Benefits of Antibiotic Stewardship Wane When Discontinued

Daniel M. Keller, PhD

October 12, 2014

PHILADELPHIA — The benefits of an outpatient antimicrobial stewardship program diminish when advice to healthcare providers is stopped, according to the results of a new study.

"These data suggest that audit and feedback was a vital element of this intervention, and although antimicrobial stewardship can be effective in the ambulatory setting, at least in this network, it should be continued in some way to engage clinicians to keep prescribing judiciously and appropriately," said Jeffrey Gerber, MD, from the Division of Infectious Diseases at Children's Hospital of Philadelphia (CHOP), in Pennsylvania.

Dr Gerber presented the study results here at IDWeek 2014. The work was published online in JAMA on October 10 to coincide with the presentation.

Although most antimicrobial stewardship programs are in hospitals, most antibiotic use and misuse occur in the outpatient setting, with more than 40 million outpatient prescriptions a year for children with acute respiratory tract infections. More than half of those are for broad-spectrum antibiotics, such as amoxicillin-clavulanate, cephalosporins, and azithromycin.

The study assessed the efficacy of an outpatient antimicrobial stewardship intervention on antibiotic prescribing for acute respiratory tract infections in five academic urban and 24 private urban, suburban, and rural pediatric primary care practices within the CHOP Care Network, all of which share a common electronic health record system.

The goal of the intervention was to reduce antibiotic prescribing for viral infections and to reduce prescribing of broad-spectrum antibiotics for conditions for which narrow-spectrum antibiotics are indicated.

In 2009, some 200 clinicians had more than one million patient encounters with more than 200,000 children. At baseline, practices and individual clinicians varied widely in their prescribing of broad-spectrum antibiotics for acute otitis media, sinusitis, group A streptococcus pharyngitis, and pneumonia.

Researchers compared a bundled intervention versus no intervention. The intervention was randomized at the practice level, and the unit of observation was each individual clinician. The intervention consisted of education, audit, and feedback. Feedback was in the form of reports to individuals on their prescribing habits, how they compared with the rest of their practice group, and how they compared with the network.

It really is old school, shoe leather epidemiology in terms of benchmarking providers against themselves in their behavior over time and also against peers.

Eighteen practices were randomized to the intervention or to no intervention. Baseline data were collected for 20 months, and then for the intervention group, Dr Gerber and colleagues provided on-site education with three feedback reports during the next 12 months. During the 32-month study period, they collected data on 185,212 patients and 1,435,605 encounters.

In the intervention, audit, and feedback period, broad-spectrum antibiotic rates significantly decreased for the intervention group compared with controls when standardized by age, sex, race, and Medicaid status (P = .01). From a baseline rate of about 32% standardized prescribing, for each group, rates fell to about 15% for the intervention group and to about 25% for controls.

But once antibiotic prescribing audits and feedback were stopped, rates rose to almost the same level as at baseline, approximately 30% to 32% in terms of standardized rates of prescribing.

Speaking with Medscape Medical News, Dr Gerber said the researchers are now looking into providing continuing audit and feedback to see whether that could help to maintain the benefits of the intervention. To develop such an online tool would require substantial resources to set up, "but it will be then just available perpetually," he said. "The challenge is getting people to look at it." One way may be to have "clinician champions" at each site to continually remind people, possibly with monthly meetings in their practices.

Session moderator Keith Kaye, MD, professor of medicine at Wayne State University and Detroit Medical Center, in Michigan, told Medscape Medical News that the study is "really innovative work in that it's community-based, outpatient settings, and it really is old school, shoe leather epidemiology in terms of benchmarking providers against themselves in their behavior over time and also against peers."

He said he is impressed with the speed with which physicians receded back to baseline in terms of practice. The study shows "the power of data and also the power of repeated follow-up," he said. "This is potentially a revolutionary study," but it should be tested to see whether it is generalizable to other geographic areas and to nonacademic-affiliated outpatient settings.

Dr Kaye noted that the resources that need to be put into an antimicrobial stewardship intervention such as the one here are relatively low compared with the large effect that they had on antibiotic prescribing.

Dr Gerber receives grant support from Pfizer for a Joint Commission administered antimicrobial stewardship project unrelated to the present study. Dr Kaye reported no relevant financial relationships and was not involved in the study.

IDWeek 2014: Abstract 612. Presented October 10, 2014.

JAMA. Published online October 10, 2014. Abstract


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