Background: Fluoroquinolones (FQ) are the leading class of antibiotics prescribed during adult ambulatory care visits, resulting in over 20 million outpatient prescriptions annually. Overuse of this class of antibiotics has contributed to increased antibiotic resistance and risk for Clostridioides difficile infection. In 2016, the Food and Drug Administration (FDA) updated the Boxed Warnings advising against FQ use for patients with uncomplicated sinusitis, bronchitis, or cystitis as the risk for potential serious side effects outweighs the benefit.
Methods: The antimicrobial stewardship team at Parkland Health & Hospital System undertook a multi-interventional approach to decrease outpatient FQ usage (Fig 1). First, the FDA warning was added to all oral FQ orders in the electronic medical record and education regarding risk and appropriate use of FQ was given to providers in the primary care clinics and emergency department. Secondly, ciprofloxacin susceptibilities were suppressed by the laboratory when organisms were susceptible to third generation cephalosporins. To assess the impact of these interventions, FQ utilization was compared across the same time period, each one year apart. Pre-education was assessed from November 2015 to February 2016, post-education from November 2016 to February 2017, and post-education plus susceptibility suppression from November 2017 to February 2018.
Results: Comparative utilization data by site was collected (Fig 2) with all sites demonstrating a decrease in FQ utilization and one site showing an 85% decrease. We observed an overall 19% decrease in outpatient FQ prescribing after education alone and 14% decrease after susceptibility suppression plus continuing education. Compared to pre-intervention baseline, there was a total 30% decrease in FQ utilization after both interventions were implemented, corresponding to approximately 150 fewer prescriptions per month (Fig 3).
Conclusion: Educational efforts alone proved effective in decreasing outpatient FQ usage. Additional improvement was observed when change was implemented at a system level via susceptibility suppression. Further decrease in FQ utilization is expected with ongoing education and additional system changes.
J. Ortwine, None
B. Prokesch, None