Last data update: Jun 17, 2024. (Total: 47034 publications since 2009)
Records 1-30 (of 41 Records) |
Query Trace: Hersh AL [original query] |
---|
Leveraging Health Systems to Expand and Enhance Antibiotic Stewardship in Outpatient Settings
Rodzik RH , Buckel WR , Hersh AL , Hicks LA , Neuhauser MM , Stenehjem EA , Hyun DY , Zetts RM . Jt Comm J Qual Patient Saf 2024 50 (4) 289-295 The widespread implementation of antibiotic stewardship programs across all health care settings is critical to slow the development of antibiotic resistance and ensure that patients receive the best medical care. Currently, most hospitals and long-term care facilities have reported implementation of antibiotic stewardship programs (95.0% of hospitals and 76.6% of long-term care facilities in 2021).1,2 However, more work is needed to expand antibiotic stewardship efforts into outpatient health care practices—including primary care, urgent care, and retail clinics, and within care provided through telemedicine services. These health care settings account for the majority of antibiotics prescribed in the United States, and previous studies have shown high rates of inappropriate prescribing.3., 4., 5., 6. | | Successful outpatient antibiotic stewardship implementation requires a coordinated effort between a diverse group of health care stakeholders to ensure that individual practices and clinicians have the resources and support they need to improve their prescribing practices. One key stakeholder group with the ability to support stewardship expansion into outpatient practices is health systems. Health care delivery in the United States has become increasingly consolidated, with one study finding that around 72% of hospitals and 49% of primary care physicians were affiliated with health systems in 2018.7 Health systems offer the ability to provide resources and infrastructure that can support antibiotic stewardship efforts across multiple outpatient practices. |
Impact of an antibiotic stewardship initiative on urgent-care respiratory prescribing across patient race, ethnicity, and language
Seibert AM , Hersh AL , Patel PK , Hicks LA , Fino N , Stanfield V , Stenehjem EA . Infect Control Hosp Epidemiol 2023 1-4 We conducted a post hoc analysis of an antibiotic stewardship intervention implemented across our health system's urgent-care network to determine whether there was a differential impact among patient groups. Respiratory urgent-care antibiotic prescribing decreased for all racial, ethnic, and preferred language groups, but disparities in antibiotic prescribing persisted. |
Antibiotic stewardship in outpatient telemedicine: Adapting Centers for Disease Control and Prevention core elements to optimize antibiotic use
Sanchez GV , Kabbani S , Tsay SV , Bizune D , Hersh AL , Luciano A , Hicks LA . Telemed J E Health 2023 The rapid expansion of telemedicine has highlighted challenges and opportunities to improve antibiotic use and effectively adapt antibiotic stewardship best practices to outpatient telemedicine settings. Antibiotic stewardship integration into telemedicine is essential to optimize antibiotic prescribing for patients and ensure health care quality. We performed a narrative review of published literature on antibiotic prescribing and stewardship in outpatient telemedicine to inform the adaptation of the Core Elements of Outpatient Antibiotic Stewardship framework to outpatient telemedicine settings. Our narrative review suggests that in-person antibiotic stewardship interventions can be adapted to outpatient telemedicine settings. We present considerations for applying the Core Elements of Outpatient Antibiotic Stewardship to outpatient telemedicine which builds upon growing evidence describing care delivery and quality improvement in this setting. Additional applied implementation research is necessary to inform the application of effective, sustainable, and equitable antibiotic stewardship interventions across the spectrum of outpatient telemedicine. |
Comparison of antibiotic prescribing between physicians and advanced practice clinicians
Hersh AL , Shapiro DJ , Sanchez GV , Hicks LA . Infect Control Hosp Epidemiol 2023 1-3 We compared antibiotic prescribing rates for respiratory conditions in a national sample of outpatient visits from 2010 to 2018 between physicians and advanced practice clinicians (APCs). APCs prescribed antibiotics more frequently than physicians (58% vs 52%), but there were no differences in selection of guideline recommended first-line agents between specialties. |
Notes from the field: Update on pediatric intracranial infections - 19 states and the District of Columbia, January 2016-March 2023
