Antibiotic stewardship bundle reduces prescribing without increasing health care contacts
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Key takeaways:
- After initiating the antibiotic stewardship bundle, the prescribing rate decreased from 21.7% to 11.2%.
- Repeat health care encounters decreased from 9.9% to 9.4%.
An outpatient antibiotic stewardship bundle initiative reduced unnecessary antibiotic prescribing for respiratory infections without increasing repeat health care contacts, a recent study showed.
“Though a robust inpatient antimicrobial stewardship program (ASP) has been in place for many years, in 2019, the Mayo Clinic Enterprise began establishing and implementing an outpatient antimicrobial stewardship program,” Ryan W. Stevens, PharmD, infectious diseases and antimicrobial stewardship pharmacist at Mayo Clinic, told Healio.
“This program specifically functions with the goal to improve antimicrobial prescribing practices in the ambulatory care setting in order to optimize patient outcomes and minimize unintended consequences of antimicrobial use,” Stevens said.
According to Stevens, when the Mayo Clinic Enterprise evaluated antimicrobial prescribing practices in outpatient care within the system, they determined that respiratory tract infections made up a significant portion of overall antimicrobial prescribing.
“As such, we decided to initially focus our improvement efforts on respiratory syndromes with specific emphasis on avoiding antimicrobial prescribing in those respiratory syndromes [that] generally should not be treated with antibiotic therapy (eg, bronchitis, bronchiolitis, rhinitis, etc.),” he said. “We began developing a bundle approach at an Enterprise level to address this issue; however, we allowed our local ASP champions at individual regions/facilities to decide on how to best implement these tools.”
Stevens explained that the bundle included a prescription pad for over-the-counter symptom management aimed at improving symptoms when antibiotics are not indicated, a prepopulated antimicrobial order panel aimed at improving prescribing when antibiotics are indicated, multifaceted educational tools and a comprehensive data model.
To assess the frequency of unnecessary antibiotic prescribing for tier 3 respiratory infection (URI) syndromes before and after this intervention, Stevens and colleagues conducted a quasi-experimental, pre/post, retrospective cohort study. All outpatient encounters of adult and pediatric patients between Jan. 1, 2019, and Dec. 31, 2022, from primary care, urgent care and emergency medicine specialties with a tier 3 URI diagnosis were included.
There were 165,658 tier 3 encounters throughout the study — 96,125 in the preintervention period and 69,533 in the postintervention period. The study showed that after the bundle implementation, the prescribing rate for tier 3 encounters decreased from 21.7% to 11.2% (P < .001). Stevens added that these reductions were seen across all diagnostic categories and all care specialties evaluated.
The researchers also assessed repeat 14-day respiratory health care contact. Stevens explained that patients who receive an antibiotic at their index visit were less likely to have repeat contact with the health care system, although they observed a small decrease in the rate of repeat health care contact in the postimplementation cohort. Specifically, the study showed that repeat health care encounters decreased from 9.9% to 9.4% (P = .004).
“Even though antimicrobial stewardship implementation in outpatient care settings presents some unique challenges, it is of critical importance in ongoing efforts to preserve the utility of this valuable resource,” Stevens said. “Outpatient ASP can be complex given the large number of encounters, lack of centrality of staffing, lack of control over dispensing, and short duration of patient contact.”
He added that data, metrics and benchmarking are not as well defined in the outpatient ASP space as compared with inpatient ASP, which he said can be “intimidating” for programs looking to stand up new initiatives.
“All of this considered, a comprehensive team with a specific goal with the right tools can have a tremendous impact on the quality of care provided and unnecessary or inappropriate antimicrobial prescribing,” Stevens said. “We estimate that our efforts prevented approximately 7,300 unnecessary antimicrobial prescriptions across the Mayo Clinic Enterprise in the postimplementation period.”
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