Outpatient Antibiotic Stewardship Research Articles

Behavioral Boosts, Getting More Bang for Your Buck: Financial incentives for outpatient antibiotic stewardship.

Behavioral Boosts, Getting More Bang for Your Buck: Financial incentives for outpatient antibiotic stewardship.

Implementing Change Through an Outpatient Antibiotic Stewardship Program.

We sought to implement a multipronged behavioral intervention to reduce and tailor antibiotic use for 2 common urologic outpatient procedures. This study was a nonblinded intervention study that consisted of a preintervention phase (November 2018-January 2019), an intervention phase (January 2020-December 2020) in which a multipronged behavioral intervention was implemented, and a postintervention phase (January 2021-March 2021). We examined antibiotic use for cystoscopy and transrectal prostate biopsy at 3 separate urologic outpatient clinics. A multipronged behavioral intervention consisted of formal physician education, modification of the electronic health order sets, clinic staff education, literature review, development and introduction of patient questionnaires, and individual audit feedback. The primary outcome was 30-day infections. Secondary outcomes were adherence to the recommended antibiotic protocols, questionnaire completion, and Escherichia coli outpatient antibiograms. A total of 2374 patients underwent 3047 cystoscopies, and 547 patients underwent 559 prostate biopsies. The proportions of cystoscopy patients receiving antibiotic prophylaxis and prostate biopsy patients receiving augmented antibiotic prophylaxis decreased 33% and 35%, respectively. The odds of postcystoscopy infection were not different between the preintervention and intervention phases and were lower in the postintervention phase. The odds of postbiopsy infection were not changed between the preintervention and intervention phases or between the preintervention and postintervention phases. Implementing a multipronged behavioral intervention reduced and tailored antibiotic use without an increase in 30-day infections. These findings suggest that outpatient antibiotic stewardship and facilitating rapid adoption of guidelines can be accomplished via this approach.

Implementation of Outpatient Automated Stewardship Information System (OASIS©) Audit and Feedback in Two Healthcare Systems

Background: Combating antibiotic resistance, exacerbated by widespread unnecessary outpatient antibiotic prescriptions, necessitates innovative stewardship solutions. Audit and feedback reports are effective but often resource heavy. We introduced a free, open-source system, Outpatient Automated Stewardship Information System (OASIS©), for automating the creation and distribution of recurring audit and feedback reports to clinicians to improve antibiotic prescribing. Methods: We used mixed methods to evaluate implementation of OASIS© across 11 clinics at Denver Health and Hospital Authority (DHHA) and Children’s Hospital Colorado (CHCO) from July 2022 to August 2023. Both sites host their own Epic® electronic healthcare and enterprise data warehouse systems. R statistical software was utilized to retrieve and process the data needed to create individual[HCM1] clinician audit and feedback reports with peer comparison. Reports were provided for 1) antibiotics prescribed for respiratory diagnoses, 2) antibiotics prescribed for respiratory diagnoses where antibiotics are never indicated, 3) first-line antibiotic prescribing for acute otitis media (AOM), and 4) five-day duration of antibiotics for children two years and older with AOM. Feedback reports for each metric were emailed to clinicians for three consecutive months. The primary outcome was adaptations needed to implement OASIS©. Secondary outcomes included fidelity (measured by email readership), time to set up and maintain the program, and barriers and facilitators to implementation (assessed by four qualitative interviews with OASIS© stakeholders). Results: The most significant adaptations made pertained to the automation of OASIS© reports for organizations not using R for data retrieval and reporting, setting up OASIS© specific email addresses, and validating clinician fidelity via read receipts. Fidelity was higher at DHHA (91-100%) compared to CHCO (10-30%). When interviewed, data analysts expressed that time for initial setup ranged from 1-6 hours. After reporting was automated, the estimated monthly time to send reports was 10 minutes. Views on setup complexity were split, but all recognized the readability of the reports and OASIS©’s value for improving prescribing behaviors. The greatest barriers to implementation included obtaining analytic resources for initial setup and the need to download additional R packages. No interviewee had prior experience creating audit and feedback reports. Conclusions: Implementing OASIS© requires addressing system diversity and knowledge gaps in outpatient informatics and antibiotic stewardship. Despite these challenges, the tool proved efficient and beneficial for monitoring and reporting antimicrobial prescribing. This free tool could likely be effectively disseminated to other health systems given the limited time and resources required for adaptations, setup, and monitoring. [HCM1]I

