Implementing Antibiotic Stewardship in a Network of Urgent Care Centers.

BACKGROUND: Most antibiotics are prescribed in outpatient settings, including urgent care clinics (UCCs); however, few UCCs have described implementing antibiotic stewardship. This study describes interventions to reduce total antibiotic and azithromycin use in a UCC network. METHODS: The researchers conducted a prospective performance improvement project in five UCCs in Delaware, with > 40 providers and > 75,000 visits annually. In April 2017 all providers received in-person education on guideline-recommended management of common infections. The UCC lead physician performed chart audits and provided group and individual feedback. Individual antibiotic utilization rates were provided beginning in February 2018, and chart audits ceased in May 2018. Patient education included posters in waiting and exam rooms, discharge materials, and external website revisions. The researchers used control charts to analyze trends in prescribing over time, and calculated rate ratios (RRs) between pre-/early, mid- and postintervention periods. RESULTS: Compared to the pre-/early intervention study period (54.7 prescriptions per 100 visits), total antibiotic use declined to 40.2 (RR, 0.74; 95% confidence interval [CI] = 0.72-0.75) in the mid-intervention period and to 35.0 (RR, 0.42; 95% CI = 0.40-0.44) in the postintervention period. Azithromycin use declined from 8.5 prescriptions/100 visits to 3.5 (RR 0.64; 95% CI = 0.63-0.65) and 1.9 (RR 0.22; 95% CI = 0.21-0.24), respectively. The control charts indicated decreasing mean antibiotic prescribing rates as well as decreased variability. CONCLUSION: A multifaceted and iterative approach significantly reduced prescribing of all antibiotics, including azithromycin, regardless of diagnosis. Although the approach was initially resource-intensive, sending prescribing data directly to providers automated the process without an observed rebound in prescribing.