Accorsi EK , Hall M , Hersh AL , Shah SS , Schrag SJ , Cohen AL . MMWR Morb Mortal Wkly Rep 2023 72 (22) 608-610 In May 2022, CDC began an investigation of a possible increase in pediatric intracranial infections, particularly those caused by Streptococcus bacteria, during the preceding year (1). January 2016–May 2022 data from a large, geographically diverse network of children's hospitals showed altered patterns in pediatric intracranial infections after the onset of the COVID-19 pandemic (1). In this update, extended hospitalization data through March 2023 from 37 hospitals in 19 states and the District of Columbia showed a higher-than-expected number of pediatric intracranial infections beginning in August 2021, with a large peak during winter 2022–2023. Pediatric intracranial infections are recognized as a severe complication of viral respiratory infection and sinusitis (2), and the winter 2022–2023 peak coincided with spikes in respiratory virus circulation*,† (3,4). Even during this peak, intracranial infections remained rare. CDC continues to track trends in pediatric intracranial infections and recommends that all persons aged ≤18 years remain current with recommended vaccinations, including influenza and COVID-19.§ |
Implementation of an antibiotic stewardship initiative in a large urgent care network
Stenehjem E , Wallin A , Willis P , Kumar N , Seibert AM , Buckel WR , Stanfield V , Brunisholz KD , Fino N , Samore MH , Srivastava R , Hicks LA , Hersh AL . JAMA Netw Open 2023 6 (5) e2313011 IMPORTANCE: Urgent Care (UC) encounters result in more inappropriate antibiotic prescriptions than other outpatient setting. Few stewardship interventions have focused on UC. OBJECTIVE: To evaluate the effectiveness of an antibiotic stewardship initiative to reduce antibiotic prescribing for respiratory conditions in a UC network. DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study conducted in a UC network with 38 UC clinics and 1 telemedicine clinic included 493 724 total UC encounters. The study compared the antibiotic prescribing rates of all UC clinicians who encountered respiratory conditions for a 12-month baseline period (July 1, 2018, through June 30, 2019) with an intervention period (July 1, 2019, through June 30, 2020). A sustainability period (July 1, 2020, through June 30, 2021) was added post hoc. INTERVENTIONS: Stewardship interventions included (1) education for clinicians and patients, (2) electronic health record (EHR) tools, (3) a transparent clinician benchmarking dashboard, and (4) media. Occurring independently but concurrent with the interventions, a stewardship measure was introduced by UC leadership into the quality measures, including a financial incentive. MAIN OUTCOMES AND MEASURES: The primary outcome was the percentage of UC encounters with an antibiotic prescription for a respiratory condition. Secondary outcomes included antibiotic prescribing when antibiotics were not indicated (tier 3 encounters) and first-line antibiotics for acute otitis media, sinusitis, and pharyngitis. Interrupted time series with binomial generalized estimating equations were used to compare periods. RESULTS: The baseline period included 207 047 UC encounters for respiratory conditions (56.8% female; mean [SD] age, 30.0 [21.4] years; 92.0% White race); the intervention period included 183 893 UC encounters (56.4% female; mean [SD] age, 30.7 [20.8] years; 91.2% White race). Antibiotic prescribing for respiratory conditions decreased from 47.8% (baseline) to 33.3% (intervention). During the initial intervention month, a 22% reduction in antibiotic prescribing occurred (odds ratio [OR], 0.78; 95% CI, 0.71-0.86). Antibiotic prescriptions decreased by 5% monthly during the intervention (OR, 0.95; 95% CI, 0.94-0.96). Antibiotic prescribing for tier 3 encounters decreased by 47% (OR, 0.53; 95% CI, 0.44-63), and first-line antibiotic prescriptions increased by 18% (OR, 1.18; 95% CI, 1.09-1.29) during the initial intervention month. Antibiotic prescriptions for tier 3 encounters decreased by an additional 4% each month (OR, 0.96; 95% CI, 0.94-0.98), whereas first-line antibiotic prescriptions did not change (OR, 1.00; 95% CI, 0.99-1.01). Antibiotic prescribing for respiratory conditions remained stable in the sustainability period. CONCLUSIONS AND RELEVANCE: The findings of this quality improvement study indicated that a UC antibiotic stewardship initiative was associated with decreased antibiotic prescribing for respiratory conditions. This study provides a model for UC antibiotic stewardship. |
Changes in outpatient antibiotic prescribing for acute respiratory illnesses, 2011 to 2018
King LM , Tsay SV , Hicks LA , Bizune D , Hersh AL , Fleming-Dutra K . Antimicrob Steward Healthc Epidemiol 2021 1 (1) 1-8 OBJECTIVES: To describe acute respiratory illnesses (ARI) visits and antibiotic prescriptions in 2011 and 2018 across outpatient settings to evaluate progress in reducing unnecessary antibiotic prescribing for ARIs. DESIGN: Cross-sectional study. SETTING AND PATIENTS: Outpatient medical and pharmacy claims captured in the IBM MarketScan commercial database, a national convenience sample of privately insured individuals aged <65 years. METHODS: We calculated the annual number of ARI visits and visits with oral antibiotic prescriptions per 1,000 enrollees overall and by age category, sex, and setting in 2011 and 2018. We compared these and calculated prevalence rate ratios (PRRs). We adapted existing tiered-diagnosis methodology for International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. RESULTS: In our study population, there were 829 ARI visits per 1,000 enrollees in 2011 compared with 760 ARI visits per 1,000 enrollees in 2018. In 2011, 39.3% of ARI visits were associated with ≥1 oral antibiotic prescription versus 36.2% in 2018. In 2018 compared with 2011, overall ARI visits decreased 8% (PRR, 0.92; 99.99% confidence interval [CI], 0.92-0.92), whereas visits with antibiotic prescriptions decreased 16% (PRR, 0.84; 99.99% CI, 0.84-0.85). Visits for antibiotic-inappropriate ARIs decreased by 9% (PRR, 0.91; 99.99% CI, 0.91-0.92), and visits with antibiotic prescriptions for these conditions decreased by 32% (PRR, 0.68; 99.99% CI, 0.67-0.68) from 2011 to 2018. CONCLUSIONS: Both the rate of antibiotic prescriptions per 1,000 enrollees and the percentage of visits with antibiotic prescriptions decreased modestly from 2011 to 2018 in our study population. These decreases were greatest for antibiotic-inappropriate ARIs; however, additional reductions in inappropriate antibiotic prescribing are needed. |
Urgent-care antibiotic prescribing: An exploratory analysis to evaluate health inequities
Seibert AM , Hersh AL , Patel PK , Matheu M , Stanfield V , Fino N , Hicks LA , Tsay SV , Kabbani S , Stenehjem E . Antimicrob Steward Healthc Epidemiol 2022 2 (1) e184 Healthcare disparities and inequities exist in a variety of environments and manifest in diagnostic and therapeutic measures. In this commentary, we highlight our experience examining our organization's urgent care respiratory encounter antibiotic prescribing practices. We identified differences in prescribing based on several individual characteristics including patient age, race, ethnicity, preferred language, and patient and/or clinician gender. Our approach can serve as an electronic health record (EHR)-based methodology for disparity and inequity audits in other systems and for other conditions. |
Amoxicillin versus other antibiotic agents for the treatment of acute otitis media in children
Frost HM , Bizune D , Gerber JS , Hersh AL , Hicks LA , Tsay SV . J Pediatr 2022 251 98-104 e5 OBJECTIVES: To compare the antibiotic treatment failure and recurrence rates between antibiotic agents (amoxicillin, amoxicillin-clavulanate, cefdinir, and azithromycin) for children with uncomplicated acute otitis media (AOM) STUDY DESIGN: We completed a retrospective cohort study of children 6 months-12 years of age with uncomplicated AOM identified in a nationwide claims database. The primary exposure was antibiotic agent, and the primary outcomes were treatment failure and recurrence. Logistic regression was used to estimate odds ratios and analyses were stratified by primary exposure, patient age and antibiotic duration. RESULTS: Among the 1,051,007 children included in the analysis, 56.6% were prescribed amoxicillin, 13.5% amoxicillin-clavulanate, 20.6% cefdinir, and 9.3% azithromycin. Most prescriptions (93%) were for 10 days and 98% were filled within 1 day of the medical encounter. Treatment failure or recurrence occurred in 2.2% (95%CI: 2.1, 2.2) and 3.3% (3.2, 3.3) of children, respectively. Combined failure and recurrence rates were low for all agents including amoxicillin (1.7%; 1.7, 1.8) amoxicillin-clavulanate 11.3% (11.1, 11.5); cefdinir 10.0% (9.8, 10.1); azithromycin 9.8% (9.6, 10.0). CONCLUSIONS: Despite microbiologic changes in AOM etiology, treatment failure and recurrence were uncommon for all antibiotic agents and were lower for amoxicillin than for other agents. These findings support the continued use of amoxicillin as a first-line agent for AOM when antibiotics are prescribed. |
A Veterans' Healthcare Administration (VHA) antibiotic stewardship intervention to improve outpatient antibiotic use for acute respiratory infections: A cost-effectiveness analysis.
