Factors associated with antibiotic prescribing for acute ...
Antibiotic Prescribing Strategy for Acute Respiratory ...
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Antibiotic Prescribing Strategy for Acute Respiratory Tract Infections in the Emergency Department Ayo Oguntoye RN, Irina Benenson, DNP, FNP & Rebecca Basso, DNP, RN • Acute RTI accounts for 14 million visits to the emergency department annually • Only 5-15% of RTI cases are attributable to bacterial infection • Evidence shows that practitioners are choosing more broad-spectrum antibiotics • Current ACCP and CDC guidelines recommend against the use of antibiotics to treat RTI with non-bacterial etiology • However, the frequency of prescriptions for antibiotics for acute bronchitis has decreased only modestly, from approximately 75 to 60 percent in the past decade • Aim of the current study is to reduce unnecessary antibiotic prescribing for RTI focusing on common cold and acute bronchitis Introduction Background and Significance • Approximately 55% of all money spent in the outpatient environment is attributed to antibiotics • Antibiotic resistance adds $1383 to the cost of treating a patient with bacterial infection. • Antibiotic resistance has an estimated national cost of $2.2 billion annually • 35,000 people in the U.S, and 700,000 worldwide die each year as a result of antibiotic-resistant infections. • By 2050 annual global mortality rate will increase to 10,000,000 people • Healthy People 2020: eliminate antibiotic prescribing for the sole diagnosis of common cold and acute bronchitis Clinical Pathway HPI • Cough, with or without sputum >5days<3wks in most cases. Medical history • Vaccination history, travel history, and cigarette smoking • Differentiate from comorbid conditions e.g GERD, asthma Physical exam • Fever suggests either influenza or pneumonia • Focal consolidation, egophony, rales or fremitus on chest exam • HR>100, RR>24, SaO2<95% and Age > 65yr Diagnostic Test • No role for routine chest x-ray, viral culture, serological essay, sputum culture, Gram stain or pulmonary function testing/spirometry q Recommend specific symptomatic therapy: Cough suppressant, antihistamine, decongestant Ideas Concerns Expectations Method • Ideas: Ask the patient about their ideas regarding diagnosis, treatment and prognosis. • Concerns: Ask the patient about their fears and worries • Expectation: Ask what the patient wants Methods Design • Quality improvement project with pre- and post-intervention comparison Study participants • 15 physicians, 5 nurse practitioners, and 3 physician assistants. Setting • Emergency room of a 451-bed, acute-care not-for profit hospital in northern New Jersey Outcomes • Antibiotic prescribing rate for RTI pre- and post-intervention, using patient records for visits with matching ICD codes for common cold and acute bronchitis during the study period n = 100 • 5 item Likert-type questionnaire to measure the attitudes of ED providers regarding the clinical pathway and ICE method. Data Analysis • Microsoft Excel and SAS statistical package Red Hat 64 • Non-parametric descriptive statistics to describe frequencies • Chi squared test used to compare the frequencies of antibiotic prescribing between pre- and post- intervention periods. • A p-value of less than 0.05 was considered statistically significant Results • Pre-intervention 42 patients were treated for RTIs compared to 48 post- intervention • Statistically significant decrease in antibiotic prescribing from 30.95% pre- intervention to 12.50% post-intervention (p=0.03) • Amoxicillin/Clavulanate was prescribed most frequently, followed by Azithromycin and Cefuroxime • Reduction in utilization of labs and diagnostic tests, although not statistically significant (p= 0.07) • 83% of participants agreed and 16% strongly agreed that ICE method should be a standard approach to patients with RTIS Conclusions and Implications Conclusions • Statistically significant reduction in antibiotic prescribing following the implementation of a clinical pathway and the ICE method • Future studies should aim to replicate similar methods with larger sample size and follow-up to assess long-term effect Implications • Practice: Training of the ICE method should be implemented on a regular basis. The study provides data to assess the performance of the Emergency Department in meeting guideline objectives regarding the diagnosis and treatment of RTIs • Patient care: Practical approach of using shared decision making to improve patient’s outcomes • Policy: Organizations may use this data to develop broad policies to guide practice • Economy: Potential cost benefit to the patients and healthcare institutions References • Braman, S. S. (2006). Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest, 129(1), 95S-103S. • Center for Disease Control and Prevention (2019). Adult treatment recommendation. https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/adult-treatment-rec.html • Center for Disease Control and Prevention. (2017). National Hospital Ambulatory Medical Care Survey: 2017. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf • Center for Disease Control and Prevention. (2017). Measuring Outpatient Antibiotic Prescribing. https://www.cdc.gov/antibiotic-use/community/programs-measurement/measuring-antibiotic- prescribing.html • Jenkins, T. C., Irwin, A., Coombs, L., DeAlleaume, L., Ross, S. E., Rozwadowski, J., ... & West, D. R. (2013). Effects of clinical pathways for common outpatient infections on antibiotic prescribing. The American journal of medicine, 126(4), 327-335. • Luo, R., Sickler, J., Vahidnia, F., Lee, Y. C., Frogner, B., & Thompson, M. (2019). Diagnosis and management of group A streptococcal pharyngitis in the United States, 2011–2015. BMC infectious diseases, 19(1), 193. Contact Information: Ayo Oguntoye, RN E-mail: [email protected] Management of Acute Bronchitis in Adults Key points • Over 90% of acute cough illness are non-bacterial • Most patients with acute bronchitis do not benefit from antibiotic therapy • Symptoms may last up to 3 weeks • Evaluation should focus on effective communication and symptom management Possible signs and symptoms Cough with or without sputum Chest soreness Wheezing Fatigue Mild headache Mild body aches Low-grade fever (less than 102F) Clinical picture consistent with acute bronchitis Any of the following present? • Adult age 65 years and older • Oral body temperature > 38C/100.4F • Respiratory rate >24 • Heart rate > 100 • Oxygen saturation < 95% • Focal consolidation, egophony, rales or fremitus on chest exam Chest X-ray only if high suspicion for pneumonia Infiltrate No Infiltrate Refer to guideline for community- acquired pneumonia Acute bronchitis likely Antibiotic therapy not indicated Recommend specific symptomatic therapy: • Cough Suppressants (codeine or dextromethorphan) • First generation antihistamine (diphenhydramine) • Decongestants (phenylephrine) *If covid-19, pertussis, influenza, or pneumonia are clinically suspected, initiate diagnostic testing and consider empiric antibiotic or antiviral therapy. References: Center for Disease Control and Prevention (2019). Adult treatment recommendation. https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/adult-treatment-rec.html Refer to the specific guideline. Microbiological testing • Respiratory Panel • Procalcitonin only if high suspicion for o Influenza A or B o Bordetella Pertussis o SARS COV-2 ICE • Ideas: Ask patient about their idea regarding diagnosis, treatment and prognosis. • Concerns: Ask about patient’s fears and worry • Expectation: Ask what the patients wants Sputum test not recommended due to low specificity for infection 90.48 90.48 66.67 0.00 0.00 80.95 16.67 58.33 58.33 87.50 8.33 0.00 75.00 4.17 0 10 20 30 40 50 60 70 80 90 100 CBC CMP PCR Strep Sputum CXR CT Labs and Diagnostic Tests Pre-Intervention Post-Intervention 69% 19% 10% 2% Pre-intervention No Antibiotic Rx Azithromycin Augmentin Cefuroxime 88% 6% 4% 2% Post-intervention No Antibiotic Rx Azithromycin Augmentin Cefuroxime -10 -5 0 5 10 15 20 25 I find the clinical pathway useful I find the ICE method useful I use the clinical pathway and ICE in my decision making Clinical pathway should be standard protocol ICE method should be standard protocol Survey of ED providers on the use of the clinical pathway and ICE method Strongly Disgree Disagree Neutral Agr ee Strongly Agree
Transcript of Antibiotic Prescribing Strategy for Acute Respiratory ...
