Changes In Antibiotic Prescribing Research Articles

The Effect of COVID-19 Vaccination on Outpatient Antibiotic Prescribing in Older Adults: A Self-Controlled Risk-Interval Study.

Coronavirus disease 2019 (COVID-19) vaccination has been associated with reduced outpatient antibiotic prescribing among older adults with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We assessed the impact of COVID-19 vaccination on outpatient antibiotic prescribing in the broader population of older adults, regardless of SARS-CoV-2 infection status. We included adults aged ≥65 years who received their first, second, and/or third COVID-19 vaccine dose from December 2020 to December 2022. We used a self-controlled risk-interval design and included cases who received an antibiotic prescription 2-6 weeks before vaccination (pre-vaccination or control interval) or after vaccination (post-vaccination or risk interval). We used conditional logistic regression to estimate the odds of being prescribed (1) any antibiotic, (2) a typical "respiratory" infection antibiotic, or (3) a typical "urinary tract" infection antibiotic (negative control) in the post-vaccination interval versus the pre-vaccination interval. We accounted for temporal changes in antibiotic prescribing using background monthly antibiotic prescribing counts. 469 923 vaccine doses met inclusion criteria. The odds of receiving any antibiotic or a respiratory antibiotic prescription were lower in the post-vaccination versus pre-vaccination interval (aOR, .973; 95% CI, .968-.978; aOR, .961; 95% CI, .953-.968, respectively). There was no association between vaccination and urinary antibiotic prescriptions (aOR, .996; 95% CI, .987-1.006). Periods with high (>10%) versus low (<5%) SARS-CoV-2 test positivity demonstrated greater reductions in antibiotic prescribing (aOR, .875; 95% CI, .845-.905; aOR, .996; 95% CI, .989-1.003, respectively). COVID-19 vaccination was associated with reduced outpatient antibiotic prescribing in older adults, especially during periods of high SARS-CoV-2 circulation.

Changes in antibiotic prescribing by dentists in the United States, 2012-2019.

Dentists prescribe 10% of all outpatient antibiotics in the United States and are the top specialty prescriber. Data on current antibiotic prescribing trends are scarce. Therefore, we evaluated trends in antibiotic prescribing rates by dentists, and we further assessed whether these trends differed by agent, specialty, and by patient characteristics. Retrospective study of dental antibiotic prescribing included data from the IQVIA Longitudinal Prescription Data set from January 1, 2012 to December 31, 2019. The change in the dentist prescribing rate and mean days' supply were evaluated using linear regression models. Dentists wrote >216 million antibiotic prescriptions between 2012 and 2019. The annual dental antibiotic prescribing rate remained steady over time (P = .5915). However, the dental prescribing rate (antibiotic prescriptions per 1,000 dentists) increased in the Northeast (by 1,313 antibiotics per 1,000 dentists per year), among oral and maxillofacial surgeons (n = 13,054), prosthodontists (n = 2,381), endodontists (n = 2,255), periodontists (n = 1,961), and for amoxicillin (n = 2,562; P < .04 for all). The mean days' supply significantly decreased over the study period by 0.023 days per 1,000 dentists per year (P < .001). From 2012 to 2019, dental prescribing rates for antibiotics remained unchanged, despite decreases in antibiotic prescribing nationally and changes in guidelines during the study period. However, mean days' supply decreased over time. Dental specialties, such as oral and maxillofacial surgeons, had the highest prescribing rate with increases over time. Antibiotic stewardship efforts to improve unnecessary prescribing by dentists and targeting dental specialists may decrease overall antibiotic prescribing rates by dentists.

Snapshots of ID Week 2022

Snapshots of ID Week 2022

Variability in changes in physician outpatient antibiotic prescribing from 2019 to 2021 during the COVID-19 pandemic in Ontario, Canada.