Yoo M , Madaras-Kelly K , Nevers M , Fleming-Dutra KE , Hersh AL , Ying J , Haaland B , Samore M , Nelson RE . Infect Control Hosp Epidemiol 2021 43 (10) 1-7 ![]() ![]() OBJECTIVES: The Core Elements of Outpatient Antibiotic Stewardship provides a framework to improve antibiotic use, but cost-effectiveness data on implementation of outpatient antibiotic stewardship interventions are limited. We evaluated the cost-effectiveness of Core Element implementation in the outpatient setting. METHODS: An economic simulation model from the health-system perspective was developed for patients presenting to outpatient settings with uncomplicated acute respiratory tract infections (ARI). Effectiveness was measured as quality-adjusted life years (QALYs). Cost and utility parameters for antibiotic treatment, adverse drug events (ADEs), and healthcare utilization were obtained from the literature. Probabilities for antibiotic treatment and appropriateness, ADEs, hospitalization, and return ARI visits were estimated from 16,712 and 51,275 patient visits in intervention and control sites during the pre- and post-implementation periods, respectively. Data for materials and labor to perform the stewardship activities were used to estimate intervention cost. We performed a one-way and probabilistic sensitivity analysis (PSA) using 1,000,000 second-order Monte Carlo simulations on input parameters. RESULTS: The proportion of ARI patient-visits with antibiotics prescribed in intervention sites was lower (62% vs 74%) and appropriate treatment higher (51% vs 41%) after implementation, compared to control sites. The estimated intervention cost over a 2-year period was $133,604 (2018 US dollars). The intervention had lower mean costs ($528 vs $565) and similar mean QALYs (0.869 vs 0.868) per patient compared to usual care. In the PSA, the intervention was dominant in 63% of iterations. CONCLUSIONS: Implementation of the CDC Core Elements in the outpatient setting was a cost-effective strategy. |
Association between antibiotic prescribing and visit duration among patients with respiratory tract infections
Shapiro DJ , King LM , Tsay SV , Hicks LA , Hersh AL . Infect Control Hosp Epidemiol 2021 43 (9) 1-4 Time constraints have been suggested as a potential driver of antibiotic overuse for acute respiratory tract infections. In this cross-sectional analysis of national data from visits to offices and emergency departments, we identified no statistically significant association between antibiotic prescribing and the duration of visits for acute respiratory tract infections. |
COVID-19 Testing to Sustain In-Person Instruction and Extracurricular Activities in High Schools - Utah, November 2020-March 2021.
Lanier WA , Babitz KD , Collingwood A , Graul MF , Dickson S , Cunningham L , Dunn AC , MacKellar D , Hersh AL . MMWR Morb Mortal Wkly Rep 2021 70 (21) 785-791 Cessation of kindergarten through grade 12 in-person instruction and extracurricular activities, which has often occurred during the COVID-19 pandemic, can have negative social, emotional, and educational consequences for children (1,2). Although preventive measures such as masking, physical distancing, hand hygiene, and improved ventilation are commonly used in schools to reduce transmission of SARS-CoV-2, the virus that causes COVID-19, and support in-person instruction (3-6), routine school-based COVID-19 testing has not been as widely implemented. In addition to these types of standard preventive measures, Utah health and school partners implemented two high school testing programs to sustain extracurricular activities and in-person instruction and help identify SARS-CoV-2 infections: 1) Test to Play,* in which testing every 14 days was mandated for participation in extracurricular activities; and 2) Test to Stay,(†) which involved school-wide testing to continue in-person instruction as an alternative to transitioning to remote instruction if a school crossed a defined outbreak threshold (3). During November 30, 2020-March 20, 2021, among 59,552 students tested through these programs, 1,886 (3.2%) received a positive result. Test to Play was implemented at 127 (66%) of Utah's 193 public high schools and facilitated completion of approximately 95% of scheduled high school extracurricular winter athletics competition events.(§) Test to Stay was conducted at 13 high schools, saving an estimated 109,752 in-person instruction student-days.(¶) School-based COVID-19 testing should be considered as part of a comprehensive prevention strategy to help identify SARS-CoV-2 infections in schools and sustain in-person instruction and extracurricular activities. |
Factors Associated with Participation in Elementary School-Based SARS-CoV-2 Testing - Salt Lake County, Utah, December 2020-January 2021.
Lewis NM , Hershow RB , Chu VT , Wu K , Milne AT , LaCross N , Hill M , Risk I , Hersh AL , Kirking HL , Tate JE , Vallabhaneni S , Dunn AC . MMWR Morb Mortal Wkly Rep 2021 70 (15) 557-559 During December 3, 2020-January 31, 2021, CDC, in collaboration with the University of Utah Health and Economic Recovery Outreach Project,* Utah Department of Health (UDOH), Salt Lake County Health Department, and one Salt Lake county school district, offered free, in-school, real-time reverse transcription-polymerase chain reaction (RT-PCR) saliva testing as part of a transmission investigation of SARS-CoV-2, the virus that causes COVID-19, in elementary school settings. School contacts(†) of persons with laboratory-confirmed SARS-CoV-2 infection, including close contacts, were eligible to participate (1). Investigators approached parents or guardians of student contacts by telephone, and during January, using school phone lines to offer in-school specimen collection; the testing procedures were explained in the preferred language of the parent or guardian. Consent for participants was obtained via an electronic form sent by e-mail. Analyses examined participation (i.e., completing in-school specimen collection for SARS-CoV-2 testing) in relation to factors(§) that were programmatically important or could influence likelihood of SARS-CoV-2 testing, including race, ethnicity, and SARS-CoV-2 incidence in the community (2). Crude prevalence ratios (PRs) were calculated using univariate log-binomial regression.(¶) This activity was reviewed by CDC and was conducted consistent with federal law and CDC policy.*. |
Low SARS-CoV-2 Transmission in Elementary Schools - Salt Lake County, Utah, December 3, 2020-January 31, 2021.