Beyond the Prescription Pad—Finding a Window of Opportunity to Prevent Antibiotic Diversion and Non-Prescription Use

Background: Non-prescription antibiotic use is defined as taking antibiotics without medical guidance, which includes using leftover antibiotics, obtaining antibiotics from friends or relatives, or purchasing antibiotics without a prescription. This study aimed to (1) determine the symptoms prompting individuals to use non-prescription antibiotics, identify their sources of acquisition, and document the types of antibiotics utilized, (2) identify any associated side effects, and (3) gain insights into antibiotic storage practices, including whether antibiotics were used beyond their expiration date. Methods: A cross-sectional quantitative survey was conducted from January 2020-June 2021 in waiting rooms of six safety-net primary care clinics and two private emergency departments in Houston, Texas. Participants were read survey questions in English or Spanish by a bilingual research coordinator, and their responses to five questions about antibiotic use were recorded. Descriptive analysis was performed. Results: Among the 564 patients surveyed, the median age was 51 (range 19-92). The majority identified as female (72%), Hispanic/Latinx (47%), Black/African American (33%), held a college education (44%), and received public health insurance, such as Medicaid or County Financial Assistance (56%). Of all patients surveyed, 44% (246) reported taking an antibiotic without a prescription and answered questions about associated symptoms. Of all symptoms/illnesses associated with non-prescription use, the most common were sore throat (18%), dental symptoms (16%), and cold/flu (13%). The most common sources for non-prescribed antibiotics were leftover antibiotics (50%), from friends or relatives (31%), and purchased abroad (13%), although 3% had purchased non-prescription antibiotics from a local store or market (Figure 1). The most common antibiotics used were amoxicillin (38%) and penicillin (7%). The reported side effects were stomach pain/upset (24%), nausea and vomiting (19%), allergic reaction (e.g., rash) (14%), and diarrhea (14%). Among 246 participants reporting antibiotic use, 63% reported that the antibiotic they took had been previously prescribed for the same symptom/illness, and 93% had acquired antibiotics in a container, of which 90% reported that the container had an expiration date. Conclusions: Our survey reveals that 63% of individuals who use non-prescription antibiotics were motivated by having received prescribed antibiotics for similar symptoms previously. Leftover antibiotics were the source for half of all non-prescription use. These observations suggest that outpatient antibiotic stewardship campaigns have a window of opportunity at the time of the initial prescription of antibiotics, to focus on providing the shortest course possible, and to deliver antibiotic safe use information at that time. Acknowledgments: Financial Support AHRQ R01HS026901Disclosure: Barbara Trautner: Stock: Abbvie--sold in December 2023; Abbott Laboratories--sold in December 2023; -Bristol Myers Squibb--sold in December 2023; Pfizer--sold in December 2023; Consultant--Phiogen—consultant. Contracted research through NIAID for STRIVE trial, currently testing Shionogi product; Contracted research--Peptilogics; Contracted research—Genentech

Identifying Outpatient-Specialized High-Volume Prescribers of Antibiotics in Older Adult Populations – Philadelphia, PA 2021