To evaluate inter-physician variability and predictors of changes in antibiotic prescribing before (2019) and during (2020/2021) the coronavirus disease 2019 (COVID-19) pandemic. We conducted a retrospective cohort analysis of physicians in Ontario, Canada prescribing oral antibiotics in the outpatient setting between January 1, 2019 and December 31, 2021 using the IQVIA Xponent data set. The primary outcome was the change in the number of antibiotic prescriptions between the prepandemic and pandemic period. Secondary outcomes were changes in the selection of broad-spectrum agents and long-duration (>7 d) antibiotic use. We used multivariable linear regression models to evaluate predictors of change. There were 17,288 physicians included in the study with substantial inter-physician variability in changes in antibiotic prescribing (median change of -43.5 antibiotics per physician, interquartile range -136.5 to -5.0). In the multivariable model, later career stage (adjusted mean difference [aMD] -45.3, 95% confidence interval [CI] -52.9 to -37.8, p < .001), family medicine (aMD -46.0, 95% CI -62.5 to -29.4, p < .001), male patient sex (aMD -52.4, 95% CI -71.1 to -33.7, p < .001), low patient comorbidity (aMD -42.5, 95% CI -50.3 to -34.8, p < .001), and high prescribing to new patients (aMD -216.5, 95% CI -223.5 to -209.5, p < .001) were associated with decreases in antibiotic initiation. Family medicine and high prescribing to new patients were associated with a decrease in selection of broad-spectrum agents and prolonged antibiotic use. Antibiotic prescribing changed throughout the COVID-19 pandemic with overall decreases in antibiotic initiation, broad-spectrum agents, and prolonged antibiotic courses with inter-physician variability. These findings present opportunities for community antibiotic stewardship interventions.

932. Analysis of Seasonal Variation of Antibiotic Prescribing for Respiratory Tract Diagnoses in Primary Care Practices

Abstract Background Seasonal fluctuations in antibiotic prescribing for respiratory tract diagnoses (RTDs) have been identified, but characteristics and appropriateness of these variations have not been well described. The objectives of this study were to describe seasonal variations for RTDs and to determine whether seasonal variation in prescribing is associated with inappropriate use. Methods From July 1, 2016 through June 30, 2017, antibiotic prescribing was analyzed for 31 primary care practices comparing winter (October-March) and summer (April-September) months. ICD-10 codes for RTDs were described as tier 1, 2, or 3 based on whether antibiotics are almost always, sometimes, or almost never indicated, respectively. Twenty visits from each of 60 providers were randomly selected and manually reviewed to determine a gold standard of antibiotic appropriateness in order to characterize the appropriateness of these seasonal variations. Associations between season and diagnosis tier, season and appropriateness, and individual provider seasonal changes in antibiotic prescribing and provider characteristics were determined. Results There was a lower proportion of visits with tier 3 diagnoses in winter months (68% v. 74%, p&amp;lt; 0.01), but a greater proportion of tier 2 diagnoses (29% v. 23%, p&amp;lt; 0.01). There were greater proportions of visits in which an antibiotic was prescribed for both tier 2 (80% vs 74%, p&amp;lt; 0.01) and tier 3 diagnoses (23% v. 16%, p&amp;lt; 0.01) in winter months. Using medical record review, inappropriate antibiotics were prescribed more frequently for RTDs in winter compared to summer months (73% v. 64%, p&amp;lt; 0.01). Greater individual provider difference in proportion of RTD visits in which an antibiotic was prescribed from summer to winter was associated with family medicine v. internal medicine specialty (8.2% v. 5.1%, p&amp;lt; 0.01), nonteaching v. teaching practice (8.1% v. 2.9%, p&amp;lt; 0.01), and nonurban v. urban setting (9.1% v. 3.9%, p&amp;lt; 0.01). Conclusion Although there was a greater proportion of tier 2 compared to tier 3 RTDs in winter months, winter months were associated with more inappropriate prescribing than in summer months. More investigation is needed to understand the drivers for seasonal variations in RTDs and inappropriate prescribing. Disclosures Kathleen Degnan, MD, Gilead: Grant/Research Support Michael Z. David, MD PhD, Contrafect: Grant/Research Support|GSK: Advisor/Consultant|Johnson and Johnson: Advisor/Consultant.

875. Guess Who’s Back: The Return of Seasonal Respiratory Viruses in the State of Wisconsin and Associated Changes in Antibiotic Prescribing for Respiratory Complaints

