Implementing outpatient antimicrobial stewardship in a primary care office through ambulatory care pharmacist-led audit and feedback.

This study aimed to determine the impact of a pharmacist-led antimicrobial stewardship program (ASP) intervention on outpatient antibiotic prescribing for upper respiratory tract infections (URIs) and urinary tract infections (UTIs) in a primary care office. The primary outcome of this study was to characterize antibiotic prescribing over time. Secondary outcomes included describing ambulatory care pharmacist (ACP) workload and types of feedback given. A retrospective pilot study was conducted within a primary care office. The office included a 0.6 full-time equivalent ACP and is part of a health system supported by a pharmacist and a physician co-led ASP. Education and guidelines were provided by the ACP and ASP leads before the intervention period August 2017-February 2018. The ACP provided bi-weekly audit of all URI and UTI prescriptions and written feedback to prescribers. During the 7-month intervention period, 1107 prescriptions were audited by the ACP, 825 URI and 282 UTI. The most common reasons for feedback included inappropriate agent (26.3%) or prolonged duration of therapy (24.3%). Guideline-concordant agent prescribed for a UTI increased from 20% at baseline to a median of 69.2%, whereas duration increased from 55% to 70.4%. Guideline-concordant agent prescribed for a URI increased from 43.3% to 86.8%, whereas the median duration of therapy decreased from 10 to 7 days. An ACP-led ASP intervention within a primary care office incorporating audit and feedback improved antibiotic prescribing for URIs and UTIs, including prescribing antibiotics when indicated, guideline-concordant antibiotic selection, and duration of therapy. Pharmacists practicing in ambulatory care settings may serve a vital role in leading successful outpatient ASP interventions.

Burns KW ，Johnson KM ，Pham SN ，Egwuatu NE ，Dumkow LE ... -  《-》

Outcomes of an ambulatory care pharmacist-led antimicrobial stewardship program within a family medicine resident clinic.

Westerhof LR ，Dumkow LE ，Hanrahan TL ，McPharlin SV ，Egwuatu NE ... -  《-》

Impact of pharmacist-led selective audit and feedback on outpatient antibiotic prescribing for UTIs and SSTIs.

An estimated 30% of all outpatient antibiotic prescriptions in the United States are unnecessary. The Joint Commission, in 2016, implemented core elements of performance requiring antimicrobial stewardship programs (ASPs) to expand to outpatient practice settings. A study was conducted to determine whether pharmacist-led audit and feedback would improve antibiotic prescribing for urinary tract infections (UTIs) and skin and soft tissue infection (SSTIs) at 2 primary care practices. A retrospective, quasi-experimental study was conducted to evaluate antibiotic prescribing for patients treated for a UTI or SSTI at 2 primary care offices (a family medicine office and an internal medicine office). The primary objective was to compare the rate of appropriate antibiotic prescribing to patients treated before implementation of a pharmacist-led audit-and-feedback process for reviewing antibiotics prescribed for UTIs and SSTIs (the pre-ASP group) and patients treated after process implementation (the post-ASP group). Total regimen appropriateness was defined by appropriate antibiotic selection, dose, duration, and therapy indication in accordance with institutional outpatient empiric therapy guidelines. Secondary objectives included comparing rates of infection-related revisits and Clostridioides difficile infection between groups. A total of 400 patients were included in the study (pre-ASP group, n = 200; post-ASP group, n = 200). The rate of total antibiotic prescribing appropriateness improved significantly, from 27.5% to 50.5% (P < 0.0001), after implementation of the audit-and-feedback process. There were also significant improvements in the post-ASP group vs the pre-ASP period in the individual components of regimen appropriateness: appropriate drug (70% vs 53%, P < 0.001), appropriate duration (83.5% vs 57.5%, P < 0.001), and appropriate therapy indication (98% vs 94%, P = 0.041). There were no significant between-group differences in other outcomes such as rates of adverse events, treatment failure, C. difficile infection, and infection-related revisits or hospitalizations within 30 days. A pharmacist-led audit-and-feedback outpatient stewardship strategy was demonstrated to achieve significant improvement in outpatient antibiotic prescribing for UTI and SSTI.

Choi PW ，Benzer JA ，Coon J ，Egwuatu NE ，Dumkow LE ... -  《-》

Half of Prescribed Antibiotics Are Not Needed: A Pharmacist-Led Antimicrobial Stewardship Intervention and Clinical Outcomes in a Referral Hospital in Ethiopia.