Hershow RB , Wu K , Lewis NM , Milne AT , Currie D , Smith AR , Lloyd S , Orleans B , Young EL , Freeman B , Schwartz N , Bryant B , Espinosa C , Nakazawa Y , Garza E , Almendares O , Abara WE , Ehlman DC , Waters K , Hill M , Risk I , Oakeson K , Tate JE , Kirking HL , Dunn A , Vallabhaneni S , Hersh AL , Chu VT . MMWR Morb Mortal Wkly Rep 2021 70 (12) 442-448 School closures affected more than 55 million students across the United States when implemented as a strategy to prevent the transmission of SARS-CoV-2, the virus that causes COVID-19 (1). Reopening schools requires balancing the risks for SARS-CoV-2 infection to students and staff members against the benefits of in-person learning (2). During December 3, 2020-January 31, 2021, CDC investigated SARS-CoV-2 transmission in 20 elementary schools (kindergarten through grade 6) that had reopened in Salt Lake County, Utah. The 7-day cumulative number of new COVID-19 cases in Salt Lake County during this time ranged from 290 to 670 cases per 100,000 persons.(†) Susceptible(§) school contacts(¶) (students and staff members exposed to SARS-CoV-2 in school) of 51 index patients** (40 students and 11 staff members) were offered SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) testing. Among 1,041 susceptible school contacts, 735 (70.6%) were tested, and five of 12 cases identified were classified as school-associated; the secondary attack rate among tested susceptible school contacts was 0.7%. Mask use among students was high (86%), and the median distance between students' seats in classrooms was 3 ft. Despite high community incidence and an inability to maintain ≥6 ft of distance between students at all times, SARS-CoV-2 transmission was low in these elementary schools. The results from this investigation add to the increasing evidence that in-person learning can be achieved with minimal SARS-CoV-2 transmission risk when multiple measures to prevent transmission are implemented (3,4). |
Rightsizing treatment for pneumonia in children
Tsay SV , Hersh AL , Fleming-Dutra KE . JAMA Pediatr 2021 175 (5) 462-463 Antibiotics are the double-edged swords we love to wield. They save lives, but they also cause harm with adverse drug events and the promotion of antibiotic resistance. Antibiotic stewardship is the effort to optimize the use of antibiotics to the right antibiotic at the right time and for the right duration. Stewardship encourages us to ask ourselves: can we decrease the biological costs of using these powerful tools, even a little, if we put them away earlier? Evidence has accumulated that we can give shorter courses of antibiotics, at least to adult patients, for many conditions, including for pneumonia, urinary tract infections, sinusitis, and cellulitis.1 This is welcome news to anyone who has taken antibiotics themselves or given their child an antibiotic and experienced diarrhea or a yeast infection; adverse events and effects are common, especially in children.2 However, in children, evidence regarding the efficacy of shorter antibiotic courses is lacking for most common conditions. At least in part because of this uncertainty, most antibiotic courses prescribed to children in the US for common infections, including pneumonia, are 10 days in duration.3 This may be owing in part to the lack of strong evidence to guide recommendations for duration of therapy for many infections. |
Pediatric research priorities in healthcare-associated infections and antimicrobial stewardship
Coffin SE , Abanyie F , Bryant K , Cantey J , Fiore A , Fritz S , Guzman-Cottrill J , Hersh AL , Huskins WC , Kociolek LK , Kronman M , Lautenbach E , Lee G , Linam M , Logan LK , Milstone A , Newland J , Nyquist AC , Palazzi DL , Patel S , Puopolo K , Reddy SC , Saiman L , Sandora T , Shane AL , Smith M , Tamma PD , Zaoutis T , Zerr D , Gerber JS . Infect Control Hosp Epidemiol 2020 42 (5) 1-4 OBJECTIVE: To develop a pediatric research agenda focused on pediatric healthcare-associated infections and antimicrobial stewardship topics that will yield the highest impact on child health. PARTICIPANTS: The study included 26 geographically diverse adult and pediatric infectious diseases clinicians with expertise in healthcare-associated infection prevention and/or antimicrobial stewardship (topic identification and ranking of priorities), as well as members of the Division of Healthcare Quality and Promotion at the Centers for Disease Control and Prevention (topic identification). METHODS: Using a modified Delphi approach, expert recommendations were generated through an iterative process for identifying pediatric research priorities in healthcare associated infection prevention and antimicrobial stewardship. The multistep, 7-month process included a literature review, interactive teleconferences, web-based surveys, and 2 in-person meetings. RESULTS: A final list of 12 high-priority research topics were generated in the 2 domains. High-priority healthcare-associated infection topics included judicious