We aimed to decrease the use of outpatient parenteral antimicrobial therapy (OPAT) for patients admitted for bone and joint infections (BJIs) by applying a consensus protocol to suggest oral antibiotics for BJI.

A quasi-experimental before-and-after study.

Inpatient setting at a single medical center.

All inpatients admitted with a BJI.

We developed a consensus table of oral antibiotics for BJI among infectious diseases (ID) specialists. Using the consensus table, we implemented a protocol consisting of a weekly reminder e-mail and case-based discussion with the consulting ID physician. Outcomes of patients during the implementation period (November 1, 2020, to May 31, 2021) were compared with those during the preimplementation period (January 1, 2019, to October 31, 2020). Our primary outcome was the proportion of patients treated with OPAT. Secondary outcomes included length of hospital stay (LOS) and recurrence or death within 6 months.

In total, 77 patients during the preimplementation period and 22 patients during the implementation period were identified to have a BJI. During the preimplementation period, 70.1% of patients received OPAT, whereas only 31.8% of patients had OPAT during the implementation period (P = .003). The median LOS after final ID recommendation was significantly shorter during the implementation period (median 3 days versus 1 day; P < .001). We detected no significant difference in the 6-month rate of recurrence (24.7% vs 31.8%; P = .46) or mortality (9.1% vs 9.1%; P = 1.00).

More patients admitted with BJIs were treated with oral antibiotics during the implementation phase of our quality improvement initiative.

Assessments of antibiotic prescribing in ambulatory care have largely focused on viral acute respiratory infections (ARIs). It is unclear whether antibiotic prescribing for bacterial ARIs should also be a target for antibiotic stewardship efforts. In this study, we evaluated antibiotic prescribing for viral and potentially bacterial ARIs in patients seen at emergency departments (EDs) and urgent care centers (UCCs).

This retrospective cohort included all ED and UCC visits by patients who were not hospitalized and were seen during weekday, daytime hours during 2016–2018 in the Veterans Health Administration (VHA). Guideline concordance was evaluated for viral ARIs and for 3 potentially bacterial ARIs: acute exacerbation of COPD, pneumonia, and sinusitis.

There were 3,182,926 patient visits across 129 sites: 80.7% in EDs and 19.3% in UCCs. Mean patient age was 60.2 years, 89.4% were male, and 65.6% were white. Antibiotics were prescribed during 608,289 (19.1%) visits, including 42.7% with an inappropriate indication. For potentially bacterial ARIs, guideline-concordant management varied across clinicians (median, 36.2%; IQR, 26.0–52.7) and sites (median, 38.2%; IQR, 31.7–49.4). For viral ARIs, guideline-concordant management also varied across clinicians (median, 46.2%; IQR, 24.1–68.6) and sites (median, 40.0%; IQR, 30.4–59.3). At the clinician and site levels, we detected weak correlations between guideline-concordant management for viral ARIs and potentially bacterial ARIs: clinicians (r = 0.35; P = .0001) and sites (r = 0.44; P < .0001).

Our findings suggest that, across EDs and UCCs within VHA, there are major opportunities to improve management of both viral and potentially bacterial ARIs. Some clinicians and sites are more frequently adhering to ARI guideline recommendations on antibiotic use.

The optimal approach to auditing outpatient antimicrobial prescribing has not been established. We assessed how different types of electronic data—including prescriptions, patient-visits, and International Classification of Disease, Tenth Revision (ICD-10) codes—could inform automated antimicrobial audits.

Outpatient visits during 2016 were retrospectively reviewed, including chart abstraction, if an antimicrobial was prescribed (cohort 1) or if the visit was associated with an infection-related ICD-10 code (cohort 2). Findings from cohorts 1 and 2 were compared.

Primary care clinics and the emergency department (ED) at the Iowa City Veterans Affairs Medical Center.

In cohort 1, we reviewed 2,353 antimicrobial prescriptions across 52 providers. ICD-10 codes had limited sensitivity and positive predictive value (PPV) for validated cases of cystitis and pneumonia (sensitivity, 65.8%, 56.3%, respectively; PPV, 74.4%, 52.5%, respectively). The volume-adjusted antimicrobial prescribing rate was 13.6 per 100 ED visits and 7.5 per 100 primary care visits. In cohort 2, antimicrobials were not indicated in 474 of 851 visits (55.7%). The antimicrobial overtreatment rate was 48.8% for the ED and 59.7% for primary care. At the level of the individual prescriber, there was a positive correlation between a provider’s volume-adjusted antimicrobial prescribing rate and the individualized rates of overtreatment in both the ED (r=0.72; P<.01) and the primary care setting (r=0.82; P=0.03).

In this single-center study, ICD-10 codes had limited sensitivity and PPV for 2 infections that typically require antimicrobials. Electronically extracted data on a provider’s rate of volume-adjusted antimicrobial prescribing correlated with the frequency at which unnecessary antimicrobials were prescribed, but this may have been driven by outlier prescribers.

Infect Control Hosp Epidemiol 2018;39:64–70