Abstract Background Return of infections caused by common respiratory viruses (RV) may be expected with the relaxation and/or removal of infection prevention measures instituted during the COVID-19 pandemic. Therefore, we examined respiratory virus detection (RVD) rates in Wisconsin during the COVID-19 period, and whether ambulatory antibiotic prescribing for respiratory complaints has increased with return of typical RVs. Methods The Wisconsin State Laboratory of Hygiene’s Viral Surveillance program collects RVD data from &amp;gt;130 laboratories across the state for influenza (FLU), respiratory syncytial virus (RSV), seasonal coronaviruses (sCOR), parainfluenza virus (PARA), enteroviruses/rhinoviruses (E/R), and human metapneumovirus (hMPV). Data were collected from 1/1/2015 to 4/30/2022. Antibiotic prescribing for ambulatory care patients presenting with respiratory complaints was collected from our EHR, which utilizes a required order form for all ambulatory antibiotic prescriptions. Statistical analysis was performed using Mann-Whitney Rank Sum and Spearman’s rank correlation. Results In the first year after COVID-19 onset, E/R and sCOR were detected at low levels while other RVs were essentially nil. After 4/2021, when infection prevention measures (i.e. mask mandates) were significantly relaxed or removed, RVDs increased for all viruses. At present, RVDs have returned to typical rates (except of FLU, Fig. 1) and seasonality variation (except of RSV, Fig. 1). Antibiotic prescribing for respiratory complaints has increased 57% in this period (3.5 to 5.5 prescriptions/1000 encounters, Fig. 2) and continues to trend up with RV activity. Prescribing rates are strongly correlated with RVD rates, but most strongly correlated with non-FLU, non-RSV RVD rates (Spearman correlation 0.71). The dashed vertical line represents relaxation/discontinuation of public infection prevention measures (e.g. masking). The dashed vertical line represents relaxation/discontinuation of public infection prevention measures (e.g. masking). * Parainfluenza virus, human metapneumovirus, enterovirus/rhinovirus, or seasonal coronavirus. Conclusion In general, RVs have returned to pre-pandemic rates with seasonality. Interestingly, this return was associated with the relaxation/removal of infection prevention measures in the second year post-COVID-19 onset, and does not appear to be impacted by ongoing COVID-19 waves. Antibiotic prescribing in ambulatory care continues to be highly associated with RV activity, indicating this should remain a high priority of ambulatory stewardship education and intervention. Disclosures All Authors: No reported disclosures.

Survey of healthcare worker perceptions of changes in infection control and antimicrobial stewardship practices in India and South Africa during the COVID-19 pandemic

To identify perceptions and awareness of changes in IPC and AMS practices among healthcare workers (HCWs) during the COVID-19 pandemic in India and South Africa (SA). A self-administered online survey which included participant demographics, knowledge and sources of COVID-19 infection, perceived risks and barriers, and self-efficacy. Data were analysed using descriptive statistics. 321 responses (response rate: 89.2%); 131/321 (40.8%) from India and 190/321 (59.2%) from SA; male to female response rate was 3:2, with majority of respondents aged 40-49 (89/321, 27.7%) and 30-39 (87/321, 27.1%) years. Doctors comprised 47.9% (57/119) of respondents in India and 74.6% (135/181) in SA. Majority of respondents in India (93/119, 78.2%) and SA (132/181, 72.9%) were from the private and public sectors, respectively with more respondents in SA (123/174, 70.7%) than in India (38/104, 36.5%) were involved in antimicrobial prescribing. Respondents reported increased IPC practices since the pandemic and noted need for more training on case management, antibiotic and personal protective equipment (PPE) use. While they noted increased antibiotic prescribing since the pandemic; they did not generally associate their practice with such increase. A willingness to be vaccinated, when vaccination becomes available, was expressed by 203/258 (78.7%) respondents. HCWs reported improved IPC practices and changes in antibiotic prescribing during the COVID-19 pandemic. Targeted education on correct use of PPE was an identified gap. Although HCWs expressed concerns about antimicrobial resistance, their self-perceived antibiotic prescribing practices seemed unchanged. Additional studies in other settings could explore how our findings fit other contexts.

Impact of the Choosing Wisely Canada recommendations on potentially inappropriate antibiotic prescribing in emergency medicine across Alberta, Canada: An interrupted time-series analysis.

