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Inappropriate use of antimicrobials remains
problematic from a number of perspectives. It gives
rise to bacterial antibiotic resistance, allergies, complications like diarrhea
and C. difficile infections, and it can be expensive.
On
the inpatient side, Magill et al. (Magill
2021)
used data from 192 US hospitals participating in the CDC’s Emerging Infections
Program (EIP) surveillance network to evaluate the appropriateness of
antimicrobial use for hospitalized patients treated for community-acquired
pneumonia (CAP) or urinary tract infection (UTI) present at admission or for
patients who had received fluoroquinolone or intravenous vancomycin treatment.
Overall, treatment was unsupported for 55.9% of patients, including 27.3% who
received vancomycin, 46.6% who received fluoroquinolones, 76.8% with a
diagnosis of UTI, and 79.5% with a diagnosis of CAP. Common reasons for
unsupported use included long duration, antimicrobial selection that deviated
from guidelines, absence of documented signs or symptoms of infection, and lack
of microbiologic evidence of infection.
the Pew Charitable Trusts (Pew 2021) used the same data and an expert panel set
community-acquired pneumonia (CAP) t
Similarly, for urinary tract infections, the
experts estimated that in about 10% of UTI cases, circumstances such as
secondary complications or severe infections may allow for exceptions to the
treatment recommendations. The panel therefore recommended a national target to
reduce inappropriate UTI prescribing by 90%.
For fluoroquinolone use, the expert panel set
a target of a 95% reduction in this use, which allows room for rare exception
events. They recommend that, given the high risks of toxicity and adverse
events associated with fluoroquinolone use, alternative and equally effective
antibiotic agents should always be favored over fluoroquinolones when
available.
Vancomycin should be used only when
necessary, and treatment guidelines recommend close monitoring of dosing to
avoid dangerous side effects. The expert panel set a target of a 95% reduction
in unsupported use of vancomycin.
The Pew report notes that these
recommendations should be applied to the adult population and did not make
recommendations for the pediatric population.
The report goes on to describe antibiotic
stewardship programs, noting that there is no “one-size-fits-all” approach to
antibiotic stewardship. Hospitals vary in terms of size, patient population,
needs, and resources. To address these differences, the CDC created two guides,
“The
Core Elements of Hospital Antibiotic Stewardship Programs” and
“Implementation
of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals”
that describe a wide variety of interventions that hospitals can tailor to meet
their own needs.
Things aren’t any
better on the outpatient side either. A study of outpatient antibiotic
prescribing using data from a US commercial insurance database found that 23.2%
of prescriptions were inappropriate, 35.5% were potentially appropriate, and
28.5% were not associated with a recent diagnosis code (Chua 2019).
Approximately 1 in 7 enrollees filled at least one inappropriate antibiotic
prescription in 2016.
And another study in a Medicaid population (Fischer 2020) showed that large fractions of antibiotic prescriptions are filled without evidence
of infection-related diagnoses or accompanying clinician visits. The authors
found 55 percent of antibiotic prescriptions were for clinician visits
with an infection-related diagnosis, but 17 percent were for clinician
visits without an infection-related diagnosis, and 28 percent were not
associated with a visit. The authors suggest that current ambulatory antibiotic
stewardship policies miss about half of antibiotic prescribing.
Another study (Tribble
2020)
looked at inappropriate antibiotic prescribing in children’s hospitals. The
researchers found that 35.0% of children had ≥ 1 active antibiotic
order. Among those receiving antibiotics for infectious use, 25.9% were
prescribed ≥ 1 suboptimal antibiotic, and 21.0% of antibiotic
orders prescribed for infectious use were considered suboptimal. Most common
reasons for inappropriate use were bug–drug mismatch (27.7%), surgical
prophylaxis > 24 hours (17.7%), overly broad empiric therapy (11.2%),
and unnecessary treatment (11.0%). The majority of
recommended modifications were to stop (44.7%) or narrow (19.7%) the drug. Of
significance is that 46.1% of suboptimal use was not captured by current
antibiotic stewardship practices.
One group of patients receiving inappropriate
antibiotics in an ambulatory setting are older adults (Pulia 2020). Pulia et al. identified multiple factors contributing to
inappropriate antibiotic use in this setting. One theme was diagnostic
uncertainty and associated concern for potential deterioration resulting in
hospital admission or death, especially the concern for progression of UTI’s or
other bacterial infections to sepsis. These concerns often led to a lower
threshold to initiate antibiotics without a clear indication, preferential use
of broad-spectrum agents, longer treatment courses, and more frequent hospital referrals
for initiation of intravenous antibiotics. Other contributing factors included
time pressures and patient demands.