Background: Inappropriate antibiotic use promotes antibiotic resistance which poses a threat to public health. Outpatient settings are responsible for 80-90% of all antibiotic use, yet up to 50% of these prescriptions may be inappropriate and at least 33% completely unnecessary. To promote outpatient antibiotic stewardship (AS), the Philadelphia Department of Public Health (PDPH) identified outpatient high-volume prescribers (HVPs) in Philadelphia and provided them with peer comparison letters along with evidence-based AS educational resources. Method: We identified HVPs using overall and drug specific antibiotic volume and rates from the Centers of Medicare and Medicaid Services (CMS) Part D Prescribers by Provider and by Provider and Drug publicly available datasets for 2021. We restricted analyses to Philadelphia prescribers specializing in internal medicine, family practice, or general practice with antibiotic and beneficiary claim counts ≥ 11. We further restricted the Provider and Drug dataset to prescribers of high-consequence drugs: levofloxacin, ciprofloxacin, and azithromycin. Prescribers with subspecialities where these three drugs are commonly used appropriately were excluded from letter distribution. We analyzed U.S. Census Bureau American Community Survey (ACS) data for overall HVPs on census tract-level to describe health equity demographic characteristics. Result: A total of 1,001 prescribers with 67,145 total antibiotic claims, and 306 unique prescribers (77 levofloxacin, 176 ciprofloxacin, and 250 azithromycin) with 37,057 total antibiotic claims met the inclusion criteria in the Provider and the Provider and Drug datasets, respectively. There were 101 overall HVPs, and 89 unique drug-specific HVPs (20 levofloxacin, 45 ciprofloxacin, and 63 azithromycin) based on the highest 10% and 25% of prescribers by antibiotic volume, respectively. The overall HVPs contributed 42.0% of all antibiotic claims. The drug-specific HVPs contributed 60.5% of all antibiotic claims and 55.5% of levofloxacin, ciprofloxacin, and azithromycin claims. These 3 drugs contributed 45.1% of all antibiotic claims. Among the overall and drug-specific HVPs, we sent peer comparison letters to the top 10 by rate per 1,000 beneficiaries (overall) and per 1,000 antibiotic claims (drug-specific), who fell within the following prescribing rates: overall 954-2,714, levofloxacin 84-396, ciprofloxacin 288-723, and azithromycin 496-1,000. Conclusion: This initiative identified prescribers at risk for inappropriate use of antibiotics, and empowered these same prescribers to self-reflect on how they prescribe antibiotics. Efforts by local health departments to provide HVPs with peer comparison feedback and AS educational resources may improve the provider knowledge and prescribing habits across different healthcare systems, targeting prescribers at highest risk for misuse or overuse of antibiotics.Disclosure: Jane Gould: Spouse receives salary support- Incyte

Changes in the Appropriateness of US Outpatient Antibiotic Prescribing After the COVID-19 Outbreak: An Interrupted Time Series Analysis of 2016-2021 Data.

No national study has evaluated changes in the appropriateness of US outpatient antibiotic prescribing across all conditions and age groups after the coronavirus disease 2019 (COVID-19) outbreak in March 2020. This was an interrupted time series analysis of Optum's de-identified Clinformatics Data Mart Database, a national commercial and Medicare Advantage claims database. Analyses included prescriptions for antibiotics dispensed to children and adults enrolled during each month during 2017-2021. For each prescription, we applied our previously developed antibiotic appropriateness classification scheme to International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes on medical claims occurring on or during the 3 days prior to dispensing. Outcomes included the monthly proportion of antibiotic prescriptions that were inappropriate and the monthly proportion of enrollees with ≥1 inappropriate prescription. Using segmented regression models, we assessed for level and slope changes in outcomes in March 2020. Analyses included 37 566 581 enrollees, of whom 19 154 059 (51.0%) were female. The proportion of enrollees with ≥1 inappropriate prescription decreased in March 2020 (level decrease: -0.80 percentage points [95% confidence interval {CI}, -1.09% to -.51%]) and subsequently increased (slope increase: 0.02 percentage points per month [95% CI, .01%-.03%]), partly because overall antibiotic dispensing rebounded and partly because the proportion of antibiotic prescriptions that were inappropriate increased (slope increase: 0.11 percentage points per month [95% CI, .04%-.18%]). In December 2021, the proportion of enrollees with ≥1 inappropriate prescription equaled the corresponding proportion in December 2019. Despite an initial decline, the proportion of enrollees exposed to inappropriate antibiotics returned to baseline levels by December 2021. Findings underscore the continued importance of outpatient antibiotic stewardship initiatives.