ObjectivesIn Alberta, Canada, we quantified the rate of potentially inappropriate oral antibiotic prescribing in emergency departments for viral infections or conditions not likely requiring antibiotics from 2010-2020 and assessed the impact of two Choosing Wisely Canada (CWC) campaigns (2015/2016 and 2018) discouraging inappropriate antibiotic prescribing in emergency medicine.&#x0D; ApproachWe linked emergency department adult and pediatric records from the National Ambulatory Care Reporting System and medication dispensations from community-based pharmacies in the Pharmaceutical Information Network. From January 2010 to February 2020, we identified emergency department visits for 5 conditions that were potentially inappropriately treated using antibiotics per CWC recommendations (bronchitis, asthma, bronchiolitis, pharyngitis, and acute otitis media). We used an interrupted time series design to detect changes in antibiotic prescribing by fitting Autoregressive Integrated Moving Average (ARIMA) models to account for secular trends and seasonality, allowing for change in slopes to measure the effect of each CWC intervention.&#x0D; ResultsAntibiotics were commonly prescribed in emergency departments for bronchitis (proportion of visits with antibiotics: 57%) and asthma (22%) in adults; bronchiolitis in children (43%); pharyngitis (39%) and acute otitis media (54%) in adults and children. Based on visual inspection, the proportion of emergency department visits for each condition where antibiotics were dispensed remained relatively consistent. The ARIMA models demonstrated mixed impacts on potentially inappropriate antibiotic prescribing associated with two interruptions: the 2015/2016 CWC recommendations and subsequent 2018 CWC Using Antibiotics Wisely campaign. Following each interruption, antibiotic prescribing was slightly reduced for bronchitis&#x0D; (-1.0%/year,p=0.03; -4.4%/year,p=0.004, respectively) and bronchiolitis (not significant)&#x0D; (-0.7%/year,p=0.57; -2.5%/year,p=0.34), but unchanged for asthma (-0.6%/year,p=0.30; 0.7%/year,p=0.74) and pharyngitis (0.0%/year,p=0.95; -0.2%/year,p=0.93), and slightly increased for acute otitis media (not significant) (1.4%/year,p=0.07; 5.9%/year,p=0.052).&#x0D; ConclusionRates of potentially inappropriate antibiotic prescribing remained constant over the past 10 years in Alberta. Campaigns to rethink antibiotic use in emergency medicine may have resulted in small decreases in antibiotic use; however, further initiatives building upon existing campaigns are required to substantially reduce rates of inappropriate antibiotic prescribing.

Effectiveness of clinical dashboards as audit and feedback or clinical decision support tools on medication use and test ordering: a systematic review of randomized controlled trials.

BackgroundClinical dashboards used as audit and feedback (A&F) or clinical decision support systems (CDSS) are increasingly adopted in healthcare. However, their effectiveness in changing the behavior of clinicians or patients is still unclear. This systematic review aims to investigate the effectiveness of clinical dashboards used as CDSS or A&F tools (as a standalone intervention or part of a multifaceted intervention) in primary care or hospital settings on medication prescription/adherence and test ordering.MethodsSeven major databases were searched for relevant studies, from inception to August 2021. Two authors independently extracted data, assessed the risk of bias using the Cochrane RoB II scale, and evaluated the certainty of evidence using GRADE. Data on trial characteristics and intervention effect sizes were extracted. A narrative synthesis was performed to summarize the findings of the included trials.ResultsEleven randomized trials were included. Eight trials evaluated clinical dashboards as standalone interventions and provided conflicting evidence on changes in antibiotic prescribing and no effects on statin prescribing compared to usual care. Dashboards increased medication adherence in patients with inflammatory arthritis but not in kidney transplant recipients. Three trials investigated dashboards as part of multicomponent interventions revealing decreased use of opioids for low back pain, increased proportion of patients receiving cardiovascular risk screening, and reduced antibiotic prescribing for upper respiratory tract infections.ConclusionThere is limited evidence that dashboards integrated into electronic medical record systems and used as feedback or decision support tools may be associated with improvements in medication use and test ordering.

Antibiotic Prescribing in Dutch Daytime and Out-of-Hours General Practice during the COVID-19 Pandemic: A Retrospective Database Study

COVID-19 restrictions have resulted in major changes in healthcare, including the prescribing of antibiotics. We aimed to monitor antibiotic prescribing trends during the COVID-19 pandemic in Dutch general practice, both during daytime and out-of-hours (OOH). Routine care data were used from 379 daytime general practices (DGP) and 28 OOH-services over the period 2019–2021. Per week, we analyzed prescription rates per 100,000 inhabitants, overall, for respiratory and urinary tract infections (RTIs and UTIs) specifically and within age categories. We assessed changes in antibiotic prescribing during different phases of the pandemic using interrupted time series analyses. Both at DGPs and OOH-services significantly fewer antibiotics were prescribed during the COVID-19 pandemic after government measures became effective. Furthermore, the number of contacts decreased in both settings. When restrictions were revoked in 2021 prescription rates increased both at DGP and OOH-services, returning to pre-pandemic levels at OOH-services, but not in DGP. Changes in antibiotic prescribing rates were prominent for RTIs and among children up to 11 years old, but not for UTIs. To conclude, while antibiotic prescribing decreased during the first year of the COVID-19 pandemic both in daytime and out-of-hours, the pandemic does not seem to have a lasting effect on antibiotic prescribing.

Changes in antibiotic prescribing following COVID-19 restrictions: Lessons for post-pandemic antibiotic stewardship.

AimsPublic health responses to reduce SARS‐CoV‐2 transmission have profoundly affected the epidemiology and management of other infections. We examined the impact of COVID‐19 restrictions on antibiotic dispensing in Australia.MethodsWe used national claims data to investigate antibiotic dispensing trends from November 2015 to October 2020 and whether changes reflected reductions in primary care consultations. We used interrupted time series analysis to quantify changes in monthly antibiotic dispensing and face‐to‐face and telehealth GP consultations and examined changes by recipient age, pharmacy State and prescriber specialty.ResultsOver the study period, an estimated 19 921 370 people had 125 495 137 antibiotic dispensings, 71% prescribed by GPs. Following COVID‐19 restrictions, we observed a sustained 36% (95% CI: 33–40%) reduction in antibiotic dispensings from April 2020. Antibiotics recommended for managing respiratory tract infections showed large reductions (range 51–69%), whereas those recommended for non‐respiratory infections were unchanged. Dispensings prescribed by GPs decreased from 63.5 per 1000 population for April–October 2019 to 37.0 per 1000 for April–October 2020. Total GP consultation rates remained stable, but from April 2020, 31% of consultations were telehealth.ConclusionIn a setting with a low COVID‐19 incidence, restrictions were associated with a substantial reduction in community dispensings of antibiotics primarily used to treat respiratory infections, coincident with reported reductions in respiratory viral infections. Our findings are informative for post‐pandemic antimicrobial stewardship and highlight the potential to reduce inappropriate prescribing by GPs and specialists for respiratory viral infections.

Antimicrobial stewardship in the UK during the COVID-19 pandemic: a population-based cohort study and interrupted time-series analysis.

BackgroundThe COVID-19 pandemic has altered the context for antimicrobial stewardship in primary care.AimTo assess the effect of the pandemic on antibiotic prescribing, accounting for changes in consultations for respiratory and urinary tract infections (RTIs/UTIs).Design and settingPopulation-based cohort study using the UK Clinical Practice Research Datalink (CPRD) GOLD database from January 2017 to September 2020.MethodInterrupted time-series analysis evaluated changes in antibiotic prescribing and RTI/UTI consultations adjusting for age, sex, season, and secular trends. The authors assessed the proportion of COVID-19 episodes associated with antibiotic prescribing.ResultsThere were 253 655 registered patients in 2017 and 232 218 in 2020, with 559 461 antibiotic prescriptions, 216 110 RTI consultations, and 36 402 UTI consultations. Compared with prepandemic months, March 2020 was associated with higher antibiotic prescribing (adjusted rate ratio [ARR] 1.13; 95% confidence interval [CI] = 1.11 to 1.16). Antibiotic prescribing fell below predicted rates between April and August 2020, reaching a minimum in May (ARR 0.73; 95% CI = 0.71 to 0.75). Pandemic months were associated with lower rates of RTI/UTI consultations, particularly in April for RTIs (ARR 0.23; 95% CI = 0.22 to 0.25). There were small reductions in the proportion of RTI consultations with antibiotic prescribed and no reduction for UTIs. Among 25 889 COVID-19 patients, 2942 (11%) had antibiotics within a COVID-19 episode.ConclusionPandemic months were initially associated with increased antibiotic prescribing, which then fell below expected levels during the national lockdown. Findings are reassuring that antibiotic stewardship priorities have not been neglected because of COVID-19. Research is required into the effects of reduced RTI/UTI consultations on incidence of serious bacterial infections.

