Outpatient stewardship intervention at Mayo Clinic linked to fewer unnecessary antibiotics

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Doctor with patient
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A multifaceted outpatient antibiotic stewardship intervention implemented at Mayo Clinic hospitals was associated with reduced unnecessary antibiotic prescribing for upper respiratory infections (URIs), researchers reported today in Open Forum Infectious Diseases.

The intervention, implemented across Mayo Clinic facilities in Minnesota, Wisconsin, Florida, and Arizona in July 2020, aimed to reduce antibiotic use for Tier 3 URI syndromes, which are defined as URIs for which antibiotics are never indicated.

Specific interventions were standardized provider education, development of a syndrome-based, pre-populated ambulatory panel, peer comparison reporting, and a provider-facing data dashboard to facilitate self-auditing of cases in which antibiotics were flagged as unnecessary. The intervention also included a patient-facing antibiotic commitment poster and handouts for patients promoting symptomatic management.

To evaluate the effect of the intervention, Mayo Clinic researchers measured the percentage of Tier 3 encounters that resulted in an antibiotic prescription before and after implementation, along with the rate of repeat respiratory-related healthcare encounters within 14 days of the index visit. They also looked at factors associated with persistent unnecessary prescribing.

Unnecessary antibiotic prescriptions nearly cut in half

A total of 165,658 Tier 3 encounters—96,125 in the pre- and 69,533 in the post-intervention period—were included in the analysis. Baseline patient characteristics were similar in the two periods, with approximately 45% of encounters involving patients aged 18 and under.

Following the intervention, the prescribing rate for Tier 3 encounters decreased from 21.7% to 11.2% overall (a 48.4% relative reduction), amounting to roughly 7,300 unnecessary antibiotic prescriptions avoided. Significant reductions were observed in all geographic regions and departments. The largest improvement was observed in urgent care (a 51.8% relative reduction in prescribing).

Repeat 14-day respiratory healthcare contact was less common when an antibiotic was prescribed in the overall cohort (6.9% antibiotics vs 9.7% no antibiotics) but was lower in the no-antibiotics patients post-intervention (9.9.% vs 9.4%). 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.  

"Our study adds to mounting evidence that targeted outpatient antibiotic stewardship programs are effective at reducing unnecessary or inappropriate antibiotic prescribing for URIs," the study authors wrote.

UK primary care costs nearly 45% higher among long-COVID patients, analysis finds

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Woman with long COVID
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Long-COVID diagnoses and long-term symptoms among nonhospitalized adults were tied to 43% and 44% increases in the costs of primary care, respectively, in the United Kingdom, according to a study published yesterday in BMC Primary Care.

A team led by University of Birmingham researchers analyzed data in the Clinical Practice Research Datalink Aurum primary care database to estimate additional primary care costs of and risk factors for persistent COVID-19 symptoms at least 3 months after infection at the individual and national level.

The study, which included 472,173 COVID-19 survivors and an equal number of matched uninfected participants, used data from January 2020 to April 2021. Long-COVID (DLC) and symptomatic long-COVID (SLC) subgroups were made up of 3,871 (0.8%) and 30,174 (6.4%) patients, respectively. The average age was 44 years, 55% were women, 64% were White, and 55% were overweight or obese. 

Phone visits made up over 60% of costs

There were 209,620 (0.44 per patient) primary care visits among unexposed participants and 245,177 (0.54) among COVID-19 survivors, respectively. The exposed group had a 22.7% higher visit rate than the unexposed group. DLC and SLC subgroups visit rates were over three and six times higher, with incremental costs of £30.52 ($38.24 US) and £57.56 ($72.13) per patient, respectively.

The support of non-hospitalised individuals with long COVID in primary care is likely to be substantial, requiring significant healthcare investment and planning.

The annual incremental cost of primary care for long COVID was £2.44 ($3.06) per patient and £23,382,452 ($29.3 million) nationally. Relative to those without persistent symptoms, patients with long COVID and symptoms were associated with a 43% and 44% increase, respectively, in primary care costs. Phone consultations accounted for over 60% of total costs among all groups and were highest among long-COVID patients.

Risk factors for increased costs were older age, female sex, obesity, White race, chronic conditions, and more previous consultations.

"The support of non-hospitalised individuals with long COVID in primary care is likely to be substantial, requiring significant healthcare investment and planning," the study authors wrote.

