Primary care stewardship cuts antibiotics, costs for respiratory infections
A cluster-randomized controlled trial conducted in Spanish primary care settings suggests a multifaceted stewardship intervention helped reduce antibiotic prescribing for acute respiratory infections (ARIs) and was cost-effective, Spanish researchers reported yesterday in Antimicrobial Resistance and Infection Control.
The intervention was introduced among primary care providers in Galicia, a region of northwest Spain where at least one third of all antibiotic prescriptions are for ARIs but only half are thought to be appropriate. It included a one-hour educational outreach visit tailored to physician knowledge gaps identified in a previous study, an online course integrated in practiced accreditation, and a clinical decision support system.
To evaluate the intervention, after a median of 19 months, researchers looked at antibiotic prescribing among 1,217 physicians recruited from seven intervention clusters and 1,393 from control clusters. The main outcomes measured were overall antibiotic prescribing for ARIs, antibiotic use by class, the ratio of consumption of broad- to narrow-spectrum antibiotics, and the savings attributed to the intervention.
The results showed a 4.23% decline in overall antibiotic prescribing in the intervention group compared with the control group, highlighted by a 6.51% reduction in penicillin use. The ratio of consumption of broad- to narrow-spectrum penicillins, cephalosporins, and macrolides fell by 8.97%. Because of the reduction in antibiotic prescriptions, Spain's National Health Service directly saved €311 (USD $377) per physician and patients directly saved €573 ($694).
"The results of this study indicate that low-cost interventions based on the previously identified gaps can be effective and, in addition, have a positive cost-benefit relationship over a short time horizon, something that could be highly relevant for their application by healthcare systems," the authors wrote.
Dec 7 Antimicrob Resist Infect Control study
VA stewardship interventions linked to reduced antibiotic use for ARIs
Implementation of the Centers for Disease Control and Prevention's Core Elements of Outpatient Antibiotic Stewardship at Veterans Affairs (VA) emergency departments and primary care clinics was associated with reduced antibiotic prescribing for uncomplicated ARIs and a drop in hospitalizations, US researchers reported today in Clinical Infectious Diseases.
Key elements of the intervention included physician education and diagnosis-based audit and feedback reports.
The quasi-experimental, controlled study compared the effects of Core Elements' implementation at 10 VA sites—four emergency departments and six primary care clinics—with prescribing data from 40 control sites over a 5-year period.
There were 16,712 and 51,275 uncomplicated ARI visits at the intervention and control sites, respectively, from 2014 through 2019. Antibiotic prescribing rates fell from 59.7% pre-intervention to 41.5% post-intervention, compared with 73.5% to 67.2% at the control sites. The proportion of visits with appropriate therapy increased from 53.8% to 69.1% at the intervention sites (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.31 to 2.14), but was unchanged at the control sites (OR, 1.04; 95% CI, 0.91 to 1.19).
There was no statistical difference in ARI-related return visits post-implementation (-1.3% vs -2.0%), but all-cause hospitalization was lower within the intervention sites (-0.5% vs -0.2%). The OR to diagnose upper respiratory tract infection not otherwise specified compared to other non-ARI diagnosis increased post-implementation for intervention sites (1.27) but not control sites (0.97).
The authors conclude that healthcare systems interested in improving antibiotic prescribing should embrace the Core Elements framework and consider implementation of similar interventions.
Dec 8 Clin Infect Dis abstract
More improper antibiotics noted for ARIs in rural vs city Tennessee kids
In another study on antibiotic prescribing for respiratory infections, researchers in Tennessee reported today in Open Forum Infectious Diseases that inappropriate antibiotic use for ARIs was significantly higher in children from rural counties compared with urban counties.
The study cohort consisted of children aged 2 months to 5 years who were enrolled in Tennessee Medicaid from 2007 through 2012 and diagnosed with an ARI in the outpatient setting during that period. Using electronic medical record and pharmacy data, researchers from Vanderbilt University Medical Center and Atrium Health compared rates of ARI and related antibiotic use among children in completely rural, mostly rural, and mostly urban counties. Multivariable regression models were used to measure associations between rurality of residence and the rate of study outcomes.
Compared with children from mostly urban areas, children from mostly rural and completely rural counties had higher rates of ARIs (adjusted incidence rate ratio [aIRR], 1.07 1.07, respectively), ARI-related antibiotic use (aIRR, 1.15 and 1.17), and ARI-related inappropriate antibiotic use (aIRR, 1.34 and 1.33).
Although the proportion of ARIs associated with overall and inappropriate antibiotic use decreased over time, they remained higher in children living in rural counties compared to urban counties throughout the study period. The strength of the association between rurality and rate of antibiotic use was higher among black children and those from households with lower median incomes.
"These findings should inform targeted outpatient stewardship efforts to reduce inappropriate antibiotic use and its consequences," the authors concluded.
Dec 8 Open Forum Infect Dis abstract