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Patient Safety Tip
of the Week
May
24, 2022
Requiring
Indication for Antibiotic Prescribing
Including
the indication on prescriptions and medication orders is an important patient
safety intervention. Our multiple columns on this issue, listed below, have
outlined the benefits of including the indication.
There
is one area where including the indication is particularly important
prescribing antibiotics. Knowing exactly why or for what infection the
antibiotic is being ordered can be an important part of every antibiotic
stewardship program, whether at the hospital or clinic/office. An antibiotic
stewardship program can help determine whether the specific antibiotic, dose,
or duration is appropriate for the intended infection.
The
core elements of CDCs Core Elements of Hospital Antibiotic Stewardship
Programs (CDC 2019) include documentation of dose, duration,
and indication for all antibiotic orders. CDC notes that requiring an
indication for antibiotic prescriptions can facilitate other interventions,
like prospective audit and feedback and optimizing post-discharge durations of
therapy, and, in and of itself, can improve antibiotic use.
One
question often asked is Are the indications actually accurate?. One study (Heil 2018) found that they are accurate. Heil et al.
reviewed 396 antibiotic orders in a pediatric ICU and adult medicine step-down
unit and found 90% agreement between provider-selected indication and
independent review. That was similar to the 86% accuracy in a random sample of
50 orders for antimicrobial treatment in a study by Patel et al. (Patel 2012). Heil et al. conclude that prompts to enter
antibiotic indication during order entry provide largely accurate information.
They suggest that accuracy could be further improved by an electronic order
entry system prompt to re-enter the antibiotic indication between 48 and 72
hours.
The
accuracy of the antibiotic indication documented in the order may vary somewhat
by specific antiobiotic. Timmons et al. (Timmons 2018) reviewed 155 antibiotic orders. Clinical
documentation supported the entered indication in 80% of vancomycin orders, 78%
of cefepime orders, and 74% of fluoroquinolone orders. The clinical
appropriateness for vancomycin, cefepime, and fluoroquinolones were 94%, 100%,
and 68%, respectively. They also noted that, when providers chose indications
from the list as opposed to choosing other and entering free text, antibiotic
orders were significantly more likely to be appropriate but also less likely to
match clinical documentation.
Antibiotic
stewardship on the outpatient side is more complex and it is particularly
important to know the indication for the antibiotic. Neels et al. (Neels 2020) note many factors that contribute to
inappropriate antibiotic prescribing in general practice. These include
automatic repeat prescriptions, inappropriate durations and quantities and the
extended period of time during which a prescription may be filled. In addition,
some prescriptions are dispensed more than 60 days after the prescription
date, suggesting likely usage for an alternate indication to that intended by
the prescriber. Patient expectations may also lead to inappropriate antibiotic
prescribing. They implemented an educational intervention in a large general
practice clinic in Australia. It included face-to-face education sessions with
physicians on antimicrobial stewardship principles, antimicrobial resistance,
current prescribing guidelines and microbiological testing. This resulted in a
significant reduction in prescriptions without a listed indication for
antimicrobial therapy, prescriptions without appropriate accompanying
microbiological tests and the provision of unnecessary repeat prescriptions.
There were significant improvements in appropriate antimicrobial selection,
appropriate duration, and compliance with guidelines.
Ray
et al. did a national cross sectional study of antibiotic prescribing without
documented indication in ambulatory care clinics (Ray 2019). Antibiotics were prescribed during 13.2%
of the estimated 990.8 million ambulatory care visits in 2015. 57% of the 130.5
million prescriptions were for appropriate indications, 25% were inappropriate,
and 18% had no documented indication. Being an adult male, spending more time
with the provider, and seeing a non-primary care specialist were significantly
positively associated with antibiotic prescribing without an indication.
Sulfonamides and urinary anti-infective agents were the antibiotic classes most
likely to be prescribed without documentation.
Saini
et al. (Saini 2022) recently did a literature review on
documentation of the indication for antimicrobial prescribing. They identified
123 peer-reviewed articles and grey literature documents for inclusion. Most
studies took place in a hospital setting (89%). The median prevalence of
antimicrobial indication documentation was 75% (range 4%100%). A benefit to
prescribing or patient outcomes was identified in 17 of 19 studies that looked
at these end points. They note that several studies have shown that
multipronged approaches can be used to improve this practice and that emerging
evidence demonstrates that antimicrobial indication documentation is associated
with improved prescribing and patient outcomes in both community and hospital
settings. However, they conclude that setting-specific and larger trials are
needed to provide a more robust evidence base for this practice.