Community antibiotic use returned to pre-pandemic levels in Europe in 2022

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An analysis of community antibiotic consumption in Europe shows a return to pre–COVID-19 pandemic levels, researchers reported last week in Eurosurveillance.

Using data from the European Surveillance of Antimicrobial Consumption Network (ESAC-Net), a team led by researchers from the European Centre for Disease Prevention and Control, analyzed community-sector consumption of antibacterials for systemic use in 29 European Union/European Economic Activity (EU/EEA) countries from 2019 through 2022.

They found an 18.5% decrease in community antibiotic consumption—measured in defined daily doses per 1,000 inhabitants per day—in 2020 compared with 2019. As in non-European countries, the reduction in community antibiotic use has been attributed to pandemic-related non-pharmaceutical interventions and disrupted access to healthcare services. Consumption rates remained similar in 2021 in most EU/EEA countries.

In 2022, however, as countries lifted non-pharmaceutical interventions, ESAC-Net data showed mean community consumption increased by 18.8% from 2021 levels and then returned to pre-pandemic levels. In 13 countries, community antibiotic consumption was higher in 2022 than in 2019, with an average increase of 8.4%.

'Missed opportunity'

The study authors say the rebound could be explained by a resurgence of viral and bacterial infections as pandemic restrictions were lifted, but "could also reflect a missed opportunity to strengthen and reinforce prudent antibiotic use."

They add that to achieve the EU target of a 20% reduction in total antibiotic consumption (community and hospital sectors combined) by 2030, most EU countries will need to intensify their efforts to reduce unnecessary antibiotic use.

"Antibiotic stewardship activities strengthening prudent community consumption plays [sic] a vital role in this, as community consumption accounts for around 90% of the total antibiotic consumption," they wrote.

In 13 countries, community antibiotic consumption was higher in 2022 than in 2019, with an average increase of 8.4%.

UN groups call for action to protect maternal and child health against climate change

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Ahead of a United Nations (UN) climate change conference (COP28) that begins next week in Dubai, UN agencies today said the impacts of climate change on the health of pregnant women and children have been neglected, underreported, and underestimated.

baby behind mosquito net
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The groups said few countries have included maternal and child health, which they said is a "glaring omission."

Rising global temperatures are increasing the spread of diseases such as cholera, malaria, and dengue, which can be severe in pregnant women and children. Infections during pregnancy can lead to preterm birth and other complications, and the diseases in children can hinder physical growth and brain development.

Seven key steps

In their report, the UN groups' call to action details seven key steps to address the risks, including reductions in greenhouse gas emissions, climate finance, and including women and children in climate and disaster-related policies.

Helen Clark, New Zealand's former prime minister and chair of the Partnership for Maternal, Newborn, and Child Health, said in a statement, "The urgency to integrate women, children and adolescent health needs into climate responses is not just a moral imperative, but an effective strategy with long-term benefits for resilient and healthy societies."

Quick takes: H9N2 avian flu case, H5N1 on fur farms, more poultry outbreaks

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  • China has reported another H9N2 avian flu case, which involves a patient from Sichuan province whose symptoms began on October 1, according to a weekly influenza update from the Hong Kong Centre for Health Protection. The report didn't note the patient's age. H9N2 infections are typically mild and are most commonly reported in children, especially those who have contact with poultry or their environments. China has reported five human H9N2 cases over the past 6 months. The virus is known to circulate in poultry in some Asian countries.
  • The Finnish Food Agency added 14 more H5N1 avian flu detections at fur farms, all housing foxes, which comes on the heels of 10 detections reported last week, according to Avian Flu Diary, an infectious disease news blog. The country is conducting surveillance at all fur farms in the wake of outbreaks that began in July. Officials have now reported 56 outbreaks on fur farms. Detections of H5N1 in mammals, especially farmed ones, have raised concerns about the risk of mutations that would allow the virus to spread more easily to humans.
  • The United States and Europe reported more highly pathogenic avian flu outbreaks in poultry, according to the latest official notifications. In the United States, the US Department of Agriculture (USDA) Animal and Plant Health Inspection Service (APHIS) reported more outbreaks in five states, including at a commercial duck breeding farm in California and three commercial turkey farms in South Dakota. Officials also reported outbreaks in backyard flocks in New Mexico, Florida, and Iowa. In Europe, notifications from the World Organization for Animal Health (WOAH) detailed H5N1 outbreaks at farms in Croatia and Hungary, as well as a detection in wild birds in Germany.

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