2057. Outpatient Antibiotic Stewardship “Bundles up” in Winter with Peer Comparison, URI Order Set and Education: Is It Enough to Weather the Storm?

Abstract

BackgroundInappropriate antibiotic use is a growing problem in the outpatient setting. Approximately 90% of all antibiotics are prescribed in outpatient practices. Nonetheless, 30–70% of antibiotic prescriptions (ARx) are unnecessary. Outpatient antimicrobial stewardship (AS) is much needed and the best approach is unknown. We used a bundle approach to outpatient AS during the winter months, by implementing a peer comparison (PC) report, upper respiratory infection (URI) order set and broad education.MethodsThis is a quasi-experimental project during the period October 2018 to March 2019 (FY19) to evaluate the impact of a bundled intervention in primary care clinics at the VA Maryland Health Care System. A historical control group from the same period the previous year (FY18) was used for comparison. The intervention included an AS directed didactic and URI order set followed by an email in 1/2019 with: (1) censored PC report (ARx/1,000 encounters) with outliers defined as above 1.5 × interquartile range, (2) URI order set reminder, and (3) education. The primary outcome was total ARx per 1,000 encounters in primary care clinics. A random sampling of 200 charts was done to compare proportion of antibiotic appropriateness and number of emergency department (ED) visits and adverse drug events (ADEs) in FY19 Q1 and FY19 Q2. Poisson regression was carried out, in addition to Χ2-statistic.ResultsThere were 3,799 vs. 3,429 ARx in FY18 and FY19, respectively, with a rate difference of 3.3 ARx per 1,000 encounters (P = 0.0056). Q1 to Q2 ARx rate increased by 7.8 and 8.0 ARx per 1,000 encounters in FY18 and FY19, respectively. Forty-eight percent (28/58) of the providers confirmed receipt of email. There were 3 and 4 outliers in FY19 Q1 and Q2, respectively. Appropriate ARx for FY19 Q1 and Q2 was found to be 45% and 35% (P = 0.44), respectively. The most common indications were URI (18% vs. 18%), urinary tract infection (13% vs. 21%). ED visits (10% vs. 6%) were uncommon and there were no ADEs.ConclusionE-mail communication with bundled approach had no effect on ARx or antibiotic appropriateness; however general AS presence and URI order set tempered some use. Removing peer censoring, providing face-to-face education and intensifying antibiotic order sets are additional interventions to be implemented. Disclosures All authors: No reported disclosures.