in URTI and diarrhoea care at RHCs, including brief consultations without standard guidelines, limited diagnostics, empirical antibiotic prescribing, incomplete drug dispensing, and lack of patient counselling. Based on the findings, the following intervention components will be developed: a clinical desk aide for diagnosis and prescribing, counselling flipbooks for allied staff (dispensers), a mobile app for patient education and engagement, and a WhatsApp bot for follow-up and safety reporting. Training manuals for doctors and allied staff will also be prepared to ensure effective implementation. Discussion This study mapped systemic and behavioural drivers of inappropriate antibiotic prescriptions using a care cascade framework in rural Punjab, Pakistan. It highlights compromised consultation time, lack of diagnostics and guidelines, and absent patient counselling as key barriers to stewardship. Integrated, context-specific interventions addressing each care task are needed to improve antibiotic prescribing.

Long-term overuse of antibiotics and inappropriate prescribing has led to widespread development of antimicrobial resistance. The Department of Health and Social Care recently published a five-year national action plan to reduce antimicrobial resistance, with the aim of reducing inappropriate antibiotic prescribing. This is mirrored in the NHS Long Term Plan, which aims to reduce unintentional exposure through a combination of antibiotic stewardship and leadership at all levels. An acute respiratory tract infection is one of the most common presentations in primary care, with 16.7% of all prescriptions issued attributed to it. Therefore, out-of-hours prescribers contribute significantly to general antibiotic consumption. This article analyses the practice of delayed prescribing of antibiotics for the treatment of self-limiting respiratory tract infections in an out-of-hours service. The advantages and disadvantages associated with delayed prescribing, to safely treat patients whilst facilitating the reduction of antimicrobial resistance, are discussed. In addition, recommendations for future practice are offered. This article also focuses on the development of an advanced nurse practitioner, reflecting on the four pillars of advanced practice, which underpin advanced clinical practice and associated competencies.

Acute bronchitis is a predominantly viral illness and, according to clinical practice guidelines, should not be treated with antibiotics. Despite clear guidelines, acute bronchitis continues to be the most common acute respiratory illness for which antibiotics are incorrectly prescribed. Although the national benchmark for antibiotic prescribing for adults with acute bronchitis is 0%, a preliminary record review before implementing the intervention at the project setting showed that 96% (N = 30) of adults with acute bronchitis in this setting were prescribed an antibiotic. This quality improvement project utilized a single-group, pre-post design. The setting for this project was a large urgent care network with numerous locations in central North Carolina. The purpose was to determine whether nurse practitioners and physician assistants, after participating in a multifaceted provider education session, would reduce inappropriate antibiotic prescribing for healthy adults with acute uncomplicated bronchitis. Twenty providers attended 1 of 4 training sessions offered in October and November 2015. The face-to-face interactive training sessions focused on factors associated with inappropriate antibiotic prescribing, current clinical practice guidelines, and patient communication skills. Retrospective medical record review of 217 pretraining and 335 posttraining encounters for acute bronchitis by 19 eligible participating providers demonstrated a 61.9% reduction in immediate antibiotic prescribing from 91.7% to 29.8%. Delayed prescribing, which accounted for a small percentage of the total prescriptions given, had a small but significant increase of 9.3% after training. Overall, this multifaceted, interactive provider training resulted in significant reductions in inappropriate prescriptions.

Background: This study aims to evaluate the antimicrobial prescribing practices in hospital settings in Italy, focusing on the appropriateness of antibiotic use. Methods: This study was carried out through a retrospective review of medical records of patients admitted in three public hospitals located in Campania Region (Italy) between 1 January and 31 December 2018. Results: More than one third (34.2%) of patients received at least one inappropriate antibiotic prescription (antibiotic administered and not indicated). Being female, having a >1 Charlson comorbidity index score, and having a longer hospital stay were significant determinants of an inappropriate antibiotic prescription. Instead, patients who had had a non-urgent hospital admission, an infection on hospital admission, and a microbiological culture test during hospital stay were significantly less likely to have an inappropriate prescription. When the antibiotic prescriptions were analyzed, in 26.6% of cases they were not indicated, while among the 687 antibiotic prescriptions with indication, incorrect choice of antibiotics (36.8%) was the most common reason of the inappropriateness. Conclusions: The findings of the study indicate that the inappropriate use of antibiotics continues to be a relevant issue in the hospital setting and specific interventions are needed to encourage a wider utilization of diagnostic tools to practice targeted therapies and to counter the antimicrobial resistance.

