Evaluation of uncomplicated acute respiratory tract infection management in veterans: A national utilization review.

BACKGROUND: Antibiotics are overprescribed for acute respiratory tract infections (ARIs). Guidelines provide criteria to determine which patients should receive antibiotics. We assessed congruence between documentation of ARI diagnostic and treatment practices with guideline recommendations, treatment appropriateness, and outcomes. METHODS: A multicenter quality improvement evaluation was conducted in 28 Veterans Affairs facilities. We included visits for pharyngitis, rhinosinusitis, bronchitis, and upper respiratory tract infections (URI-NOS) that occurred during the 2015-2016 winter season. A manual record review identified complicated cases, which were excluded. Data were extracted for visits meeting criteria, followed by analysis of practice patterns, guideline congruence, and outcomes. RESULTS: Of 5,740 visits, 4,305 met our inclusion criteria: pharyngitis (n = 558), rhinosinusitis (n = 715), bronchitis (n = 1,155), URI-NOS (n = 1,475), or mixed diagnoses (>1 ARI diagnosis) (n = 402). Antibiotics were prescribed in 68% of visits: pharyngitis (69%), rhinosinusitis (89%), bronchitis (86%), URI-NOS (37%), and mixed diagnosis (86%). Streptococcal diagnostic testing was performed in 33% of pharyngitis visits; group A Streptococcus was identified in 3% of visits. Streptococcal tests were ordered less frequently for patients who received antibiotics (28%) than those who did not receive antibiotics 44%; P < .01). Although 68% of visits for rhinosinusitis had documentation of symptoms, only 32% met diagnostic criteria for antibiotics. Overall, 39% of patients with uncomplicated ARIs received appropriate antibiotic management. The proportion of 30-day return visits for ARI care was similar for appropriate (11%) or inappropriate (10%) antibiotic management (P = .22). CONCLUSIONS: Antibiotics were prescribed in most uncomplicated ARI visits, indicating substantial overuse. Practice was frequently discordant with guideline diagnostic and treatment recommendations.

Reducing inappropriate outpatient antibiotic prescribing: normative comparison using unblinded provider reports.

Importance: Antibiotic resistance is a global health issue. Up to 50% of antibiotics are inappropriately prescribed, the majority of which are for acute respiratory tract infections (ARTI). Objective: To evaluate the impact of unblinded normative comparison on rates of inappropriate antibiotic prescribing for ARTI. Design: Non-randomised, controlled interventional trial over 1 year followed by an open intervention in the second year. Setting: Primary care providers in a large regional healthcare system. Participants: The test group consisted of 30 primary care providers in one geographical region; controls consisted of 162 primary care providers located in four other geographical regions. Intervention: The intervention consisted of provider and patient education and provider feedback via biweekly, unblinded normative comparison highlighting inappropriate antibiotic prescribing for ARTI. The intervention was applied to both groups during the second year. Main outcomes and measures: Rate of inappropriate antibiotic prescription for ARTI. Results: Baseline inappropriate antibiotic prescribing for ARTI was 60%. After 1 year, the test group rate of inappropriate antibiotic prescribing decreased 40%, from 51.9% to 31.0% (p<0.0001), whereas controls decreased 7% (61.3% to 57.0%, p<0.0001). In year 2, the test group decreased an additional 47% to an overall prescribing rate of 16.3%, and the control group decreased 40% to a prescribing rate of 34.5% after implementation of the same intervention. Conclusions and relevance: Provider and patient education followed by regular feedback to provider via normative comparison to their local peers through unblinded provider reports, lead to reductions in the rate of inappropriate antibiotic prescribing for ARTI and overall antibiotic prescribing rates.

Outcomes Associated With Antimicrobial De-escalation of Treatment for Pneumonia Within the Veterans Healthcare Administration.

De-escalation, an antimicrobial stewardship concept, involves narrowing broad-spectrum empiric antimicrobial therapy based on clinical data. Current health outcomes evidence is lacking to support de-escalation. Studying Veterans Healthcare Administration pneumonia patients, de-escalation was associated with improved length of stay without affecting 30-day readmission or 30-day Clostridium difficile infection rates.

Advances in the medical management of skin and soft tissue infections.

Skin and soft tissue infections are some of the most common infectious disease diagnoses in both inpatient and outpatient settings. With bacterial resistance to antimicrobials growing, decision making on empiric antibiotics is becoming increasingly difficult. Additionally, the most recent guidance from a professional society on the treatment of skin and soft tissue infections was published in 2014 by the Infectious Diseases Society of America and is now two years old. New antimicrobial agents have been developed and approved for the treatment of skin and soft tissue infections since then, and more are in the pipeline. This review summarizes the evidence on treatments that are new or in development and the potential repurposing of old antimicrobials. The clinical utility of these treatments is also discussed.

Total duration of antimicrobial therapy in veterans hospitalized with uncomplicated pneumonia: Results of a national medication utilization evaluation.

OBJECTIVE: Practice guidelines recommend the shortest duration of antimicrobial therapy appropriate to treat uncomplicated pneumonia be prescribed to reduce the emergence of resistant pathogens. A national evaluation was conducted to assess the duration of therapy for pneumonia. DESIGN: Retrospective medication utilization evaluation. SETTING: Thirty Veterans Affairs medical centers. PATIENTS: Inpatients discharged with a diagnosis of pneumonia. MEASUREMENTS: A manual review of electronic medical records of inpatients discharged with uncomplicated community-acquired pneumonia (CAP) or healthcare-associated pneumonia (HCAP) was conducted. Appropriate CAP therapy duration was defined as at least 5 days, and up to 3 additional days beginning the first day the patient achieved clinical stability criteria; the appropriate HCAP therapy duration was defined as 8 days. The duration of antimicrobial therapy for intravenous (IV) and oral (PO) inpatient administration, PO therapy dispensed upon discharge, Clostridium difficile infection (CDI), hospital readmission, and death rates were measured. RESULTS: Of 3881 pneumonia admissions, 1739 met inclusion criteria (CAP [n = 1195]; HCAP [n = 544]). Overall, 13.9% of patients (CAP [6.9%], HCAP [29.0%]) received therapy duration consistent with guideline recommendations. The median (interquartile range) days of therapy were 4 days (3-6 days), 1 day (0-3 days), and 6 days (4-8 days) for inpatient IV, inpatient PO, and outpatient PO antimicrobials, respectively. CDI was rare but more common in patients who received therapy duration consistent with guidelines. Therapy duration was not associated with the readmission or mortality rate. CONCLUSIONS: Antimicrobials were commonly prescribed for a longer duration than guidelines recommend. The majority of excessive therapy was completed upon discharge, identifying the need for strategies to curtail unnecessary use postdischarge. Journal of Hospital Medicine 2015;11:832-839. © 2015 Society of Hospital Medicine.