testing for Clostridioides difficile infection, chlorhexidine (CHG) bathing, measuring and preventing hospital-onset bloodstream infection rates, surgical site infection prevention, surveillance and prevention of multidrug resistant gram-negative rod infections. Antimicrobial stewardship topics included β-lactam allergy de-labeling, judicious use of perioperative antibiotics, intravenous to oral conversion of antimicrobial therapy, developing a patient-level "harm index" for antibiotic exposure, and benchmarking and or peer comparison of antibiotic use for common inpatient conditions. CONCLUSIONS: We identified 6 healthcare-associated infection topics and 6 antimicrobial stewardship topics as potentially high-impact targets for pediatric research. |
Unnecessary antibiotic prescribing in pediatric ambulatory care visits for bronchitis and bronchiolitis in the United States, 2006-2015
Snyder RL , King LM , Hersh AL , Fleming-Dutra KE . Infect Control Hosp Epidemiol 2020 42 (5) 1-4 Antibiotics are not indicated for the treatment of bronchitis and bronchiolitis. Using a nationally representative database from 2006-2015, we found that antibiotics were prescribed in 58% of outpatient visits for bronchitis and bronchiolitis in children, serving as a possible baseline for the expanded HEDIS 2020 measure regarding antibiotic prescribing for bronchitis. |
Duration of outpatient antibiotic therapy for common outpatient infections, 2017
King LM , Hersh AL , Hicks LA , Fleming-Dutra KE . Clin Infect Dis 2020 72 (10) e663-e666 Our objective was to describe the duration of antibiotic therapy for the management of common outpatient conditions. The median duration of antibiotic courses for most common conditions, except acute cystitis, was 10 days, in many cases exceeding guideline-recommended durations. |
Unnecessary antibiotic prescribing in US ambulatory care settings, 2010-2015
Hersh AL , King LM , Shapiro DJ , Hicks LA , Fleming-Dutra KE . Clin Infect Dis 2020 72 (1) 133-137 The proportion of antibiotic prescriptions prescribed in US physician offices and emergency departments that were unnecessary decreased slightly, from 30% in 2010-2011 to 28% in 2014-15. However, a greater decrease occurred in children: 32% in 2010-11 to 19% in 2014-15. Unnecessary prescribing in adults did not change during this period. |
Association between use of diagnostic tests and antibiotic prescribing for pharyngitis in the United States
Shapiro DJ , King LM , Fleming-Dutra KE , Hicks LA , Hersh AL . Infect Control Hosp Epidemiol 2020 41 (4) 1-3 Pharyngitis is a common reason for outpatient antibiotic prescribing in the United States.1,2 With few exceptions, antibiotics should be prescribed for pharyngitis only after confirmation of group A Streptococcus (GAS) by laboratory testing.3 Since rapid antigen detection tests (RADTs) have a specificity of greater than 95% but a sensitivity that is often less than 90% compared to throat cultures, national guidelines recommend performing cultures when RADTs are negative in children but not in adults.3,4 Inappropriate antibiotic prescribing for pharyngitis occurs when antibiotics are prescribed without testing or when antibiotics other than narrow-spectrum penicillins are chosen for non-allergic patients.3,5 Since the prevalence of GAS among cases of pharyngitis is estimated to be 20–30% in children and 5–15% in adults, prescription rates higher than these thresholds suggest overuse.1,3 Appropriate laboratory testing for pharyngitis in patients who are prescribed antibiotics is a Healthcare Effectiveness Data and Information Set (HEDIS) performance measure in children, and it will be expanded in 2020 to include adults.5 Our objectives were to describe use of laboratory testing and antibiotic prescribing for GAS in the United States. |
Antibiotic prescribing variability in a large urgent care network: A new target for outpatient stewardship
Stenehjem E , Wallin A , Fleming-Dutra KE , Buckel WR , Stanfield V , Brunisholz KD , Sorensen J , Samore MH , Srivastava R , Hicks LA , Hersh AL . Clin Infect Dis 2019 70 (8) 1781-1787 Improving antibiotic prescribing in outpatient settings is a public health priority. In the United States, urgent care (UC) encounters are increasing and have high rates of inappropriate antibiotic prescribing. Our objective was to characterize antibiotic prescribing practices during UC encounters, with a focus on respiratory tract conditions. This was a retrospective cohort study of UC encounters in the Intermountain Healthcare network. Among 1.16 million UC encounters, antibiotics were prescribed during 34% of UC encounters and respiratory conditions accounted for 61% of all antibiotics prescribed. Of respiratory encounters, 50% resulted in antibiotic prescriptions, yet the variability at the level of the provider ranged from 3% to 94%. Similar variability between providers was observed for respiratory conditions where antibiotics were not indicated and in first-line antibiotic selection for sinusitis, otitis media, and pharyngitis. These findings support the importance of developing antibiotic stewardship interventions specifically targeting UC settings. We describe antibiotic prescribing in a large network of urgent care (UC) clinics. The high volume of infectious diseases encounters and extreme provider variability in antibiotic prescribing frequency and quality highlight the importance of antibiotic stewardship interventions specifically targeting UCs. |
