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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 CDC’s “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).
Today’s 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:
CDC (Centers for Disease Control and Prevention). Core Elements of Hospital Antibiotic Stewardship Programs. CDC 2019
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
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
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
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
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
Public Health Ontario. Antimicrobial Stewardship Strategy: Improved antimicrobial documentation. March 28, 2016
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