Infection Control & Hospital Epidemiology
Table 1. Patient Demographic, Provider, and Treatment Setting Characteristics Characteristic
All Patientsa
Age, mean y (±SD) Male
Current smoker β-lactam allergy
Vital signs Temp. >38.3°C (101°F) HR > 90 beats/min RR > 20 breaths/min
Comorbidityc No comorbidities 1 comorbidity ≥2 comorbidity
Treating providerd Staff physician provider Mid-level provider Medical trainees Other provider
Treatment settinge Emergency department Urgent care clinic Primary care clinic
Other outpatient clinic
(n=4,303), No. (%) 50 (16)
3,564 (83) 1,117 (26) 517 (12)
29 (<1)
1,129 (26) 97 (2)
3,979 (92) 270 (6) 56 (1)
2,999 (70) 857 (20) 351 (8) 94 (2)
2,218 (52) 640 (15)
1,356 (32) 89 (2.0)
50 (16)
2,449 (84) 839 (29) 364 (13)
21 (<1) 758 (26) 73 (3)
2,673 (92) 191 (7) 43 (2)
2,101 (70) 632 (74) 117 (33) 55 (59)
1,570 (71) 417 (65) 880 (65) 40 (45)
441
Antibiotics Prescribed (n=2,907), No. (%)
No Antibiotics Prescribed (n=1,396), No. (%)
49 (16)
1,114 (80) 278 (20) 153 (11)
8 (<1)
371 (27) 24 (2)
1,304 (93) 79 (6)
13 (<1)
898 (30) 225 (26) 234 (67) 39 (42)
648 (29) 223 (35) 476 (35) 49 (55)
P Valueb or Significance
.08
<.01 <.01 .15
.69 .74 .12
Ref
1.2 (0.9,1.5) 1.6 (0.9,3)
Ref
1.2 (1.0,1.4) 0.2 (0.2,0.3) 0.6 (0.4,0.9)
Ref
0.8 (0.6,0.9) 0.8 (0.7,0.9) 0.3 (0.2,0.5)
Note. HR, heart rate; RR, respiratory rate; OR, odds ratio; CI, confidence interval. aNot all observations for each variable were recorded resulting in missing data for select characteristics. Two patients lacked antibiotic prescribing information
documented (n= 4,303). Due to rounding, all percentages may not add up to 100%. bReported P values compare patients with antibiotics prescribed and patients with no antibiotics prescribed. Bold indicates significance. cComorbidities evaluated renal disease, diabetes, liver disease, chronic heart failure, and history of cerebrovascular accident/transient ischemic attack. Two patients in the “no comorbidities” category did not have documentation indicating whether antibiotics were prescribed recorded (n=3,977). Significance is
reported as the odds ratio (OR ± 95% CI) of receiving an antibiotic with “no comorbidities” as the reference group. dMid-level providers included physician assistants and nurse practitioners. Other providers included nonphysician trainees, nurses, pharmacists, or providers who were unidentifiable. Four patients did not have a type of provider recorded (n =4,301). Significance is reported as the odds ratio (OR ±95% CI) of receiving
an antibiotic with staff physician provider as the reference group. eOther outpatient clinic included Women’s clinic and select community-based outreach clinics (CBOC). Two patients did not have a treatment setting recorded (n=4,303). Significance is reported as the odds ratio (OR ± 95% CI) of receiving an antibiotic with “emergency department” as the reference group.
appropriate antibioticmanagement. In total, 1,497 of 3,884 patients diagnosed with uncomplicated ARIs (39%) received appropriate antibiotic management. After removal of visits with mixed diagnoses and delayed pre-
scriptions, for 704 of 3,884 visits (18%), follow-up encounters (in person or by phone) related to the initial ARI visit had been recorded. Patient outcomes were assessed among 2 axes: patients who did or did not initially receive antibiotics (Table 3) and patients who did or did not receive appropriate antibiotic manage- ment (Table 4). Among patients who did (457 of 2,552, 18%) or did not (247 of 1,332, 19%) initially receive antibiotics, there was no difference in the frequency of additional encounters (P = .65). However, patients with rhinosinusitis who did not receive antibiotics (22 of 79, 28%) more commonly had a subsequent ARI-related encounter than patients who did receive antibiotics (106 of 630, 17%; P =.02). Patients who did not receive antibiotics in the initial encounter were more likely to receive an antibiotic during a subsequent encounter (84 of 1,332 [6%] vs 105 of 2,552 [4%]; P<.01), especially for patients with an initial diagnosis of acute bronchitis (12 of 158 [8%] vs 39 of 990 [4%]; P = .04) or
URI-NOS (58 of 921 [6%] vs 19 of 550 [4%]; P = .02). Also, 30-day Clostridium difficile infection (2 of 3,884, <1%) and 30-day hospi- talization (33 of 3,884, 1%) were uncommon and did not differ based on receipt of an antibiotic during the initial ARI visit. Appropriate and inappropriate antibiotic management assess-
ment revealed few differences in patient outcomes (Table 4). ARI- related return encounters were similar for patients who received appropriate (288 of 1,497, 19%) versus inappropriate initial anti- biotic management (416 of 2,387, 17%; P=.15). However, patients who received initial appropriate management were more likely to receive an antibiotic during a return encounter (93 of 1,497, 6%) than those who received inappropriate initial management (96 of 2,387, 4%; P < .01). Patients who had antibiotics appropri- ately withheld were less likely to have a return encounter or patient initiated phone call than patients with antibiotics inappropriately withheld: 239 of 1,314 (18%) versus 8 of 18 (44%; P<.01) and 35 of 1,314 (3%) versus 2 of 18 (11%; P = .03), respectively. Conversely, patients who had antibiotics appropriately initiated were more likely to have a return encounter or to initiate a follow-up phone call than patients who had antibiotics inappropriately initiated:
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