Impact of order sentence implementation on outpatient antibiotic prescribing for urinary tract infection and skin and soft tissue infection

ABSTRACT

Introduction: Due to the high volume of outpatient antibiotic prescribing, the Joint Commission now requires antimicrobial stewardship program (ASP) expansion to ambulatory practice settings. Unfortunately, ASP resources in these settings are scarce. The purpose of this study was to determine whether the implementation of antibiotic order sentences alongside education would improve antibiotic prescribing for urinary tract infections (UTI) and skin and soft tissue infections (SSTI). Objectives: The primary objective was to compare the proportion of total guideline-concordant antibiotic prescribing before (pre-ASP) vs after (post-ASP) implementing order sentences. Guideline concordance was defined as antibiotic selection, dosing, and duration in accordance with the health system's empiric guidelines. Secondary objectives included comparing patient-centered outcomes, such as infection-related revisits and Clostridiodes difficile infections between groups. Methods: This retrospective, quasi-experimental study evaluated adult patients treated for uncomplicated UTI or SSTI at an outpatient Family Medicine office between 1 February 2020 and 1 January 2021. The institution's stewardship team provided in-person education and set prescribing order sentence “favorites” for providers. Patients were excluded who were diagnosed with a complicated UTI, treated only with topical antibiotics, were pregnant, or received care via telephone encounter. Results: Two hundred sixty patients were included in this study (pre-ASP n = 139, post-ASP n = 121). Total antibiotic appropriateness improved significantly from 24.5% to 39.7% after implementation of order sentences and education (P =.008). Significant improvement was seen for appropriate drug selection (52.5% vs 66.9%, P =.018) and duration (47.5% vs 68.6%, P =.001). There were no differences observed in patient-centered outcomes between groups. Conclusion: Implementing stewardship-focused order sentences significantly improved outpatient antibiotic prescribing for UTI and SSTI. Tailoring antibiotic order sentences may be a useful tool for ASP expansion into the outpatient setting with limited resources to allocate to stewardship efforts.