Barriers and Facilitators Affecting Long-Term Antibiotic Prescriptions for Acne Treatment

Dermatologists prescribe more oral antibiotics per clinician than clinicians in any other specialty. Despite clinical guidelines that recommend limitation of long-term oral antibiotic treatments for acne to less than 3 months, there is little evidence to guide the design and implementation of an antibiotic stewardship program in clinical practice. To identify salient barriers and facilitators to long-term antibiotic prescriptions for acne treatment. This qualitative study assessed data collected from stakeholders (including dermatologists, infectious disease physicians, dermatology resident physicians, and nonphysician clinicians) via an online survey and semistructured video interviews between March and August 2021. Data analyses were performed from August 12, 2021, to January 20, 2024. Online survey and qualitative video interviews developed with the Theoretical Domains Framework. Thematic analyses were used to identify salient themes on barriers and facilitators to long-term antibiotic prescriptions for acne treatment. Among 30 participants (14 [47%] males and 16 [53%] females) who completed the study requirements and were included in the analysis, knowledge of antibiotic guideline recommendations was high and antibiotic stewardship was believed to be a professional responsibility. Five salient themes were to be affecting long-term antibiotic prescriptions: perceived lack of evidence to justify change in dermatologic practice, difficulty navigating patient demands and satisfaction, discomfort with discussing contraception, iPLEDGE-related barriers, and the absence of an effective system to measure progress on antibiotic stewardship. The findings of this qualitative study indicate that multiple salient factors affect long-term antibiotic prescribing practices for acne treatment. These factors should be considered in the design and implementation of any future outpatient antibiotic stewardship program for clinical dermatology.

2204. Excess Antibiotic Therapy for 5 Common Conditions in Primary Care: Low-Hanging Fruit for Outpatient Antibiotic Stewardship

Abstract Background Improving duration can be a key intervention in outpatient antibiotic stewardship as most conditions require only 5 days of therapy or less. Cellulitis, acute otitis media (AOM), sinusitis, community-acquired pneumonia (CAP), and uncomplicated urinary tract infections (UTI) encounters account for the majority of outpatient antibiotic prescriptions and have been associated with durations longer than necessary. We characterized the duration of antibiotic prescriptions associated with these conditions in our primary care (PC) network. Methods We retrospectively evaluated prescribing practices for cellulitis, AOM, sinusitis, CAP, and UTI encounters among patients ≥ 3 years-old from January 1st, 2022 – December 31st, 2022 in the Intermountain Health (IH) PC network. IH is an integrated healthcare system operating 119 PC clinics (69 family medicine, 22 internal medicine, 23 pediatric). System-specific evidence-based ambulatory guidelines for the conditions of interest during the study recommended 5-7 days of therapy. Encounters, patient characteristics, and prescription information were electronically extracted from the electronic health record. We analyzed duration of therapy by categories (≤5 days, 6-9 days, 10-14 days, or 14+ days) for each condition in pediatric (≥ 3-18 years-old) and adult (≥ 19 years-old) patients. Results There were 14,918 and 38,790 encounters for the studied conditions among pediatric and adult patients, respectively. The mean age of pediatric patients was 9.0 years and among adults, 56.8. Pediatric and adult patients were predominantly White, non-Hispanic, female, and preferred speaking English (Table 1). Overall, only 10.4% (8,965) of all prescriptions were ≤ 5 days and consistent with the recommended duration. Duration of prescriptions associated with each condition are presented in Figure 1. UTI exhibited the highest percentage of ≤ 5 day prescriptions (22.1% pediatrics, 29.1% adults) while sinusitis had the lowest (0.9% pediatrics, 2.6% adults).Table 1.Total encounters for all studied conditions and patient characteristicsFigure 1.Duration of antibiotic prescriptions associated with cellulitis, acute otitis media (AOM), sinusitis, community-acquired pneumonia (CAP), and uncomplicated urinary tract infection (UTI) encounters for patients 3-18 years-old (pediatric) and ≥19 years-old (adult) in the Intermountain Health primary care network. Conclusion Duration of therapy for cellulitis, AOM, sinusitis, CAP, and UTIs is almost always longer than the recommended 5 days of therapy in our PC network. There is substantial opportunity to improve duration for these conditions. Disclosures Payal K. Patel, MD MPH, qiagen: Honoraria

1649. Tracking and reporting antibiotic use: Rising antibiotic prescriptions for URI illness in children during the COVID-19 pandemic.

