Development of an Electronic Algorithm to Target Outpatient Antimicrobial Stewardship Efforts for Acute Bronchitis and Pharyngitis

Ebbing Lautenbach, Keith W Hamilton, Robert Grundmeier, Melinda M Neuhauser, Lauri A Hicks, Anne Jaskowiak-Barr, Leigh Cressman, Tony James, Jacqueline Omorogbe, Nicole Frager, Muida Menon, Ellen Kratz, Lauren Dutcher, Kathleen Chiotos, Jeffrey S Gerber, Ebbing Lautenbach, Keith W Hamilton, Robert Grundmeier, Melinda M Neuhauser, Lauri A Hicks, Anne Jaskowiak-Barr, Leigh Cressman, Tony James, Jacqueline Omorogbe, Nicole Frager, Muida Menon, Ellen Kratz, Lauren Dutcher, Kathleen Chiotos, Jeffrey S Gerber

Abstract

Background: A major challenge for antibiotic stewardship programs is the lack of accurate and accessible electronic data to target interventions. We developed and validated separate electronic algorithms to identify inappropriate antibiotic use for adult outpatients with bronchitis and pharyngitis.

Methods: We used International Classification of Diseases, 10th Revision, diagnostic codes to identify patient encounters for acute bronchitis and pharyngitis at outpatient practices between 3/15/17 and 3/14/18. Exclusion criteria included immunocompromising conditions, complex chronic conditions, and concurrent infections. We randomly selected 300 eligible subjects each with bronchitis and pharyngitis. Inappropriate antibiotic use based on chart review served as the gold standard for assessment of the electronic algorithm, which was constructed using only data in the electronic data warehouse. Criteria for appropriate prescribing, choice of antibiotic, and duration were based on established guidelines.

Results: Of 300 subjects with bronchitis, 167 (55.7%) received an antibiotic inappropriately based on chart review. The electronic algorithm demonstrated 100% sensitivity and 95.3% specificity for detection of inappropriate prescribing. Of 300 subjects with pharyngitis, 94 (31.3%) had an incorrect prescribing decision. Among 29 subjects with a positive rapid streptococcal antigen test, 27 (93.1%) received an appropriate antibiotic and 29 (100%) received the correct duration. The electronic algorithm demonstrated very high sensitivity and specificity for all outcomes.

Conclusions: Inappropriate antibiotic prescribing for bronchitis and pharyngitis is common. Electronic algorithms for identifying inappropriate prescribing, antibiotic choice, and duration showed excellent test characteristics. These algorithms could be used to efficiently assess prescribing among practices and individual clinicians. Interventions based on these algorithms should be tested in future work.

Keywords: algorithm; antibiotic; electronic; stewardship.

© The Author(s) 2022. Published by Oxford University Press on behalf of the Infectious Diseases Society of America.

References

    1. King LM, Bartoces M, Fleming-Dutra KE, Roberts RM, Hicks LA. Changes in US outpatient antibiotic prescriptions from 2011–2016. Clin Infect Dis 2020; 70:370–7.
    1. Barnett ML, Linder JA. Antibiotic prescribing for adults with acute bronchitis in the United States, 1996–2010. JAMA 2014; 311:2020–2.
    1. Barnett ML, Linder JA. Antibiotic prescribing to adults with sore throat in the United States, 1997–2010. JAMA Intern Med 2014; 174:138–40.
    1. Fairlie T, Shapiro DJ, Hersh AL, Hicks LA. National trends in visit rates and antibiotic prescribing for adults with acute sinusitis. Arch Intern Med 2012; 172:1513–4.
    1. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. . Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA 2016; 315:1864–73.
    1. Dellit TH, Owens RC, McGowan JE Jr, et al. . Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44:159–77.
    1. Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep 2016; 65:1–12.
    1. Drekonja DM, Filice GA, Greer N, et al. . Antimicrobial stewardship in outpatient settings: a systematic review. Infect Control Hosp Epidemiol 2015; 36:142–52.
    1. Gerber JS, Prasad PA, Fiks AG, et al. . Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial. JAMA 2013; 309:2345–52.
    1. Meeker D, Linder JA, Fox CR, et al. . Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. JAMA 2016; 315:562–70.
    1. Dooling KL, Shapiro DJ, Van Beneden C, Hersh AL, Hicks LA. Overprescribing and inappropriate antibiotic selection for children with pharyngitis in the United States, 1997–2010. JAMA Pediatr 2014; 168:1073–4.
    1. Linder JA, Bates DW, Lee GM, Finkelstein JA. Antibiotic treatment of children with sore throat. JAMA 2005; 294:2315–22.
    1. ESCMID Sore Throat Guideline Group, Pelucchi C, Grigoryan L, et al. . Guideline for the management of acute sore throat. Clin Microbiol Infect 2012; 18(Suppl 1):1–28.
    1. Shulman ST, Bisno AL, Clegg HW, et al. . Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012; 55:e86–102.
    1. Bohan JG, Madaras-Kelly K, Pontefract B, et al. . Evaluation of uncomplicated acute respiratory tract infection management in veterans: a national utilization review. Infect Control Hosp Epidemiol 2019; 40:438–46.
    1. Global Initiative for Chronic Obstructive Lung Disease (GOLD) . Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2018. Available at: . Accessed 13 November 2020.
    1. El Feghaly RE, Burns A, Goldman JL, Myers A, Purandare AV, Lee BR. Novel outpatient antibiotic prescribing report of respiratory infections in a pediatric health system’s emergency departments and urgent care clinics. Am J Infect Control 2021; 49:398–400.
    1. Matheny ME, Fitzhenry F, Speroff T, et al. . Detection of blood culture bacterial contamination using natural language processing. AMIA Annu Symp Proc 2009; 2009:411–5.
    1. Fiszman M, Chapman WW, Aronsky D, Evans RS, Haug PJ. Automatic detection of acute bacterial pneumonia from chest x-ray reports. J Am Med Inform Assoc 2000; 7:593–604.

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa