Category: Federal Forum Posters
Purpose: In 2014, over 250 million outpatient prescriptions were written for antibiotics with approximately 50 percent of those prescriptions being inappropriately prescribed. Inappropriate outpatient prescribing of antibiotics leads to increase antibiotic resistance, adverse events and clostridium difficile infections. National organizations developed plans to combat antibiotic resistance by reducing inappropriate antibiotic prescribing by 50 percent. In October 2017, the Veterans Affairs (VA) began an antimicrobial stewardship campaign for Acute Respiratory Tract Infection (ARI). The objective of this outpatient antibiotic stewardship initiative was to reduce inappropriate antibiotic prescribing for uncomplicated ARI in VA outpatient-based clinics while ensuring appropriate antibiotic selection when appropriate.
Methods: The Acute Respiratory Tract Infection (ARI) clinical initiative was approved by the VA Veterans Integrated Service Network (VISN) and the local Pharmacy and Therapeutics Committee. The facility goal was to reduce antibiotic prescribing for ARI to less than thirty percent and to improve appropriate antibiotic selection to ninety percent. The facility utilized a multi-prong approach to facilitate this initiative, which included: education to medical provider group and individual providers; education to primary care and call center nursing staff; approval of non-antibiotic medications for symptomatic relief of ARI in outpatient clinics; development of computerized order sets for non-antibiotic medications; “what’s got you sick?” posters in patient waiting rooms and provider offices; and quarterly provider specific metrics by utilizing “superhero” reports. Facility leadership support allowed quick turnaround time for order set approval, development and implementation. Outpatient Medical Providers were educated in Grand Rounds as well as individual Provider education and metric review. Providers also provided input on non-antibiotic medications for symptomatic relief and patient education letter on ARI. Non-antibiotic medications included medications for pain, nasal congestion or rhinorrhea, throat discomfort, cough and wheezing. Metrics were de-identified and utilization of a superhero name for each provider engaged competition and improved provider performance.
Results: The facility implemented the outpatient antimicrobial stewardship ARI strategies in Fiscal Year 2018 (FY18) Quarter one (Q1) which correlates to October to December 2017. The overall antibiotic prescribing rate for uncomplicated ARI decreased from 44.8 percent in FY17Q4 (July to September 2017) to 22.2 percent in FY18Q3 (March to June 2018). The preferred antibiotic selection for uncomplicated pharyngitis went from zero percent in FY17Q4 to 100 percent in FY18Q3 and for uncomplicated rhinosinusitis went from 60 percent to 67 percent in the same time frame. Eighty percent of prescribers with overall antibiotic prescribing rate greater than 60 percent for uncomplicated ARI reduced their prescribing rate to less than 30 percent in the one year time frame. Unfortunately, several new Primary Care Providers started in July and August 2018 without proper education on the ARI clinical initiative which increased the overall prescribing rate for uncomplicated ARI to 52.2 percent.
Conclusion: Outpatient antimicrobial stewardship strategies can reduce inappropriate antibiotic utilization and improve antibiotic selection, dosing and duration for acute uncomplicated respiratory tract infections. Although Provider buy-in, tracking metrics, and order sets are vital to a successful antimicrobial stewardship program, availability of supportive non-antibiotic medications and patient education are imperative to ensure patient satisfaction with ARI management. Continued Provider education, especially to new Providers, and metric tracking will ensure sustainment in antimicrobial stewardship activities.