Abstract Background During COVID-19 there was an increase in antibiotic utilization across all settings. West Virginia has the highest outpatient antibiotic prescribing rate in the country. As part of our outpatient antibiotic stewardship initiative, we developed and utilized a dashboard to track and report prescribing data in two pediatric clinics in a large health system. Methods We reviewed prescribing data from Oct 2020- Mar 2022 in two outpatient pediatric clinics using a dashboard within the electronic medical record. Both clinics are affiliated with a large health system but clinic A was academic and clinic B was non-academic clinic. We also collected data on total number of visits and visits that had antibiotics prescribed. We reviewed prescription data on visits that were diagnosed with upper respiratory tract illness (URI) like acute otitis media, acute sinusitis, acute pharyngitis etc. We compared URI antibiotic prescriptions in Jan 2021-Mar 2021 with Jan 2022- Mar 2022. Results There were more than 15,000 visits during the study period. A steady increase in antibiotic prescriptions written per visit was noted in both clinics (Figure 1). There was a significant increase in percentage of prescriptions for URI in the respiratory season for 2021 and 2022 (30.2% vs. 47.7%, p< 0.0001). The most common diagnosis for antibiotic prescription in both clinics was acute otitis media (67 and 72%, respectively). However, clinic B wrote cefdinir prescriptions for 38 % cases of otitis media vs. 12% in clinic A. Conclusion There was an increase in overall prescriptions for antibiotics and prescriptions for URI in both clinic sites. This was most likely due to the prolonged viral season following cessation of COVID-19 mitigation measures. There were significant differences noted in prescribing practices, like cefdinir overuse for treatment of otitis media, which will guide our antimicrobial stewardship interventions in future. Disclosures All Authors: No reported disclosures

Evaluation of Multisite Programmatic Bundle to Reduce Unnecessary Antibiotic Prescribing for Respiratory Infections: A Retrospective Cohort Study.

The aim of this study was to evaluate the frequency of unnecessary antibiotic prescribing for Tier 3 upper respiratory infection (URI) syndromes across the Mayo Clinic Enterprise before and after a multifaceted antimicrobial stewardship intervention, and to determine ongoing factors associated with antibiotic prescribing and repeat respiratory healthcare contact in the postintervention period. This was a quasi-experimental, pre/post, retrospective cohort study from 1 January 2019 through 31 December 2022, with 12-month washout during implementation from 1 July 2020 through 30 June 2021. All outpatient encounters, adult and pediatric, from primary care, urgent care, and emergency medicine specialties with a Tier 3 URI diagnosis were included. The intervention was a multifaceted outpatient antibiotic stewardship bundle. The primary outcome was the rate of antibiotic prescribing in Tier 3 encounters. Secondary outcomes included 14-day repeat healthcare contact for respiratory indications and factors associated with persistent unnecessary prescribing. A total of 165 658 Tier 3 encounters, 96 125 in the preintervention and 69 533 in the postintervention period, were included. Following intervention, the prescribing rate for Tier 3 encounters decreased from 21.7% to 11.2% (P < .001). Repeat 14-day respiratory healthcare contact in the no antibiotic group was lower postintervention (9.9.% vs 9.4%; P = .004). Multivariable models indicated that increasing patient age, Charlson comorbidity index, and primary diagnosis selected were the most important factors associated with persistent unnecessary antibiotic prescribing. Outpatient antibiotic stewardship initiatives can reduce unnecessary antibiotic prescribing for Tier 3 URIs without increasing repeat respiratory healthcare contact. Advancing age and number of comorbidities remain risk factors for persistent unnecessary antibiotic prescribing.

Which trial do we need? Treatment of multiple erythema migrans with doxycycline for 7 days versus 14 days

Which trial do we need? Treatment of multiple erythema migrans with doxycycline for 7 days versus 14 days

Implementing a health-system–wide antibiotic stewardship program in ambulatory surgery centers

Background: In 2016, the CDC released the Core Elements of Outpatient Antibiotic Stewardship, which extended the requirements previously released for hospital facilities and nursing homes to the outpatient setting. Several regulatory agencies focused on outpatient antimicrobial use. However, The Joint Commission and the Ambulatory Surgery Center (ASC) Leapfrog Group excluded ambulatory surgery centers from their medication management standards and questions. Due to the public health and patient safety benefits of implementing an antimicrobial stewardship program (ASP) and increasing regulatory interest in the matter, the Hospital Corporation of America (HCA) Ambulatory Surgery Division formally launched a nationwide ASP for its ambulatory surgery centers in March 2021. Methods: HCA is a large healthcare system with 146 ASCs in 16 states in 2021. The structure of the ASCs are local surgery centers with a medical director, a nurse responsible for infection prevention, and a pharmacist at a regional level. The types of surgeries vary based on location and ASC site. In 2019, a multidisciplinary team formed the corporate planning committee. The program was modeled after the CDC Core Elements and The Joint Commission’s requirements for an ASP. Each ASC was asked to build a local ASP team, led by a local physician and a regionally based pharmacist. In addition, a stewardship goal was established to update all preoperative antibiotic surgical-site infection prophylaxis order sets. The corporate committee provided educational resources, including evidence-based guidelines for appropriate antibiotic selection for surgical-site infections. They collected antibiotic cost per case as a baseline metric to track and analyze. Pediatric, ophthalmic, and gastrointestinal endoscopic procedures were excluded from the program. Results: From January 1, 2020, through December 31, 2021, including only centers that were operational during this period and excluding single specialty endoscopy centers, antibiotic cost per case decreased annually from $2.38 to $1.84 (t = 4.157; P &lt; .005), and the postoperative infection rate also declined from 0.370 to 0.304 (t = 2.079; P = .040). Conclusions: Our findings suggest that implementing a health-system–wide outpatient antibiotic stewardship program in the ambulatory surgery center setting is feasible and may contribute to decreased antibiotic cost per case and improved postoperative surgical site infection rates.Disclosures: None

“Acute urinary antibiotics”—A simple metric to identify outpatient antibiotic stewardship opportunities in renal transplant

Background:International Classification of Diseases, Tenth Edition (ICD-10) data help track outpatient antibiotic prescribing but lack validation in immunocompromised populations or subspecialty clinics for this purpose. Asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) are important stewardship targets in renal transplant (RT) patients, but they may require alternative metrics to best monitor prescribing patterns. We describe ICD-10 utilization for RT clinic encounters in which antibiotics were prescribed. We developed a metric classifying “acute urinary antibiotics” (AUA) to track antibiotic use for ASB and UTI, and we validated systematic identification of AUA to enable practical implementation. Methods: We examined RT clinic visit and telemedicine encounters from 2018 to 2021 conducted 1 month after transplant. This project was deemed non–human-subjects research by the Stanford Panel on Human Subjects in Medical Research. Results: The analytic cohort included 420 antibacterial prescriptions from 408 encounters (Fig. 1). Of 238 patients, 136 (57%) were male and 112 (47%) were Hispanic or Latino. The most common primary ICD-10 code was Z94.0 (kidney transplant status) (N = 302 of 408 encounters, 75%); 26 encounters (6%) were coded for UTI (eg, N39.0, urinary tract infection, site not specified); and 214 encounters (53%) had multiple ICD-10 codes. The R82.71 code (bacteriuria) was never used. However, 215 prescriptions (51%) were classified as AUA (Fig. 2). The validation cohort included 130 prescriptions; 59 (45%) were classified as AUA and 51 (39%) had documented intent to treat ASB or UTI (positive percent agreement, 83%; negative percent agreement, 97%) (Table 1). For patients &gt;1 month after transplant, the positive percent agreement was 95% and the negative percent agreement was 98%. Of 51 patients receiving AUA, 32 (63%) were asymptomatic despite frequently having a code for UTI (Fig. 3). Conclusions: ICD-10 coding may not be helpful in monitoring antibiotic prescribing in RT patients. The AUA metric offers a practical alternative to track antibiotic prescribing for urinary syndromes and reliably correlates with physician intent. Monitoring AUA prescribing rates could help identify opportunities to optimize antibiotic use in this complex outpatient setting.Disclosures: None

The Challenge of Outpatient Antibiotic Stewardship

The Challenge of Outpatient Antibiotic Stewardship

Evaluating the Efficacy and Safety of EZC Pak, a 5-Day Combination Echinacea-Zinc-Vitamin C Dose Pack with or without Vitamin D, in the Management of Outpatient Upper Respiratory Infections.

