Infection Control & Hospital Epidemiology
prescribing. Although antibiotics were prescribed in ~67% of patients with pharyngitis, only 5% of patients tested positive for β-hemolytic Streptococcus. Of the patients treated, <33% received penicillin or amoxicillin. Furthermore, documentation of suspected pertussis exposure
and testing was rare, and the proportion of acute bronchitis cases treated with antibiotics was high. Only 7 documented cases of sus- pected exposure to pertussis occurred with no confirmed cases. Nonetheless, 86% of patients with acute bronchitis received anti- biotics. Similarly, >33% of patients with URI-NOS, a condition for which antibiotics are never indicated, were treated with antibiotics. In addition, detailed assessments of patient outcomes relative to initial receipt of antibiotics indicated similar proportions of ARI-related return visits and low frequency of complications, Clostridium difficile infections, and hospitalizations. Patients who did not receive antibiotics during their initial encounter were more likely to receive them during a subsequent encounter; how- ever, the overall frequency of subsequent visits with antibiotics pre- scribed was low. Although there were few differences in outcomes for patients who received or did not receive appropriate antibiotic management, patients who had antibiotics inappropriately with- held were more likely to seek follow-up care. Finally, patients who had antibiotics appropriately initiated were more likely to receive follow-up care than patients for whom antibiotics were inappropriately initiated. We were unable to ascertain the reason for this because there were no differences in worsening symptoms or infectious complications between these groups. A strength of this analysis includes the systematic removal of complicated ARI cases through extraction from the CDW, which was confirmed by manual chart review. The manual chart review identified small numbers (ie, 278 of 5,740, 5%) of additional patients with significant pulmonary and immunological comor- bidity (Fig. 1), conditions where antibiotic use might be justified, verifying that the combination of diagnostic coding and recent prescription of select medications (Supplementary Appendix A online) applied to electronic records was effective at identifying patients with comorbidity. Even though not all exclusions were identified by the algorithm, manual records review identified the remaining cases not meeting uncomplicated ARI criteria. The manual records review also facilitated collection of information on documentation of clinical diagnostic criteria and verification of outcomes. These data, which were not retrievable through CDW databases, were used to conduct a detailed assessment of appropriate antibiotic management and clinical endpoints. This analysis has several limitations. The VHA population is
predominantly male, and not all veterans receive care exclusively through the VHA, with most visits occurring in the emergency department. Some excluded cases identified through manual chart review indicated prior encounters that occurred outside the VHA, and it is possible that not all comorbidities were documented within the VHA record, which could have impacted the accuracy of appropriate antibiotic management estimates. Furthermore, the analysis excluded clinics without VHA pharmacy services for dis- pensing acute medications (ie, community-based outreach clinics). Point-of-care rapid diagnostic testing availability within the VHA may be lower than in private settings. A 2015 VA-wide survey of antimicrobial stewardship resources indicated that ~50% of VAMCs hadRADTtesting,whereas throat culture testing wasmore widely available.18 This study was a quality improvement evaluation with a consensus-based approach to MUE protocol development, and the diagnostic and treatment criteria for rhinosinusitis were not identical to IDSA recommendations. For example, ≥7days
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instead of 10 days was used to define the prolonged symptoms diagnostic threshold for treatment of rhinosinusitis, and amoxicillin in addition to amoxicillin clavulanate was considered acceptable first-line therapy.4,5 Because sites volunteered to participate, we can- not rule out bias in the characteristics of participating sites. These findings should not be generalized beyond uncomplicatedARI cases because not all ARI visits identified by diagnostic codes met this definition. Our findings parallel a VHA-wide analysis that reported an
antibiotic prescribing rate of 69% in 2012.10 Respiratory tract infections, primarily ARIs, account for 45% of all outpatient pre- scriptions, with an overall estimated annual appropriate antibiotic prescribing rate ranging from 45% to 63% for adults.1 Our finding of 39% for appropriate antibiotic management based on manual records review is slightly lower than the claims-based estimate. Reports from nation-wide, commercially insured populations sug- gest overall outpatient antibiotic use decreased 9% between 2010 and 2016, with a 16% reduction in pediatrics but only a 5% reduc- tion in adults.19 We recently reported a similar drop in outpatient antibiotic prescription for uncomplicated ARIs within the VHA system within a similar timeframe.20 Data on provider documen- tation of diagnostic criteria and their relationship to antibiotic treatment decisions for uncomplicated ARIs were limited.21–24 Similarly, a recent observational cohort study identified an 83% prescription rate for rhinosinusitis in adults and that 38% had symptoms for<3 days.19That study found a lower (48%) antibiotic prescribing rate for pharyngitis and a higher rate of RADT testing for pharyngitis (91%). Antibiotics were prescribed in 47% of patients who had negative RADTs or no RADT tests. In our analysis, that patients who did not initially receive antibiotics were slightly more likely to subsequently receive one on a follow-up visit, which has been previously reported.25 Finally, similar rates of return visits and low rates of complications for patients with ARIs irrespective of antibiotic treatment have been reported.26,27 Although many approaches have been utilized to improve
ARI management, few have demonstrated sustainability.28 Our evaluation informed the development of a national VHA ARI cam- paign to reduce unnecessary antibiotic use. The campaign compo- nents include provider-directed interventions of academic detailing coupled with audit/feedback. Preliminary results suggest improve- ments in appropriate antibiotic management for uncomplicated ARIs, althoughlongitudinal follow-up is needed.20 Because scalability requires the ability to accurately identify, track, and report cases effi- ciently, further work is needed to assess diagnostic and treatment decisions without the need for chart review. Improvements in elec- tronicmedical record templates to captureARI symptoms and natu- ral language processingmay aid in that approach.29–31 Finally, future work should include tools to capture and aid assessment of untoward patient outcomes, including antibiotic adverse events, rare infectious complications, and ecological effects such as antibiotic resistance associated with inappropriate management decisions. Overall, we observed high rates of antibiotic prescription for uncomplicated ARIs in VHA outpatient settings, suggesting that considerable overuse did not change substantially between 2012 and 2016. Practice patterns were frequently discordant with guide- line diagnosis and treatment recommendations. Most patient- related outcomes were similar irrespective of treatment approach suggesting that interventions to reduce use inappropriate antibiotic management are needed.
Supplementary material. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2019.16.
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