First-line antibiotic selection in outpatient settings
Palms DL , Hicks LA , Bartoces M , Hersh AL , Zetts R , Hyun DY , Fleming-Dutra KE . Antimicrob Agents Chemother 2019 63 (11) Using the 2014 IBM MarketScan Commercial Database, we compared antibiotic selection for pharyngitis, sinusitis, and acute otitis media in retail clinics, emergency departments, urgent cares, and offices. Only 50% of visits for these conditions received recommended first-line antibiotics. Improving antibiotic selection for common outpatient conditions is an important stewardship target. |
Antibiotic prescribing for children in United States emergency departments: 2009-2014
Poole NM , Shapiro DJ , Fleming-Dutra KE , Hicks LA , Hersh AL , Kronman MP . Pediatrics 2019 143 (2) OBJECTIVES: To characterize and compare ambulatory antibiotic prescribing for children in US pediatric and nonpediatric emergency departments (EDs). METHODS: A cross-sectional retrospective study of patients aged 0 to 17 years discharged from EDs in the United States was conducted by using the 2009-2014 National Hospital Ambulatory Medical Care Survey ED data. We estimated the proportion of ED visits resulting in antibiotic prescriptions, stratified by antibiotic spectrum, class, diagnosis, and ED type ("pediatric" defined as >75% of visits by patients aged 0-17 years, versus "nonpediatric"). Multivariable logistic regression was used to determine factors independently associated with first-line, guideline-concordant prescribing for acute otitis media, pharyngitis, and sinusitis. RESULTS: In 2009-2014, of the 29 million mean annual ED visits by children, 14% (95% confidence interval [CI]: 10%-20%) occurred at pediatric EDs. Antibiotics overall were prescribed more frequently in nonpediatric than pediatric ED visits (24% vs 20%, P < .01). Antibiotic prescribing frequencies were stable over time. Of all antibiotics prescribed, 44% (95% CI: 42%-45%) were broad spectrum, and 32% (95% CI: 30%-34%, 2.1 million per year) were generally not indicated. Compared with pediatric EDs, nonpediatric EDs had a higher frequency of prescribing macrolides (18% vs 8%, P < .0001) and a lower frequency of first-line, guideline-concordant prescribing for the respiratory conditions studied (77% vs 87%, P < .001). CONCLUSIONS: Children are prescribed almost 7 million antibiotic prescriptions in EDs annually, primarily in nonpediatric EDs. Pediatric antibiotic stewardship efforts should expand to nonpediatric EDs nationwide, particularly regarding avoidance of antibiotic prescribing for conditions for which antibiotics are not indicated, reducing macrolide prescriptions, and increasing first-line, guideline-concordant prescribing. |
Antibiotic prescriptions associated with dental-related emergency department visits
Roberts RM , Hersh AL , Shapiro DJ , Fleming-Dutra KE , Hicks LA . Ann Emerg Med 2018 74 (1) 45-49 STUDY OBJECTIVE: The frequency of antibiotic prescribing and types of antibiotics prescribed for dental conditions presenting to the emergency department (ED) is not well known. The objective of this study is to quantify how often and which dental diagnoses made in the ED resulted in an antibiotic prescription. METHODS: From 2011 to 2015, there were an estimated 2.2 million (95% confidence interval [CI] 1.9 to 2.5 million) ED visits per year for dental-related conditions, which accounted for 1.6% (95% CI 1.5% to 1.7%) of ED visits. This is based on an unweighted 2,125 observations from the National Hospital Ambulatory Medical Care Survey in which a dental-related diagnosis was made. RESULTS: An antibiotic, most often a narrow-spectrum penicillin or clindamycin, was prescribed in 65% (95% CI 61% to 68%) of ED visits with any dental diagnosis. The most common dental diagnoses for all ages were unspecified disorder of the teeth and supporting structures (44%; 95% CI 41% to 48%; International Classification of Diseases, Ninth Revision, Clinical Modification[ICD-9-CM] code 525.9), periapical abscess without sinus (21%; 95% CI 18% to 25%; ICD-9-CM code 522.5), and dental caries (18%; 95% CI 15% to 22%; ICD-9-CM code 521.0). Recommended treatments for these conditions are usually dental procedures rather than antibiotics. CONCLUSION: The common use of antibiotics for dental conditions in the ED may indicate the need for greater access to both preventive and urgent care from dentists and other related specialists as well as the need for clearer clinical guidance and provider education related to oral infections. |
Reply to Mercuro et al
