Infection Control & Hospital Epidemiology


Acute respiratory tract infections (ARIs), including rhinosinusitis, pharyngitis, bronchitis, and common cold (URI-NOS), account for 30% of antibiotics prescribed in outpatient settings, yet viruses cause most ARIs.1 Antibiotics are indicated for rhinosinusitis and pharyngitis if specific criteria are met.1,2 Infectious Diseases Society of America (IDSA) guidelines for management of streptococcal pharyngitis recommend identifying suitable candidates for group AStreptococcus testing and only prescribing antibiotics for patients with positive results.3 IDSA guidelines recommend antibiotic treatment for bacterial rhinosinusitis based on identifying constel- lations of signs and symptoms to determine probability of bacterial infection: prolonged symptom duration, worsening after initial improvement, or severe presentation.4,5 When antibiotics are indi- cated, guidelines recommend penicillin or penicillin derivatives except for patients with a β-lactam allergy. Numerous sources rec- ommend against routine antibiotic prescribing for acute bronchitis (unless pertussis is suspected) or URI-NOS.2,6–7 The Veterans Healthcare Administration (VHA) provides care


to 7 million veterans nationwide through>150VAmedical centers (VAMCs). In 2014, the VHA required each VAMC to implement an antimicrobial stewardship program (ASP). Many VAMCs developed robust inpatient ASPs8; however, most antibiotics are prescribed in the outpatient setting.9 Antibiotic prescriptions for uncomplicated ARIs increased within the VHA between 2005 and 2012, and azithromycin was the leading antibiotic prescribed.10 The VA Center for Medication Safety (VAMedSAFE) is tasked


with evaluating andpromoting safe andeffective drug therapywithin VHA by performingmedication utilization evaluations (MUEs).An MUE is a systematic, criteria-based quality improvement analysis of medication or disease(s) designed to improve patient outcomes.11 VAMedSAFE previously partnered with the VA Antimicrobial Stewardship Task Force to conductMUEs tomonitor and improve antibiotic therapy for pneumonia and urinary tract infections.8,12,13 The purpose of the presentMUEwas to evaluate ARI diagnostic


and treatment appropriateness and to inform development of a VHA-wide campaign to improve ARI management. Our objectives were (1) to determine frequency of appropriate antibiotic manage- ment (ie, appropriately withholding or initiating antibiotic therapy based on documentation of clinical and diagnostic criteria) congruent with published guidelines, and (2) to compare relevant outcomes between those who did and did not receive appropriate antibiotic management.


Methods


VAMedSAFE created a retrospective cohort of patient visits from veterans with an outpatient ARI diagnosis from 28 VAMCs that volunteered to participate in the MUE. The first eligible visit for each patient during the evaluation period was included. Diagnoses were identified by International Classification of Diseases Tenth Edition, Clinical Modification (ICD-10CM) codes for acute rhinosi- nusitis, pharyngitis, bronchitis, or URI-NOS for visits occurring between October 1, 2015, and March 30, 2016 (see Supplementary AppendixAonline).14Visitswere excluded for the following reasons: complete lackofARIsymptomortreatmentdocumentation, resolved ARI on visit date, hospitalization within 1 day after visit, antecedent ARI within 30 days, chronic sinusitis or pharyngitis, concurrent non-ARI infection requiring antibiotics, antibiotic self-treatment or chronic antibiotic use. Furthermore, we excluded patients with certain comorbidities: chronic lung disease (COPD), end-stage renal disease, active neoplasm,marrowor organ transplantation,HIV, and other immunocompromising conditions. Prescription for an oral


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antibiotic dispensed from the VHA <2 days before or <3daysafter the encounter was attributed to the visit.10 Potential cases were extracted from electronic data using


inclusion criteria by VAMedSAFE from the VHA Corporate Data Warehouse (CDW) in collaboration with the Informatics Decision Enhancement and Analytic Sciences Center (IDEAS 2.0).15 Exclusions based on ICD-10 codes and prescription data, select patient demographics, comorbidities, and 30-day all-cause hospitalization were extracted as well. Local reviewers, blinded to specific ARI diagnoses, were provided lists of≤250 visits per facility. These reviewers (antibiotic stewards and trainees) performed a manual review of electronic health records to confirm and/or extract inclusion and exclusion criteria, signs and symptoms, pro- vider indicated diagnoses, laboratory test results, antibiotics(s) pre- scribed, and outcomes. Data abstraction protocol, case report form, andmonthly teleconferences facilitated standardized data col- lection (Supplementary Appendix B online). Completed cases were uploaded to a VAMedSAFE database for integration and analysis. Indications for antibiotic initiation and definitions of appropri-


ate therapy were adapted from guideline recommendations.2–7 For pharyngitis, penicillin, and amoxicillin were appropriate first-line therapies for patients with a positive rapid antigen detection test (RADT) or a throat culture positive for group A, C, or G Streptococcus.3 First-generation cephalosporins, clindamycin, or macrolides were appropriate second-line therapies for patients with penicillin allergy. For rhinosinusitis, amoxicillin/clavulanate or amoxicillin were considered appropriate first-line therapies in patients with purulent nasal discharge and/or facial pain/pres- sure/fullness plus one of the following: prolonged (≥7 days), severe (temperature ≥38.9°C [102°F] for >2 days), or worsening symp- toms after ≥4 days.4,5 Tetracyclines, moxifloxacin, or levofloxacin were appropriate second-line therapies for patients with penicillin allergy. For acute bronchitis, azithromycin or trimethoprim/sulfa- methoxazole therapy (in case of macrolide allergy) was considered appropriate if the provider documented suspicion of pertussis exposure or performed pertussis testing.6,7 For URI-NOS, antibi- otic therapy was considered inappropriate.2 Based upon ARI diag- nosis, documentation of diagnostic criteria, antibiotic initiation, and antibiotic selection, antibiotic management for each case was classified as appropriate or inappropriate. Visits with mixed ARIs (>1 simultaneous ARI diagnosis) or those with a “delayed pre- scription” filled outside the 3-day postvisit window were excluded from the appropriate management and outcomes assessments. Demographics, signs, symptoms, diagnostics, antibiotics pre-


scribed, and outcomes were compared with descriptive statistics, parametric tests, or nonparametric tests as indicated. A 2-tailed P value <.05 was considered significant. We used SASR version 9.4 software (SAS Institute, Cary NC) for these analyses.Outcomes were reported based upon appropriate and inappropriate antibiotic management classifications. Based on the VA Policy Handbook guideline1058.05, which


defines operations activities that constitute research, the Hines VA Institutional Review Board deemed this evaluation to be a quality improvement project and to be exempt from VA Human Subjects Research requirements.16 Data use agreements were signed by all participating sites.


Results


Of the visits reviewed, 4,305 of 5,740 (75%) met criteria for assess- ment of diagnosis, and 3,884 of 5,740 (68%) met our criteria for assessment of antibiotic management appropriateness and


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