Antibiotic Prescribing Strategy for Acute Respiratory Tract Infections in the Emergency DepartmentAyo Oguntoye RN, Irina Benenson, DNP, FNP & Rebecca Basso, DNP, RN
• Acute RTI accounts for 14 million visits to the emergency department annually • Only 5-15% of RTI cases are attributable to bacterial infection • Evidence shows that practitioners are choosing more broad-spectrum
antibiotics • Current ACCP and CDC guidelines recommend against the use of antibiotics
to treat RTI with non-bacterial etiology• However, the frequency of prescriptions for antibiotics for acute bronchitis
has decreased only modestly, from approximately 75 to 60 percent in the past decade• Aim of the current study is to reduce unnecessary antibiotic prescribing for
RTI focusing on common cold and acute bronchitis
Introduction
Background and Significance
• Approximately 55% of all money spent in the outpatient environment is attributed to antibiotics• Antibiotic resistance adds $1383 to the cost of treating a patient with
bacterial infection. • Antibiotic resistance has an estimated national cost of $2.2 billion annually• 35,000 people in the U.S, and 700,000 worldwide die each year as a result
of antibiotic-resistant infections. • By 2050 annual global mortality rate will increase to 10,000,000 people• Healthy People 2020: eliminate antibiotic prescribing for the sole diagnosis
of common cold and acute bronchitis
Clinical Pathway
HPI• Cough, with or without sputum >5days<3wks in most cases.
Medical history• Vaccination history, travel history, and cigarette smoking• Differentiate from comorbid conditions e.g GERD, asthma
Physical exam• Fever suggests either influenza or pneumonia• Focal consolidation, egophony, rales or fremitus on chest exam• HR>100, RR>24, SaO2<95% and Age > 65yr
Diagnostic Test• No role for routine chest x-ray, viral culture, serological essay,
sputum culture, Gram stain or pulmonary function testing/spirometry
q Recommend specific symptomatic therapy: Cough suppressant, antihistamine, decongestant
Ideas Concerns Expectations Method
• Ideas: Ask the patient about their ideas regarding diagnosis, treatment and prognosis.• Concerns: Ask the patient about their fears and worries• Expectation: Ask what the patient wants
MethodsDesign• Quality improvement project with pre- and post-intervention comparison
Study participants• 15 physicians, 5 nurse practitioners, and 3 physician assistants.
Setting• Emergency room of a 451-bed, acute-care not-for profit hospital in northern
New Jersey
Outcomes • Antibiotic prescribing rate for RTI pre- and post-intervention, using patient
records for visits with matching ICD codes for common cold and acute bronchitis during the study period n = 100• 5 item Likert-type questionnaire to measure the attitudes of ED providers
regarding the clinical pathway and ICE method.Data Analysis•Microsoft Excel and SAS statistical package Red Hat 64 • Non-parametric descriptive statistics to describe frequencies • Chi squared test used to compare the frequencies of antibiotic prescribing
between pre- and post- intervention periods. • A p-value of less than 0.05 was considered statistically significant
Results• Pre-intervention 42 patients were treated for RTIs compared to 48 post-
intervention• Statistically significant decrease in antibiotic prescribing from 30.95% pre-
intervention to 12.50% post-intervention (p=0.03)• Amoxicillin/Clavulanate was prescribed most frequently, followed by Azithromycin
and Cefuroxime• Reduction in utilization of labs and diagnostic tests, although not statistically
significant (p= 0.07)• 83% of participants agreed and 16% strongly agreed that ICE method should be a
standard approach to patients with RTIS
Conclusions and Implications
Conclusions• Statistically significant reduction in antibiotic prescribing following
the implementation of a clinical pathway and the ICE method• Future studies should aim to replicate similar methods with larger
sample size and follow-up to assess long-term effect
Implications• Practice: Training of the ICE method should be implemented on a
regular basis. The study provides data to assess the performance of the Emergency Department in meeting guideline objectives regarding the diagnosis and treatment of RTIs • Patient care: Practical approach of using shared decision making to
improve patient’s outcomes• Policy: Organizations may use this data to develop broad policies to
guide practice• Economy: Potential cost benefit to the patients and healthcare
institutions
References
• Braman, S. S. (2006). Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest, 129(1), 95S-103S.• Center for Disease Control and Prevention (2019). Adult treatment recommendation.