Growing antibiotic resistance is among the most serious threats to public health, with antibiotic misuse considered a leading driver of the problem. One of the largest areas of misuse is in outpatient upper respiratory infections (URIs). The purpose of this research is to evaluate the efficacy of EZC Pak, a combination Echinacea-Zinc-Vitamin C dose pack with or without Vitamin D, on the duration of illness and symptom severity of non-specific URIs as an alternative to antibiotics when none are deemed clinically necessary. A secondary analysis was carried out on patient satisfaction. A total of 360 patients across the United States were enrolled and randomized in a double-blind manner across two intervention groups, EZC Pak, EZC Pak+Vitamin D, and one placebo group. The study utilized a smartphone-based app to capture data. Once a participant reported the first URI symptom, they were instructed to take the intervention as directed and complete the daily symptom survey score until their symptoms resolved. The average EZC Pak participant recovered 1.39 days (90% CI 1.05 to 1.73) faster than the average placebo participant (p=0.017). The average EZC Pak participant reported a 17.43% (90% CI 17.1 to 17.8) lower symptom severity score versus placebo (p=0.029). EZC Pak users reported 2.9 times higher patient satisfaction versus placebo users (p=0.012). The addition of Vitamin D neither benefited nor harmed illness duration or symptom severity. The findings support the potential use of EZC Pak as an alternative to patient request for antibiotics when none are deemed clinically necessary at the time of initial clinical presentation. The decision to replete vitamin D in the acute phase of URI is an individualized decision left to the patient and their clinician. EZC Pak may play a critical role in improving outpatient URI management and antibiotic stewardship (ClinicalTrials.gov number, NCT04943575).

Antimicrobial Stewardship Practices in a Subset of Community Pharmacies across the United States

Antimicrobial stewardship in the community is essential as most antibiotic prescribing occurs in the outpatient setting. Pharmacists are recognized as co-leaders for implementing efforts to improve antimicrobial use. the purpose of this study is to evaluate current antimicrobial stewardship practices in community pharmacies across the United States and identify perceptions and challenges faced by community pharmacists. a survey based on the Center of Disease Control and Prevention (CDC) Core Elements of Outpatient Antibiotic Stewardship was created and distributed. Sixty-one community pharmacists participated in the survey. The majority of pharmacists practiced in chain pharmacies. Based on the responses, a minority of pharmacies met the requirements of the CDC core elements: commitment (27.9%), action (24.6%), tracking and reporting (14.8%), and education and expertise (23% for providing pharmacist resources and 9.8% for providing patient resources). Regarding perception, 67.9% felt antimicrobial stewardship is important in the community and would participate in antimicrobial stewardship activities if the opportunity was provided (88.5%). Challenges faced by community pharmacists include the lack of time, staff, training, and technology support; pushback from prescribers and patients; and the lack of leadership, financial incentives, funding, and legal requirements. many challenges exist in community pharmacies inhibiting the full potential of pharmacists in implementing antimicrobial stewardship.

Correction to: Leveraging Existing and Soon-to-Be-Available Novel Diagnostics for Optimizing Outpatient Antibiotic Stewardship in Patients With Respiratory Tract Infections

Correction to: Leveraging Existing and Soon-to-Be-Available Novel Diagnostics for Optimizing Outpatient Antibiotic Stewardship in Patients With Respiratory Tract Infections

Impact of the COVID-19 pandemic and multiplex polymerase chain reaction test on outpatient antibiotic prescriptions for pediatric respiratory infection.