Pulia et al. note
that studies in ambulatory care settings have found that the following
interventions show promise in improving antibiotic stewardship:
Another factor influencing inappropriate
antibiotic prescribing is patients’ prior care experiences. Shi et al. (Shi
2020)
used data from a national US insurer to identify patients <65 years old with
an index acute respiratory illness (ARI) during an urgent care center visit.
They were able to determine provider prescribing rates as well. In the year
after the index ARI visit, patients seen by the highest-prescribing clinicians
received more ARI antibiotics compared to those seen by the lowest-prescribing
clinicians. Interestingly, the increase in antibiotics was also observed among
the patients’ spouses.
And we often forget
about dental practices. Dentists actually prescribe about 10% of all outpatient
antibiotics and unnecessary dental prophylaxis may be associated with serious
adverse effects (Gross 2019, Suda 2019). Up to 80% of antibiotics prescribed
prophylactically prior to dental procedures may be unnecessary. Gross et al.
found that, even though antibiotic prophylaxis is prescribed for a short
duration (≤2 days), it is not without risk. They found that 3.8% of unnecessary
prescriptions were associated with an antibiotic-related adverse event. And,
since most antibiotic-related adverse events are diagnosed in medical settings,
dentists may not be aware of these adverse effects.
Hopefully, you’ve
upgraded your antimicrobial stewardship programs in keeping with last year’s
CMS mandate.
Incorporating “the 4 moments of antibiotic
decision making” into clinical practice is recommended as a
way to reduce inappropriate antibiotic prescribing (Tamma 2019).
The 4 “moments” are:
Note that an Australian hospital adopted a
stewardship program based on the “5 Moments of Antimicrobial Prescribing” (Ghizzone 2019).
The “5 Moments” included:
The CDC does acknowledge that some progress
has been made in antibiotic stewardship. A CDC report found that the number of
hospitals that reported having an antibiotic stewardship program meeting all
seven of CDC’s Core Elements of Hospital Antibiotic Stewardship Programs almost
doubled from 2014 to 2017 (CDC
2019).
(The seven core elements are leadership commitment, accountability, drug
expertise, action, tracking, reporting and education.) Of the 4,992 acute care
hospitals responding to the 2017 National Healthcare Safety Network (NHSN)
Annual Hospital Survey, 3,816 (76.4%) reported uptake of all seven Core
Elements. They attributed this increase to a number of
factors, including new accreditation requirements for hospitals.
But the report also identified the following
opportunities to improve antibiotic prescribing:
The CDC report has links to many useful
resources for antibiotic stewardship.
The Pulia article
mentioned above (Pulia 2020)
noted that clinical decision support was sometimes of help as an antibiotic
stewardship tool. Another study from the UK (Gulliford 2019)
evaluated an antimicrobial stewardship intervention comprised a brief training
webinar, automated monthly feedback reports of antibiotic prescribing, and
electronic decision support tools to inform appropriate prescribing. Compared
to usual care, electronically delivered interventions, integrated into practice
workflow, resulted in moderate reductions of antibiotic prescribing for
respiratory tract infections in adults. There was no evidence of effect for
children younger than 15 or people aged 85 years and older. Importantly, there
was no evidence of an increase in serious bacterial complications.
Goss et al. (Goss
2020)
evaluated an indication‐based clinical decision support tool to improve
antibiotic prescribing in the emergency department for skin and soft tissue
infections, respiratory infections, and urinary infections. For those
conditions, selection rate of a guideline‐approved antibiotic for a given
indication improved from 67.1% to 72.2%. When duration of therapy is included
as a criterion, selection of a guideline‐approved antibiotic was lower
and improved from 24.7% to 31.4%, highlighting that duration of therapy is
often missing at the time of prescribing. The most substantial improvements
were seen for pneumonia and pyelonephritis with an increase from 87.9% to 97.5%
and 62.8% to 82.6%, respectively. They conclude that antibiotic prescribing can
be improved both at the drug and duration of therapy level using a
non‐interruptive and indication based‐clinical decision support
approach. They note that incorporation of duration of therapy guidelines into
the antibiotic prescribing process is needed.
All these studies show that we still have
lots of opportunities to improve our antimicrobial stewardship programs. CDC’s
two guides, “The
Core Elements of Hospital Antibiotic Stewardship Programs” and
“Implementation
of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals” are
great resources to help you improve your antimicrobial stewardship programs.
