Evaluation of Antibiotic Prescribing in a Veterans Affairs Outpatient Setting: Identification of Stewardship Targets.

OBJECTIVE: To evaluate antibiotic prescribing practices for geriatric outpatients in a Veterans Affairs (VA) health care system.
DESIGN: This is a single-center, observational, prospective cohort study.
SETTING: Veterans Affairs Healthcare System.
PATIENTS: Outpatients treated with oral antibiotics between June and September 2017.
INTERVENTIONS: None.
MAIN OUTCOME MEASURE(S): Appropriate therapy was assessed based on clinical practice guidelines. Multivariable logistic regression was used to identify predictors of appropriate treatment.
RESULTS: This study yielded 1,063 prescriptions for analysis. No significant difference was observed for antibiotic indicated (60%), correct drug (50%), or correct duration (75%). Patients older than 65 years of age were more likely to receive an inappropriate dose (86% vs. 76%; P < 0.002). In the multivariable analysis, patients with chronic obstructive pulmonary disease (COPD) were more than 1.4 times likely to be treated appropriately (95% confidence interval 1.03-1.9) versus those without COPD. Older patients were not more likely to be re-treated or admitted within 30 days.
CONCLUSION: Antibiotics are often inappropriately used in the outpatient setting; but not more frequently in elderly patients. Older adults were more likely to be prescribed an antibiotic at an inappropriate dose. Opportunities exist for stewardship teams to provide value in the outpatient setting to ensure appropriate antibiotic prescribing with a focus on dosing.

Antibiotic stewardship targets in the outpatient setting.

BACKGROUND: Outpatient prescriptions comprise 60% of antibiotic use. This study prospectively identified inappropriate antibiotic use enabling a focused approach to outpatient antimicrobial stewardship. METHODS: Outpatients at the Veterans Affairs Western New York Healthcare System were identified via an electronic antibiotic alert from June 2017 to September 2017. Descriptive statistics and multivariable logistic regression identified stewardship targets. RESULTS: Of the 1,063 patients, 40% of antibiotic prescriptions were not indicated. Urinary tract infections (21%), bronchitis (20%), skin structure infections (17%), and sinusitis (10%) were common causes of inappropriate antibiotic use. Azithromycin (37%) was prescribed unnecessarily most often, followed by ciprofloxacin (16%), amoxicillin/clavulanate (13%), and cephalexin (12%). The correct drug was chosen in 52%, dose in 81%, and duration in 75% of patients. When the antibiotic was indicated, the correct drug was 2.9 times more likely to be prescribed and 2 times more likely to have the correct duration and receive care in the emergency room. DISCUSSION: Focusing on 4 drugs; amoxicillin/clavulanate, azithromycin, ciprofloxacin, and cephalexin accounted for 80% of unnecessary drug use. This study provides a guide to concentrate efforts during implementation of an outpatient stewardship program. CONCLUSIONS: Poor antibiotic prescribing was found in the outpatient setting. This study identifies areas for improvement via stewardship.