BackgroundThe Carolinas HealthCare Outpatient Antimicrobial Stewardship Empowerment Network (CHOSEN) collaborates with more than 150 primary care ambulatory practices to improve antibiotic use in the Charlotte, NC area. CHOSEN aims for a 20% reduction in outpatient antimicrobial prescribing over 2 years with a focus on acute respiratory conditions. Initial qualitative research of provider interviews with 17 providers at 13 practices revealed the need for improved clinician reporting of prescribing rates and trends.MethodsWorking with our research and analytics division, a strategy team including clinicians, quality and pharmacy identified key drivers of over prescribing and target conditions. Previous antibiotic prescribing data collected from 281,315 adult and pediatric patients seen by nearly 900 providers was analyzed and served as a baseline. ICD-9 and 10 codes associated with acute sinusitis, nonsuppurative otitis media, acute bronchitis, cough, non-bacterial pharyngitis, upper respiratory infection, common cold, allergic rhinitis and influenza were included. Prescribing data were abstracted at the encounter level. Prescribing rates were calculated for pediatrics, internal medicine, family medicine and urgent care practices to target a 10% reduction in 2018 compared with 2017.ResultsA dashboard was developed in Microsoft Power BI with means to view prescribing data by indication and antibiotics, comparing year-to-year and rolling 24-months. Dashboard capabilities include option to drill down to the practice and provider level. An overall CHOSEN target rate for 2018 was set at 41.9% based on a baseline prescribing rate of 45.7%. Final target rates for specialties, pediatrics, internal medicine, family medicine and urgent care, were 40.8%, 38.7%, 40% and 47.2%, respectively. Provider and practice leaders were educated on use of the dashboard, along with tips to address high prescribing. Data are updated monthly and highest prescribing groups are targeted for additional onsite education.ConclusionThe development of an innovative antibiotic prescribing dashboard is achievable. CHOSEN successfully designed and applied a dashboard with focus on reduction of inappropriate antibiotic prescribing in an ambulatory care setting.Disclosures E. Gentry, Duke Endowment: Grant Investigator, Grant recipient. C. Sweeney, Duke Endowment: Grant Investigator, Grant recipient. M. Spencer, Duke Endowment: Grant Investigator, Grant recipient. Eli Lilly and Company: Grant Investigator, Grant recipient. E. Handy, Duke Endowment: Grant Investigator, Grant recipient. L. Davidson, Duke Endowment: Grant Investigator, Grant recipient.

Objective The aim of this study was to identify perceived barriers to appropriate antibiotic prescribing across different healthcare settings. Methods A cross-sectional survey of clinicians in Australian hospitals and primary care was undertaken between June and October 2019. The perceived barriers to appropriate antibiotic prescribing were considered as dependent variables, whereas age, sex, clinical experience, healthcare setting and the use of guidelines were considered independent variables. We used multivariate logistic regression to identify factors predictive of inappropriate antibiotic prescribing. Content analysis of free-text responses provided additional insights into the impediments to appropriate prescribing. Results In all, 180 clinicians completed the survey. Overall, diagnostic uncertainty and limited access to guidelines and prescribing information were significant barriers to appropriate antibiotic prescribing. Factors associated with these barriers were clinical experience, care setting (hospitals vs primary care) and the use of guidelines. Experienced clinicians (>11 years) were less likely to consider that limited access to information negatively affected prescribing practices (experience 11-20 years, odds ratio (OR) 0.66, 95% confidence interval (CI) 0.31-0.84; experience >20 years, OR 0.51, 95% CI 0.24-0.91). Conversely, general practitioners considered diagnostic uncertainty (OR 1.31, 95% CI 1.09-1.63) and patient expectations (OR 1.41, 95% CI 1.12-1.84) were more likely to be perceived barriers to appropriate prescribing. The use of guidelines and clinical experience may counteract this. Conclusion Years of experience, use of guidelines and type of setting were predictors of clinicians' perceptions regarding antibiotic prescribing. Our data highlight the importance of individual and setting characteristics in understanding variations in prescribing practices and designing targeted interventions for appropriate antibiotic prescribing. What is known about the topic? Inappropriate antibiotic prescribing is a significant health issue in Australia. Drivers of inappropriate prescribing are known, but how individual and setting characteristics contribute to variations in prescribing behaviour has not been fully understood. What does this paper add? Diagnostic uncertainty and limited access to prescribing information, including guidelines, formulary restrictions and antibiotic resistance patterns, can limit appropriate antibiotic prescribing. Clinicians' years of experience, the healthcare settings and clinician use of guidelines are important predictors of antibiotic prescribing behaviour. What are the implications for practitioners? The findings of this study can inform the design of tailored interventions to promote rational antibiotic prescribing practices in general practice and hospital settings.