Kabbani S , Hersh AL , Shapiro DJ , Fleming-Dutra KE , Pavia AT , Hicks LA . Clin Infect Dis 2018 67 (8) 1307-1308 We read with great interest the assessment by Mercuro and colleagues [1] of a single month of adult fluoroquinolone prescribing at hospital discharge. Although analyses of large national data sets are critical for understanding the epidemiology of prescribing, we agree with the authors that observational studies, medication use evaluations, and surveys that identify common errors in antibiotic prescribing are needed to identify targets for antibiotic stewardship action at the local level. Their study highlights an important opportunity to improve antibiotic prescribing at the time of hospital discharge. Antibiotics are commonly prescribed when patients are discharged from the hospital [2], and are frequently prescribed inappropriately [3–5]. One analysis found that most antibiotic prescriptions at discharge were oral (86.0%), and fluoroquinolones were the most common antibiotic class prescribed (23.5%) [5]. |
Comparison of antibiotic prescribing in retail clinics, urgent care centers, emergency departments, and traditional ambulatory care settings in the United States
Palms DL , Hicks LA , Bartoces M , Hersh AL , Zetts R , Hyun DY , Fleming-Dutra KE . JAMA Intern Med 2018 178 (9) 1267-1269 This cohort study compares antibiotic prescribing in 2014 among retail clinics, urgent care centers, emergency departments, and traditional medical offices in the United States. |
National incidence of pediatric mastoiditis in the United States, 2000-2012: Creating a baseline for public health surveillance
King LM , Bartoces M , Hersh AL , Hicks LA , Fleming-Dutra KE . Pediatr Infect Dis J 2018 38 (1) e14-e16 Between 2000-2012, the national estimated incidence rate of pediatric mastoiditis, a rare but serious complication of acute otitis media (AOM), was highest in 2006 (2.7 per 100,000 population) and lowest in 2012 (1.8 per 100,000 population). This measure provides a baseline for public health surveillance in the pneumococcal conjugate vaccine era as stewardship efforts target antibiotic use in AOM. |
Opportunities to improve fluoroquinolone prescribing in the United States for adult ambulatory care visits
Kabbani S , Hersh AL , Shapiro DJ , Fleming-Dutra KE , Pavia AT , Hicks LA . Clin Infect Dis 2018 67 (1) 134-136 The Food and Drug Administration warned against fluoroquinolone use for conditions with effective alternative agents. An estimated 5.1% of adult ambulatory fluoroquinolone prescriptions were for conditions that did not require antibiotics, and 19.9% were for conditions where fluoroquinolones are not recommended first-line therapy. Unnecessary fluoroquinolone use should be reduced. |
Outpatient macrolide antibiotic prescribing in the United States, 2008-2011
Sanchez GV , Shapiro DJ , Hersh AL , Hicks LA , Fleming-Dutra KE . Open Forum Infect Dis 2017 4 (4) ofx220 National Ambulatory Medical Care Survey data were used to assess outpatient macrolide prescribing and selection. Conditions for which macrolides are firstline therapy represented 5% of macrolide prescribing. Family practitioners selected macrolides for children more frequently than pediatricians. Macrolides are an important antibiotic stewardship target. |
Geographic variability in diagnosis and antibiotic prescribing for acute respiratory tract infections
Hersh AL , Shapiro DJ , Pavia AT , Fleming-Dutra KE , Hicks LA . Infect Dis Ther 2017 7 (1) 171-174 INTRODUCTION: Antibiotic prescribing rates vary substantially across regions in the USA. Whether these differences are driven primarily by a greater tendency to treat certain infections (i.e., overtreatment) in certain regions or differences in the tendency to diagnose certain infections (i.e., overdiagnosis) is poorly understood. METHODS: We examined data from 2012 to 2013 using the National Ambulatory Medical Care Survey, which is a nationally representative sample of visits to office-based physicians. For each of nine geographic regions, we examined the relationship between the visit rate/1000 population for respiratory diagnoses for which antibiotics were prescribed to the visit rate/1000 population for selected respiratory diagnoses where antibiotic therapy may be warranted. RESULTS: The visit rate for all respiratory conditions resulting in an antibiotic prescription was lowest (109/1000 population) in the Pacific Region and highest (176/1000, 95% CI 138-213) in the East South Central Region. The diagnosis rate for selected respiratory conditions where antibiotic therapy may be warranted was also lowest (119/1000, 95% CI 91-147) in the Pacific Region and highest (189/1000, 95% CI 153-225) in the East South Central Region. CONCLUSION: Antibiotic prescribing rates for respiratory conditions vary by region and are strongly associated with the rate with which selected respiratory conditions are diagnosed. |
- Page last reviewed:Feb 1, 2024
- Page last updated:Jun 17, 2024
- Content source:
- Powered by CDC PHGKB Infrastructure