SGEM#263: Please Stop, Prescribing – Antibiotics for Viral Acute Respiratory Infections

Date: July 22nd, 2019 Reference: Yadav et al. A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings. AEM July 2019 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and clinical lecturer in Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Case: A 25-year-old female presents to the urgent care with two days of cough, purulent sputum, fever and myalgias. Vitals signs are within normal limits and her exam is unremarkable. She asks for a prescription for antibiotics to help treat her infection.  Background: Inappropriate antibiotic use exposes patients to opportunistic infections, accelerates the development of antibiotic resistant bacteria and leads to adverse drug events [1]. Acute respiratory infections (ARIs) are a major cause of unnecessary antibiotic use. Emergency departments (EDs) in the United States write 10 million antibiotic prescriptions each year, approximately half of which are inappropriate [2, 3, 4]. Given these risks, strategies to reduce inappropriate antibiotic use in the ED and urgent care centers (UCCs) are needed. Despite recognizing the need for antibiotic stewardship by EDs and emergency providers, this has not led to practice change [5, 6]. Providers in the ED and UCC setting are faced with numerous challenges that may limit change, including: Frequent interruptions, boarding and overcrowding, frequent patient handoffs, and the need to see high volumes of patients [7, 8, 9]. There is evidence in both the medical literature and economic theory to support using a package of feedback, nudges and peer comparisons to improve prescribing outcomes. This has been shown to reduce unnecessary antibiotic prescribing in primary care, and in one study of peer comparisons in outpatient clinics and doctor’s offices, these improvements were sustained for at least 12 months after the interventions were completed [10, 11, 12]. Richard Thaler and Cass Sunstein wrote a book on the nudge theory. The book is called Nudge: Improving Decisions about Health, Wealth, and Happiness. The authors discuss psychologic and behavioral economics research to support active engineering of choice architecture. It’s a great book to put on your reading list. Clinical Question: Is an enhanced intervention using audit and feedback, peer comparisons, and nudges more effective than a standard intervention in reducing inappropriate antibiotic prescribing for acute respiratory infections by clinicians in an ED/UCC setting? Reference: Yadav et al. A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings. AEM July 2019 Population: Clinicians (general ED physicians, pediatric ED physicians, advanced care practitioners, internists and pediatricians) at five EDs and four UCCs in three academic health systems who prescribed antibiotics for ARIs. Excluded: Resident physicians Intervention: Enhanced intervention: This used all the elements of the adapted intervention, but also included peer comparison feedback via email, comparison to top performing peers, and additional locally tailored public posters demonstrating commitment to judicious antibiotic use. Comparison: Adapted intervention: This incorporated strategies from the Centre for Disease Control and Prevention’s Core Elements for Outpatient Antibiotic Stewardship, including provider and patient education, a physician champion and departmental feedback. This used adapted brochures and other campaign messages for acute care providers. Outcome: Primary Outcome: Rate of inappropriate outpatient antibiotic prescribing for acute respiratory infections diagnosis that were deemed antibiotic-nonresponsive. Secondary Outcome: Difference between the enhanced and adapted intervention g...