The 2019 CDC report (CDC
2019)
also has links to some good resources.
Some of our prior columns on antibiotic stewardship:
References:
Magill SS, O’Leary E, Ray SM, et al.
Assessment of the Appropriateness of Antimicrobial Use in US Hospitals. JAMA Netw Open 2021; 4(3): e212007
The Pew Charitable Trusts. Health Experts
Establish Targets to Improve Hospital Antibiotic Prescribing. National data
shows inappropriate prescribing, opportunities for improvements. Report March
19, 2021
CDC. The Core Elements of Hospital Antibiotic
Stewardship Programs. Page last reviewed: March 19, 2021
https://www.cdc.gov/antibiotic-use/core-elements/hospital.html
CDC. Implementation of Antibiotic Stewardship
Core Elements at Small and Critical Access Hospitals. Page last reviewed:
February 6, 2020
https://www.cdc.gov/antibiotic-use/core-elements/small-critical.html
Chua K-P. Appropriateness of outpatient
antibiotic prescribing among privately insured US patients: ICD-10-CM based
cross sectional study. BMJ 2019; 364 :k5092
https://www.bmj.com/content/364/bmj.k5092
Fischer
MA, Mahesri M, Lii J,
Linder JA. Non-Infection-Related And Non-Visit-Based
Antibiotic Prescribing Is Common Among Medicaid Patients. Health Affairs 2020;
39(2): 280-288
https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2019.00545?journalCode=hlthaff
Tribble AC, Lee BR, Flett
KB, et al.on behalf of the
SHARPS Collaborative. Appropriateness of Antibiotic Prescribing in U.S.
Children’s Hospitals: A National Point Prevalence Survey, Clinical Infectious
Diseases 2020; 71(8):, e226–e234
Pulia MS, Keller
SC, Crnich CJ, et al. Antibiotic Stewardship for
Older Adults in Ambulatory Care Settings: Addressing an Unmet Challenge. J Am Geriatr Soc 2020; 68(2): 244-249
https://onlinelibrary.wiley.com/doi/10.1111/jgs.16256
Shi Z, Barnett ML, Jena AB, et al,
Association of a clinician’s antibiotic prescribing rate with patients’ future
likelihood of seeking care and receipt of antibiotics, Clinical Infectious
Diseases 2020; ciaa1173 Published 10 August 2020
https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1173/5890453
Gross AE, Suda KJ,
et al. Abstract 1895 - SHEA Featured Oral Abstract: Serious Antibiotic-Related
Adverse Effects Following Unnecessary Dental Prophylaxis in the United States.
SHEA 2019 October 4, 2019
https://www.eventscribe.com/2019/IDWeek/fsPopup.asp?Mode=presInfo&PresentationID=582703
Suda KJ, Calip GS,
Zhou J, et al. Assessment of the Appropriateness of Antibiotic Prescriptions
for Infection Prophylaxis Before Dental Procedures, 2011 to 2015. JAMA Netw Open 2019; 2(5): e193909 May 31, 2019
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2734798
Tamma PD, Miller
MA, Cosgrove SE. Rethinking How Antibiotics Are Prescribed. Incorporating the 4
Moments of Antibiotic Decision Making Into Clinical
Practice. JAMA 2019; 321(2): 139-140
https://jamanetwork.com/journals/jama/article-abstract/2719862
Ghizzone M. ‘5
Moments of Antimicrobial Prescribing’ metric increases prescribing
appropriateness. Helio Infectious Disease 2019;
August 20, 2019
CDC. Antibiotic Use in the United States,
2018 Update: Progress and Opportunities. Atlanta, GA: US Department of Health
and Human Services, CDC; 2019
https://www.cdc.gov/antibiotic-use/stewardship-report/pdf/stewardship-report-2018-508.pdf
Gulliford M C, Prevost A T, Charlton J, et
al. Effectiveness and safety of electronically delivered prescribing feedback
and decision support on antibiotic use for respiratory illness in primary care:
REDUCE cluster randomised trial. BMJ 2019; 364: l236
https://www.bmj.com/content/364/bmj.l236
Goss FR, Bookman K, Baron M, et al.
Improved antibiotic prescribing using indication‐based clinical decision
support in the emergency department. JACEP Open 2020; 1-8
https://onlinelibrary.wiley.com/doi/full/10.1002/emp2.12029
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