https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/adult-treatment-rec.html• Center for Disease Control and Prevention. (2017). National Hospital Ambulatory Medical Care Survey: 2017.
https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf• Center for Disease Control and Prevention. (2017). Measuring Outpatient Antibiotic Prescribing.
https://www.cdc.gov/antibiotic-use/community/programs-measurement/measuring-antibiotic-prescribing.html• Jenkins, T. C., Irwin, A., Coombs, L., DeAlleaume, L., Ross, S. E., Rozwadowski, J., ... & West, D. R. (2013). Effects
of clinical pathways for common outpatient infections on antibiotic prescribing. The American journal of medicine, 126(4), 327-335.• Luo, R., Sickler, J., Vahidnia, F., Lee, Y. C., Frogner, B., & Thompson, M. (2019). Diagnosis and management of
group A streptococcal pharyngitis in the United States, 2011–2015. BMC infectious diseases, 19(1), 193.
Contact Information: Ayo Oguntoye, RN
E-mail: [email protected]
Management of Acute Bronchitis in Adults
Key points • Over 90% of acute cough illness
are non-bacterial • Most patients with acute bronchitis
do not benefit from antibiotic therapy
• Symptoms may last up to 3 weeks • Evaluation should focus on
effective communication and symptom management
Possible signs and symptoms Cough with or without sputum Chest soreness Wheezing Fatigue Mild headache Mild body aches Low-grade fever (less than 102F)
Clinical picture consistent with acute bronchitis
Any of the following present? • Adult age 65 years and older • Oral body temperature > 38C/100.4F • Respiratory rate >24 • Heart rate > 100 • Oxygen saturation < 95% • Focal consolidation, egophony, rales or fremitus on
chest exam
Chest X-ray only if high suspicion for pneumonia
Infiltrate No Infiltrate
Refer to guideline for community-acquired pneumonia
Acute bronchitis likely
Antibiotic therapy not indicated Recommend specific symptomatic therapy: • Cough Suppressants (codeine or
dextromethorphan) • First generation antihistamine
(diphenhydramine) • Decongestants (phenylephrine)
*If covid-19, pertussis, influenza, or pneumonia are clinically suspected, initiate diagnostic testing and consider empiric antibiotic or antiviral therapy. References: Center for Disease Control and Prevention (2019). Adult treatment recommendation.
https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/adult-treatment-rec.html
Refer to the specific guideline.
Microbiological testing • Respiratory Panel • Procalcitonin only if high suspicion for o Influenza A or B o Bordetella Pertussis o SARS COV-2
ICE • Ideas: Ask patient about their idea regarding diagnosis,
treatment and prognosis. • Concerns: Ask about patient’s fears and worry • Expectation: Ask what the patients wants
Sputum test not recommended due to low specificity for infection
90.48 90.48
66.67
0.00 0.00
80.95
16.67
58.33 58.33
87.50
8.33 0.00
75.00
4.170
10
20
30
40
50
60
70
80
90
100
CBC CMP PCR Strep Sputum CXR CT
Labs and Diagnostic Tests
Pre-Intervention Post-Intervention
69%
19%
10% 2%
Pre-intervention
No Antibiotic Rx
Azithromycin
Augmentin
Cefuroxime
88%
6%4%2%
Post-intervention
No Antibiotic Rx
Azithromycin
Augmentin
Cefuroxime
-10 -5 0 5 10 15 20 25
I find the clinical pathway useful
I find the ICE method useful
I use the clinical pathway and ICE in my decision making
Clinical pathway should be standard protocol
ICE method should be standard protocol
Survey of ED providers on the use of the clinical pathway and ICE method
Strongly Disgree Disagree Neutral Agree Strongly Agree
