The pressure to prescribe: Antibiotic stewardship in the outpatient setting


Arlington, Va., April 16, 2019

Outpatient healthcare providers inappropriately prescribed antibiotics to 40 percent of patients in a major Veterans Affairs healthcare system - a higher figure than in previous studies examining outpatient antibiotic use - according to a new study appearing in the American Journal of Infection Control (AJIC), the journal of the Association for Professionals in Infection Control and Epidemiology, published by Elsevier.

Researchers within the Veterans Affairs Western New York Healthcare System utilized an electronic antibiotic alert following prescription to understand the most common causes of inappropriate antibiotic use. They ultimately identified four conditions that often led to over-prescription: urinary tract infections (UTIs); bronchitis; skin structure infections; and sinusitis. The study also identified the most commonly overused antibiotics, which included azithromycin, ciprofloxacin, amoxicillin/clavulanate, and cephalexin. Together, these four drugs accounted for nearly 80 percent of unnecessary drug use in the outpatient setting.

Outpatient antibiotic prescriptions comprise 60 percent of overall antibiotic use, making them a critical target for antimicrobial stewardship initiatives. Improper use of antibiotics has been associated with increased morbidity, costs, and the proliferation of resistant bacteria. According to the Centers for Disease Control (CDC), antibiotic resistance occurs when bacteria develop the ability to defeat the drugs designed to kill them. Stewardship programs focus on optimizing antibiotic use.

The study bore a unique finding: patients seen in emergency departments were twice as likely to receive an antibiotic only when needed, compared to patients seen in outpatient clinics. This suggests that patients seen in the emergency room are more likely to have legitimate antibiotic needs.

Patient-provider relationship may also be key to understanding misuse, as healthcare providers may feel a pressure to prescribe to achieve higher patient satisfaction scores.

“Our study targeted the most commonly overused antibiotics and the associated conditions in order to enable an approach focused on these factors in the outpatient setting,” said the study’s lead author, Alexis White, PharmD. “We found that real-time alerts when an antibiotic is prescribed, allowing for immediate intervention, may be an effective way to begin a stewardship program, supplemented by patient education on when an antibiotic is not needed and the harmful effects of misuse.”

The alert system enabled researchers to conduct a thorough chart review of all antibiotic prescriptions, evaluating for set criteria and stewardship targets. A drug’s use as first-line therapy, dosing, and duration were all used as benchmarks for appropriate prescription.

Additional key findings from the study included:

  • Patients with a diagnosis of sinusitis did not require an antibiotic in 32 percent of cases, as their symptoms were consistent with the common cold. Furthermore, with a sinusitis diagnosis, the incorrect drug was chosen in 53 percent of cases.
  • Prescribing patterns associated with UTIs indicate that the correct drug was chosen in 54.9 percent of cases. Antibiotics were most commonly prescribed for asymptomatic urine bacteria, a condition that does not require antibiotics.
  • Fifty-five percent of the 288 prescriptions for azithromycin were deemed unnecessary – it was most commonly misused for bronchitis, sinusitis, upper respiratory tract infections, chronic obstructive pulmonary disease, and community-acquired pneumonia.

“Antimicrobial stewardship programs are common in inpatient scenarios, but this research reinforces the point that there continues to be a significant need to build momentum for such initiatives in the outpatient setting,” said 2019 APIC President Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC. “Using a targeted approach, as recommended by the study authors, may be an effective intervention to reduce inappropriate prescribing.”

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Notes for editors
The article is “Antibiotic stewardship targets in the outpatient setting,” by Alexis T. White, Collin M. Clark, John A. Sellick, and Kari A. Mergenhagen (https://doi.org/10.1016/j.ajic.2019.01.027). It will appear in the American Journal of Infection Control, volume 47, issue 5 (May 2019) published by Elsevier.

The article is openly available at https://www.ajicjournal.org/article/S0196-6553(19)30071-9/fulltext.

About AJIC: American Journal of Infection Control
AJIC: American Journal of Infection Control
covers key topics and issues in infection control and epidemiology. Infection preventionists, including physicians, nurses, and epidemiologists, rely on AJIC for peer-reviewed articles covering clinical topics as well as original research. As the official publication of APIC, AJIC is the foremost resource on infection control, epidemiology, infectious diseases, quality management, occupational health, and disease prevention. AJIC also publishes infection control guidelines from APIC and the CDC. Published by Elsevier, AJIC is included in MEDLINE and CINAHL. www.ajicjournal.org

About APIC
The Association for Professionals in Infection Control and Epidemiology (APIC) is creating a safer world through the prevention of infection. APIC’s nearly 16,000 members develop and direct infection prevention and control programs that save lives and improve the bottom line for healthcare facilities. APIC advances its mission through patient safety, education, implementation science, competencies and certification, advocacy, and data standardization. Visit us at apic.org

About Elsevier
Elsevier is a global information analytics business that helps scientists and clinicians to find new answers, reshape human knowledge, and tackle the most urgent human crises. For 140 years, we have partnered with the research world to curate and verify scientific knowledge. Today, we’re committed to bringing that rigor to a new generation of platforms. Elsevier provides digital solutions and tools in the areas of strategic research management, R&D performance, clinical decision support, and professional education; including ScienceDirect, Scopus, SciVal, ClinicalKey and Sherpath. Elsevier publishes over 2,500 digitized journals, including The Lancet and Cell, 39,000 e-book titles and many iconic reference works, including Gray's Anatomy. Elsevier is part of RELX, a global provider of information-based analytics and decision tools for professional and business customers. www.elsevier.com

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