Outpatient prescriptions consist of 60% of all antibiotic use. Prior studies have shown antibiotic overuse in the outpatient setting which contributes to rising rates of resistance and unnecessary adverse drug events. This study aimed to prospectively identify antibiotic stewardship targets in outpatient settings including drug selection, dose, duration, and if guideline criteria was met to necessitate an antibiotic.
The patient population consisted of outpatients seen at the Veterans Affairs Western New York Healthcare System and its affiliated community-based outreach clinics. Patients were prospectively identified via on a real-time alert received by the infectious disease pharmacist at the time when an oral antibiotic was prescribed from June to September 2017. Data was then collected via chart review and all infections were evaluated based on guidelines. Descriptive statistics and a multivariable logistic regression was used to identify stewardship targets.
Of the 1,063 patients included, the most common infections treated included skin and skin structure infection (26.3%), urinary tract infection (18.1%), and sinusitis (11.9%). Azithromycin was the most commonly used antibiotic (27%), followed by cephalexin (13%) and ciprofloxacin (12%). Overall, 40% of antibiotics prescribed were not indicated for use. The incorrect drug was chosen for indication in 40%, the improper dose was ordered in 22%, and the incorrect duration was used in 30%. ICD-10 codes were unreliable in capturing oral antibiotic use, as only 41% antibiotic use was associated with an ICD-10 code relating to an infection. Per the multivariable logistic regression, when the antibiotic was indicated, patients were 2.9 times more likely to receive the correct drug (95% CI, 2.2 - 3.8) and 2 times more likely to receive the correct duration for the antibiotic (95% CI, 1.5 – 2.7). Emergency room patients were twice as likely to receive an antibiotic when indicated based on guidelines (95% CI, 1.5 – 2.7) compared to those seen in clinics.
Poor antibiotic prescribing practices was found throughout the outpatient setting. This study provides a guide to focus efforts during implementation an outpatient stewardship program.
A. White, None
C. Clark, None
M. Ott, None