97. Assessment of the accuracy of direct antimicrobial susceptibility testing from positive blood cultures in pediatric patients and its utility as an antimicrobial stewardship tool

BackgroundHospitalized pediatric patients with bacteremia receive broad-spectrum antibiotics while organism identification and antibiotic susceptibilities are pending. Direct susceptibility testing (DST) using unstandardized Kirby-Bauer disk diffusion provides early results before standardized (final) antimicrobial susceptibility testing (AST) is available. The accuracy of DST in comparison with AST has been poorly studied. If DST is highly accurate, it could facilitate earlier de-escalation of antibiotics.MethodsRetrospective cohort study of all positive blood cultures at Boston Children’s Hospital between January 1, 2017 and October 20, 2019. Isolates were eligible for inclusion if a DST result was available. Isolates were excluded if more than one organism grew from a blood culture or if a patient had repeat blood cultures positive for the same organism within 14 days. Patient characteristics and antibiotic orders were identified via a local data warehouse. Positive and negative predictive value (PPV: accuracy of susceptibility on DST in identifying susceptibility on AST result; NPV: accuracy of DST in identifying non-susceptibility on AST result) and 95% confidence interval were calculated for each bug-drug combination. Antibiotic Spectrum Index was evaluated at 3 time points to assess change in antibiotic prescribing after availability of DST and AST results.Results496 patients (median age: 51 months, IQR: 7–165 months) with 603 positive blood cultures were included in the final analysis. PPV of DST was ≥96%for most organism-antibiotic pairs (Table). NPV of DST varied substantially across organism-antibiotic pairs and was frequently lower than PPV. The proportion of patients with more narrow spectrum antibiotic orders increased after the DST result and again after the AST result (Figure).TableTest performance of direct susceptibility testing (DST) of clinical isolates from patients with bacteremia to identify organism susceptibility to the noted antibiotic. Positive predictive value measures the ability of a susceptible DST result to predict a susceptible AST result. Negative predict value measures the ability of an intermediate or resistant DST result to predict an intermediate or resistant AST result. *Includes Staphylococcus capitis, Staphylococcus epidermidis, Staphylococcus haemolyticus, Staphylococcus hominis, Staphylococcus pettenkoferi, and Staphylococcus warneri. ‡Includes Citrobacter freundii complex, Citrobacter koseri, Enterobacter aerogenes, Enterobacter cloacae complex, Escherichia coli, Escherichia vulneris, Klebsiella oxytoca, Klebseilla pneumoniae, Klebsiella variicola, Pantoea species, Proteus mirabilis, Salmonella species, Salmonella typhi, Serratia liquefaciens, and Serratia marcescens. FigureDistribution of spectrum of antibiotics ordered to treat bacteremia in pediatric patients. Antibiotic spectrum, as measured by the antibiotic spectrum index, is represented in this Sankey diagram on the Y-axis. The height of each group indicates the proportion of patients with an aggregate antibiotic spectrum falling in that category at three time points. The ASI of empiric antibiotics was measured just before the DST result to provide time for a treating physician to settle on an empiric regimen. The ASI with the DST result was measured just before the ASI result. The ASI with the AST result was measured 24 hours after the AST result was available. Green bars indicate the proportion of patients within a group whose ASI remained unchanged between time points. Blue bars indicate the proportion of patients within a group whose ASI decreased, and red bars indicate the proportion of patients whose ASI increased between time points. ConclusionDST is highly accurate at identifying susceptibility to antibiotics for many bug-drug combinations in pediatric blood culture isolates, but its ability to identify non-susceptibility is less robust. The observed spectrum of prescribed antibiotics was narrower after DST results, suggesting some clinicians may be using the result to de-escalate therapy. DST may be a useful low-cost tool for antimicrobial stewardship.Disclosures All Authors: No reported disclosures

Improving Antibiotic Prescribing for Pediatric Urinary Tract Infections in Outpatient Settings

To determine if a multicomponent intervention was associated with increased use of first-line antibiotics (cephalexin or sulfamethoxazole and trimethoprim) among children with uncomplicated urinary tract infections (UTIs) in outpatient settings. The study was conducted at Kaiser Permanente Colorado, a large health care organization with ∼127 000 members <18 years of age. After conducting a gap analysis, an intervention was developed to target key drivers of antibiotic prescribing for pediatric UTIs. Intervention activities included development of new local clinical guidelines, a live case-based educational session, pre- and postsession e-mailed knowledge assessments, and a new UTI-specific order set within the electronic health record. Most activities were implemented on April 26, 2017. The study design was an interrupted time series comparing antibiotic prescribing for UTIs before versus after the implementation date. Infants <60 days old and children with complex urologic or neurologic conditions were excluded. During January 2014 to September 2018, 2142 incident outpatient UTIs were identified (1636 preintervention and 506 postintervention). Pyelonephritis was diagnosed for 7.6% of cases. Adjusted for clustering of UTIs within clinicians, the proportion of UTIs treated with first-line antibiotics increased from 43.4% preintervention to 62.4% postintervention (P < .0001). The use of cephalexin (first-line, narrow spectrum) increased from 28.9% preintervention to 53.0% postintervention (P < .0001). The use of cefixime (second-line, broad spectrum) decreased from 17.3% preintervention to 2.6% postintervention (P < .0001). Changes in prescribing practices persisted through the end of the study period. A multicomponent intervention with educational and process-improvement elements was associated with a sustained change in antibiotic prescribing for uncomplicated pediatric UTIs.