An
overview on improving antimicrobial documentation by Public Health Ontario
noted several approaches (Public Health Ontario 2016). In addition to educational efforts, chart
stickers, specific antimicrobial charting forms, and a place of prominence in
the chart or medication administration record for recording details of
antimicrobial therapy are all ways of improving antimicrobial documentation. Antimicrobial
documentation can also be facilitated by using computerized physician order
entry systems; by requiring physicians to document certain information before
finalizing an order; and/or by specifying a rationale for opting out of a
protocol (e.g., ordering antimicrobials for a longer duration than
recommended).
Todays
CPOE systems and ePrescribing systems should prompt
for indication any time an antimicrobial is being ordered or prescribed. Dtop-down lists should be as specific as possible and try
to avoid using an other category as much as possible. Knowing the indication
for an antimicrobial is critical for successful antimicrobial stewardship
programs and for promoting good patient outcomes.
Some of our other columns on including indication
for medication orders:
March
23, 2010 ISMP Guidelines for Standard Order Sets
December 18, 2018 Great Recommendations for e-Prescribing
August
2019 Including
Indications for Medications: We Are Failing
March
1, 2022 Including
the Indication on Prescriptions
Some of our prior columns on antibiotic
stewardship:
- October 14, 2014 Antibiotic Stewardship
- November
2015 Medications Most Likely to
Harm the Elderly Are
- July
2016 NQF/CDC Guideline on Antibiotic Stewardship
- August
2016 Some Reassurance on Antibiotic Stewardship
- November
2016 C. Diff and Your Predecessors Room
- December
2016 Update on Ambulatory Antibiotic Stewardship
- July
2017 Antibiotics and Adverse Events
- July
2019 Dental Prescribing Called Into Question
- July
21, 2020 Is This Patient Allergic to Penicillin?
- March
30, 2021 Need for Better Antibiotic Stewardship
- August
2021 Antibiotic Stewardship in Pediatrics
References:
CDC
(Centers for Disease Control and Prevention). Core Elements of Hospital
Antibiotic Stewardship Programs. CDC 2019
https://www.cdc.gov/antibiotic-use/core-elements/hospital.html
Heil
EL, Pineles L, Mathur P, et al. Accuracy of
Provider-Selected Indications for Antibiotic Orders. Infect Control Hosp
Epidemiol 2018; 39(1): 111-113
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352307/
Patel
JA, Esterly JS, Scheetz MH, Postelnick
MJ. An analysis of the accuracy of physician-entered indications on
computerized antimicrobial orders. Infect Control Hosp Epidemiol 2012; 33: 1066-1067
Timmons
V, Townsend J, McKenzie R, Burdalski C, Adams-Sommer
V. An evaluation of provider-chosen antibiotic indications as a targeted
antimicrobial stewardship intervention. American Journal of Infection Control
2018; 46(10): 1174-1179
https://www.ajicjournal.org/article/S0196-6553(18)30215-3/fulltext
Neels
AJ, Bloch AE, Gwini SM, Athen
E. The effectiveness of a simple antimicrobial
stewardship
intervention in general practice in Australia: a pilot study. BMC Infectious
Diseases 2020; 20: 586
https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-020-05309-8
Ray M
J, Tallman G B, Bearden D T, Elman M R, McGregor J C. Antibiotic prescribing
without documented indication in ambulatory care clinics: national cross
sectional study BMJ 2019; 367: l6461
https://www.bmj.com/content/367/bmj.l6461
Saini
S, Leung V, Si E, et al. Documenting the indication for antimicrobial
prescribing: a scoping review. BMJ Quality & Safety 2022; Published Online
First: 12 May 2022
https://qualitysafety.bmj.com/content/early/2022/05/12/bmjqs-2021-014582
Public
Health Ontario. Antimicrobial Stewardship Strategy: Improved antimicrobial
documentation. March 28, 2016
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