Intense antibiotic consumption in Low- and Middle-Income Countries (LMICs) is fueled by critical gaps in laboratory infrastructure and entrenched syndromic management of infectious syndromes. Few data inform the achievability and impact of antimicrobial stewardship interventions, particularly in Sub-Saharan Africa. Our goal was to demonstrate the feasibility of a pharmacist-led laboratory-supported intervention at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia, and report on antimicrobial use and clinical outcomes associated with the intervention. Methods: This was a single-center prospective quasi-experimental study conducted in two phases: (i) an intervention phase (November 2017 to August 2018), during which we implemented weekly audit and immediate (verbal and written) feedback sessions on antibiotic prescriptions of patients admitted in 2 pediatric and 2 adult medicine wards, and (ii) a post-intervention phase (September 2018 to January 2019) during which we audited antibiotic prescriptions but provided no feedback to the treating teams. The intervention was conducted by an AMS team consisting of 4 clinical pharmacists (one trained in AMS) and one ID specialist. Our primary outcome was antimicrobial utilization (measured as days of therapy (DOT) per 1,000 patient-days and duration of antibiotic treatment courses); secondary outcomes were length of hospital stay and in-hospital all-cause mortality. A multivariable logistic regression model was used to explore factors associated with all-cause in-hospital mortality. Results: We collected data on 1,109 individual patients (707 during the intervention and 402 in the post-intervention periods). Ceftriaxone, vancomycin, cefepime, meropenem, and metronidazole were the most commonly prescribed antibiotics; 96% of the recommendations made by the AMS team were accepted. The AMS team recommended to discontinue antibiotic therapy in 54% of cases during the intervention period. Once the intervention ceased, total antimicrobial use increased by 51.6% and mean duration of treatment by 4.1 days/patient. Mean LOS stay as well as crude mortality also increased significantly in the post-intervention phase (LOS: 24.1 days vs. 19.8 days; in hospital death 14.7 vs. 6.9%). The difference in mortality remained significant after adjusting for potential confounders. Conclusions: A pharmacist-led AMS intervention focused on duration of antibiotic treatment was feasible and had good acceptability in our setting. Cessation of audit-feedback activities was associated with immediate and sustained increases in antibiotic consumption reflecting a rapid return to baseline (pre-intervention) prescribing practices, and worse clinical outcomes (increased length of stay and in-hospital mortality). Pharmacist-led audit-feedback activities can effectively reduce antimicrobial consumption and result in better-quality care, but require organizational leadership's commitment for sustainable benefits.

Gebretekle GB ，Haile Mariam D ，Abebe Taye W ，Mulu Fentie A ，Amogne Degu W ，Alemayehu T ，Beyene T ，Libman M ，Gedif Fenta T ，Yansouni CP ，Semret M ... -  《Frontiers in Public Health》

Impact of outpatient antimicrobial stewardship guideline implementation in an urgent care setting.

Urgent care medicine is a rapidly growing health care sector where patients are commonly treated for acute infectious diseases-related conditions. However, there are few antimicrobial stewardship interventions described in these settings. The objective of this study is to determine whether implementing outpatient antimicrobial stewardship guidelines would improve antibiotic prescribing for acute upper respiratory tract infections (ARTIs), skin and soft tissue infections (SSTI), and urinary tract infections (UTI) at a single urgent care site. This was a pre-post interventional study comparing antibiotic prescribing patterns for ARTI, SSTI, and UTI at a single urgent care site in the preintervention group (November 2019 to January 2020) with the postintervention group (November 2020 to January 2021) after implementation of outpatient stewardship guidelines. A second urgent care site that did not receive any interventions served as a control. The outpatient stewardship guidelines were implemented in October 2020 via didactic provider education and pocket guide distribution. The primary end point was the rate of total guideline-concordant antibiotic prescribing. Secondary end points included the rates of guideline concordance of each component of the prescription, including antibiotic selection, duration, dose, therapy indication, and patient safety outcomes. The primary outcome of total guideline-concordant antibiotic prescribing significantly improved after implementation of outpatient antimicrobial stewardship guidelines at the study site (50% vs. 70%, P < 0.001), which was also reflected when comparing postintervention study site with postperiod control site (70% vs. 48%, P < 0.001). There was a statistically significant improvement in guideline-concordant duration of antibiotic therapy (43% vs. 61%, P = 0.001), driven by a reduction in antibiotic duration for UTI (7 [interquartile range (IQR) 5-7] vs. 5 [IQR 5-7] days, P = 0.007), which was also observed when comparing the postintervention study site with the postperiod control site (61% vs. 48%, P = 0.02). Patient safety outcomes were similar between groups. An antimicrobial stewardship intervention comprising institutional outpatient guideline implementation and provider education significantly improved total guideline-concordant antibiotic prescribing by 20% for ARTI, UTI, and SSTI in an urgent care site.

Lee P ，Rico M ，Muench S ，Yost C ，Hall Zimmerman L ... -  《-》