It’s Possible to Reduce Unneeded Antibiotic Scripts in Primary Care

A national antibiotic stewardship program at ambulatory care centers was associated with reduced antibiotic prescribing during the pandemic, both overall and for acute respiratory infection (ARI) cases, researchers found.

In an analysis involving nearly 300 practices who took part in the Agency for Healthcare Research and Quality’s (AHRQ) program for improving antibiotic use, there were nine fewer antibiotic prescriptions for every 100 visits by the end of the intervention (95% CI -10 to -8), as well as 15 fewer prescriptions for every 100 ARI-related visits (95% CI -17 to -12), reported Sara Keller, MD, MPH, MSPH, of Johns Hopkins University in Baltimore.

“We want to ensure that patients who need antibiotics receive the most appropriate medication for the shortest effective duration and to reduce use of antibiotics when they are not needed,” Keller told MedPage Today. “This is critical if we are to beat back antimicrobial resistance.”

In ARI cases, the biggest reduction was seen among the penicillin class of antibiotics, at seven fewer prescriptions for every 100 visits (95% CI -9 to -6), according to findings presented at virtual IDWeek.

“We know that it’s possible to improve antibiotic prescribing, but less is understood about how to do that, especially in the ambulatory setting where most antibiotics are prescribed,” Keller explained. “These results demonstrate that, with some tools and resources and engagement of practices, members of ambulatory practices can work together to improve antibiotic prescribing.”

AHRQ’s Safety Program for Improving Antibiotic Use is a national program that involves presentations, webinars, patient handouts, and other educational tools (including the Four Moments of Antibiotic Decision Making tool) and emphasizes three key areas for clinicians: developing and improving antibiotic stewardship; learning strategies for discussing antibiotic prescribing with colleagues, patients, and their families; and best practices for diagnosing and managing common infectious syndromes, as well as allergies to antibiotic.

“A key part of our program was to enable practices to talk among themselves — everybody in the practice, the front office staff, clinicians, rooming staff — about antibiotic prescribing,” co-investigator Jeffrey Linder, MD, MPH, of Northwestern University Feinberg School of Medicine in Chicago, said during a press briefing.

“There’s a lot of social, emotional, behavioral aspects that go into dealing with common respiratory infections and trying to avoid inappropriate antibiotic prescribing,” he added. “It’s not just about making the right diagnosis, often that’s the easiest part, but what you do when a patient you think or has said they want an antibiotic and they clearly have a viral illness, and empowering everyone in the office to address that was a key part of the program.”

Keller noted that the ARIs in the cohort “were primarily viral respiratory tract infections for which antibiotics are not indicated, but are one of the most common reasons that ambulatory patients are prescribed an antibiotic.”

For their study, the researchers evaluated 467 practices that enrolled in AHRQ’s program, 389 of which completed the program and 292 that submitted data on 6,590,485 visits. Of the practices that submitted data, 35% were primary care centers, 48% were urgent care clinics, 12% were federally funded practices, and 5% were specialty clinics that included primary care services.

To assess changes in prescribing habits, the researchers compared a pre-intervention period (September to November 2019) with a post-intervention period (December 2019 to November 2020). Antibiotic prescriptions dropped from about 19 to 10 per 100 visits, in total, and from about 40 to 25 per 100 ARI visits.

Patient visits per practice decreased from March to May 2020, due to the COVID-19 pandemic, but returned to baseline by study end. ARI visits remained below baseline by study completion, however.

The analysis had several limitations, the researchers acknowledged, including that not all practices have time and resources to incorporate the AHRQ program. Also, data were collected during the pandemic, which could have affected some of the trends.