Associations between declining antimicrobial use in primary care in Scotland and patient satisfaction and hospitalisation due to infection: a longitudinal study of greater than five million patients

Background. Scottish antimicrobial prescribing in the community has fallen since 2012, but this could have unintended consequences. The aim was to examine associations between changes in antibiotic prescribing in primary care and hospital admissions and patient satisfaction. Methods. Data for 877 Scottish general practices with 5.1 million patients were provided by NHS National Services Scotland. Practices were classified into four equal groups (quartiles) in terms of change in total antibiotic prescribing (rate/1000 registered patients in each quarter) 2012-2018. Changes in hospital admission with infection were examined comparing the four groups. Multivariate regression examined associations between change in antibiotic prescribing and patient satisfaction with the practice using national survey data. Results. Across Scotland, primary care antibiotic prescribing decreased by 15% from 194.1 (95%CI 193.8-194.4) in Q1 2012 to 165.3 (95%CI 165.0-165.6 ) in Q2 2012, with considerable variation between practices (non-significant increase of 0.22 prescriptions/1000/quarter [p=0.49] for the quartile of practices with least reduction in antibiotic prescribing, vs reduction of -2.95 prescriptions/1000/quarter [p&lt;0.001] for quartile with the largest reduction). Rates of hospital admissions with infection increased over the time period but there were no significant association with changes in antibiotic prescribing. Patient satisfaction decreased over the period, but change in antibiotic prescribing was not associated with patient satisfaction. Conclusion. There have been clinically significant reductions in Scottish primary care antibiotic use since 2012, varying considerably between practices. Longitudinal analysis of Scotland-wide practice level data found no associations between practice-level reductions in primary care antibiotic prescribing and hospital admissions or patient satisfaction.

Impact of a pilot NHS-funded sore throat test and treat service in community pharmacies on provision and quality of patient care

ObjectiveA National Health Service (NHS)-funded sore throat test and treat (STTT) service was introduced in selected pharmacies in two local health boards in Wales, as an extension to the national...

Is ‘Health for All’ synonymous with ‘antibiotics for all’: changes in antibiotic prescribing in a performance-based financing pilot in Zanzibar

Universal Health Coverage, to meet the Sustainable Development Goal of 'Health for All', aims to increase the access of preventative and curative care services, particularly to the poor and vulnerable. However, the very provision of curative services by health providers in the primary care setting in low-income countries is considered one of the major drivers of antimicrobial resistance. The Zanzibar Ministry of Health introduced performance-based financing (PBF) in 2 of 10 Health Districts in July 2013. Payments to health facilities and staff were on a fee-for-service basis using 'direct quality indicators'. Results of an evaluation of secondary data of two indicators, 'treatment according to guidelines' and 'antibiotics prescribed according to guidelines' from 31 Primary Health Care Units in the two PBF pilot districts are compared with 28 in non-PBF districts. The proportion of patients treated with an antibiotic not in accordance with treatment guidelines after the introduction of PBF fell to 2%, 6% and 5% in 2014, 2015 and 2016, respectively, compared with an increase from 25% (2013) to 31% (2014) and 22% (2015, 2016) in non-PBF facilities. The key take-home messages from this evaluation are firstly that 'direct quality indicators' to improve the use of treatment guidelines, introduced into a national PBF reform that includes financial incentives and rigorous verification of register entries, have the potential to significantly reduce inappropriate use of antibiotics in high population density settings in Africa. Secondly, for a sustained reduction in the overall proportion of unnecessary antibiotic prescriptions rigorous monitoring of health worker behaviour is required to address changes in prescribing practice. A well-designed and monitored PBF with 'direct quality indicators' has the potential to ensure that 'Health for All', in terms of increased access to primary health services is not synonymous with 'antibiotics for all'.