This study aimed to evaluate the impact of the prolonged COVID-19 pandemic on outpatient antibiotic prescriptions for pediatric respiratory infections at an acute care hospital in Japan in order to direct future pediatric outpatient antibiotic stewardship. The impact of the COVID-19 pandemic and the FilmArray Respiratory Panel (RP) on outpatient antibiotic prescriptions was assessed from January 2019 to December 2021 using an interrupted time series analysis of children <20 years. The overall antimicrobial prescription rate decreased from 38.7% to 22.4% from the pre-pandemic period to the pandemic. The pandemic (relative risk [RR] level, 0.97 [0.58-1.61]; P = 0.90; RR slope, 1.05 [0.95-1.17] per month; P = 0.310) and FilmArray RP (RR level, 0.90 [0.46-1.75]; P = 0.75; RR slope, 0.95 [0.85-1.06] per month; P = 0.330) had no significant effect on the monthly antibiotic prescription rates. The COVID-19 pandemic was not significantly related to the antibiotic prescription rate, suggesting that it did not impact physicians' behavior toward antibiotic prescriptions. Replacing rapid antigen tests with the FilmArray RP introduced on December 1, 2020, did not affect the magnitude of the reduction in antibiotic prescription rate for pediatric respiratory infections.

Comparative Safety and Attributable Healthcare Expenditures Following Inappropriate Versus Appropriate Outpatient Antibiotic Prescriptions Among Adults With Upper Respiratory Infections.

Little is known about the clinical and financial consequences of inappropriate antibiotics. We aimed to estimate the comparative risk of adverse drug events and attributable healthcare expenditures associated with inappropriate versus appropriate antibiotic prescriptions for common respiratory infections. We established a cohort of adults aged 18 to 64 years with an outpatient diagnosis of a bacterial (pharyngitis, sinusitis) or viral respiratory infection (influenza, viral upper respiratory infection, nonsuppurative otitis media, bronchitis) from 1 April 2016 to 30 September 2018 using Merative MarketScan Commercial Database. The exposure was an inappropriate versus appropriate oral antibiotic (ie, non-guideline-recommended vs guideline-recommended antibiotic for bacterial infections; any vs no antibiotic for viral infections). Propensity score-weighted Cox proportional hazards models were used to estimate the association between inappropriate antibiotics and adverse drug events. Two-part models were used to calculate 30-day all-cause attributable healthcare expenditures by infection type. Among 3 294 598 eligible adults, 43% to 56% received inappropriate antibiotics for bacterial and 7% to 66% for viral infections. Inappropriate antibiotics were associated with increased risk of several adverse drug events, including Clostridioides difficile infection and nausea/vomiting/abdominal pain (hazard ratio, 2.90; 95% confidence interval, 1.31-6.41 and hazard ratio, 1.10; 95% confidence interval, 1.03-1.18, respectively, for pharyngitis). Thirty-day attributable healthcare expenditures were higher among adults who received inappropriate antibiotics for bacterial infections ($18-$67) and variable (-$53 to $49) for viral infections. Inappropriate antibiotic prescriptions for respiratory infections were associated with increased risks of patient harm and higher healthcare expenditures, justifying a further call to action to implement outpatient antibiotic stewardship programs.

Outpatient Antibiotic and Antiviral Utilization Patterns in Patients Tested for Respiratory Pathogens in the United States: A Real-World Database Study.

This retrospective observational study evaluated outpatient treatment patterns among patients with molecular-based viral diagnostic testing for suspected upper respiratory tract infections in the United States. Patients with a respiratory viral test were identified from 1 August 2016 to 1 July 2019 in a large national reference laboratory database linked to IQVIA’s prescription and medical claims databases. Antibiotic and influenza antiviral treatment patterns were reported up to 7 days post-test result. Predictors of antibiotic utilization were assessed using multivariable logistic regression. Among 9561 patients included in the study, 24.6% had evidence of ≥1 filled antibiotic prescription. Antibiotic utilization was higher in patients who tested negative for all viral targets (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.17–1.50) and patients positive for non-influenza viruses (OR, 1.28; 95% CI, 1.09–1.51) compared with those influenza-positive only. Age ≥ 50 years and location outside of the northeast United States also predicted antibiotic utilization. Influenza antivirals were more common in influenza-positive patients compared with patients with other test results (32.5% vs. 3.6–9.0%). Thus, in this real-world study, antibiotic utilization was elevated in patients positive for non-influenza viruses, although antibiotics would generally not be indicated. Further research on pairing diagnostic tools with outpatient antibiotic stewardship programs is needed.