1471. Medical Claims Analysis as a Tool to Evaluate Empiric and Targeted Antibiotic Therapy in UTIs

BackgroundEmpiric therapy is a mainstay of the inpatient management of urinary tract infections (UTIs), and the choice of empiric antibiotic is shaped by local epidemiology and patient risk factors and comorbidities. Pathogen identification (ID) and antibiotic susceptibility testing (AST) provide information that can guide adjustments in therapy, allowing de-escalation to more targeted, narrow-spectrum antibiotics.MethodsReal-world data (hospital billing claims) from 2017 was used to extract relevant information from general hospitals on inpatients with bacterial UTIs including patient demographics and antibiotics line of therapy progression. Patients were projected to the USA national event totals and validated with other projection-related data sources (HCUP) and secondary market research. Data obtained in the claims analysis was validated by primary market research (PMR).ResultsAnalysis of 33M claims identified 169K patients with a code for UTI; in at least one-third of patients, there were no codes associated with ID/AST assays. Among those with codes for ID/AST assays, the vast majority were performed in the first 3 days following hospital admission. Approximately two-thirds of patients with associated ID/AST codes were already receiving an antibiotic when the assays were performed, which was assumed to be the empiric treatment. Analysis of the line of antibiotic therapy progression in patients where ID/AST was performed identified subsequent changes in antibiotic prescribing in approximately one-third of patients within 3 days, compatible with changes due to delivery of conclusive results and were interpreted as a transition from empiric to targeted treatment.ConclusionTo the best of our knowledge, this is the first attempt at understanding the impact of ID/AST assays on prescribing practices with basis on analysis of claims data. Our results align with PMR conducted by DRG internally, supporting the validity of this methodology. Although this claims analysis delivers reliable data when claims are associated with ID/AST assays, it is limited by incompletely filled claims, which may underestimate the use of these assays.Disclosures All authors: No reported disclosures.

Antibiotic Prescribing by Informal Healthcare Providers for Common Illnesses: A Repeated Cross-Sectional Study in Rural India.

Informal healthcare providers (IHCPs) are predominant healthcare providers in rural India, who prescribe without formal training. Antibiotic prescription by IHCPs could provide crucial information for controlling antibiotic resistance. The aim of this study is to determine the practices and seasonal changes in antibiotic prescribing for common illnesses by IHCPs. A repeated cross-sectional study was conducted over 18 months, covering different seasons in the rural demographic surveillance site, at Ujjain, India. Prescriptions given to outpatients by 12 IHCPs were collected. In total, 15,322 prescriptions for 323 different complaint combinations were analyzed, of which 11,336 (74%) included antibiotics. The results showed that 14,620 (95%) of antibiotics prescribed were broad spectrum and the most commonly prescribed were fluoroquinolones (4771,31%), followed by penicillin with an extended spectrum (4119,27%) and third-generation cephalosporin (3069,20%). Antibiotics were prescribed more frequently in oral and dental problems (1126,88%), fever (3569,87%), and upper respiratory tract infections (3273, 81%); more during the monsoon season (2350,76%); and more frequently to children (3340,81%) than to adults (7996,71%). The study concludes that antibiotics were the more commonly prescribed drugs compared to other medications for common illnesses, most of which are broad-spectrum antibiotics, a situation that warrants further investigations followed by immediate and coordinated efforts to reduce unnecessary antibiotic prescriptions by IHCPs.

Effect of Patient and Provider Education on Antibiotic Overuse for Respiratory Tract Infections.

Antibiotic overuse for respiratory tract infections (RTIs) in primary care (PC) is a known important contributor to the serious health threat of antibiotic resistance, yet remains a difficult problem to improve. The purpose of the study was to assess the effects of a combination patient and provider education program on antibiotic prescribing in RTIs in a rural primary care clinic. Utilizing a quasi-experimental pretest-posttest design, a retrospective electronic medical record review was conducted to determine if a patient and provider education program changed the rates of antibiotics being prescribed (immediate or delayed) during a visit for RTI for 207 randomly selected patients during the established evaluation time periods. The antibiotic prescription rate for the preintervention group was 56.3% compared to 28.8% for the postintervention group (p < .01). Immediate antibiotics were ordered in the preintervention group 31.1% of the time compared to 13.5% for the postintervention group (p < .05). The results of this study demonstrate that educational interventions can be effective in rural settings and that changes in antibiotic prescribing are possible.