Acute respiratory tract infection: A practice examines its antibiotic prescribing habits

Department of Family Medicine, Mayo Clinic, Scottsdale, AZ 85260, USA.
The Journal of family practice (Impact Factor: 0.89). 06/2012; 61(6):330-5.
Source: PubMed


We wanted to better understand our practice behaviors by measuring antibiotic prescribing patterns for acute respiratory tract infections (ARTIs), which would perhaps help us delineate goals for quality improvement interventions. We determined (1) the distribution of ARTI final diagnoses in our practice, (2) the frequency and types of antibiotics prescribed, and (3) the factors associated with antibiotic prescribing for patients with ARTI.
We looked at office visits for adults with ARTI symptoms that occurred between December 14, 2009, and March 4, 2010. We compiled a convenience sample of 438 patient visits, collecting historical information, physical examination findings, diagnostic impressions, and treatment decisions.
Among the 438 patients, cough was the most common presenting complaint (58%). Acute sinusitis was the most frequently assigned final diagnosis (32%), followed by viral upper respiratory tract infection (29%), and acute bronchitis (24%). Sixty-nine percent of all ARTI patients (304/438) received antibiotic prescriptions, with macrolides being most commonly prescribed (167/304 [55%]). Prescribing antibiotics was associated with a complaint of sinus pain or shortness of breath, duration of illness ≥8 days, and specific abnormal physical exam findings. Prescribing rates did not vary based on patient age or presence of risk factors associated with complication. Variations in prescribing rates were noted between individual providers and groups of providers.
We found that we prescribed antibiotics at high rates. Diagnoses of acute sinusitis and bronchitis may have been overused as false justification for antibiotic therapy. We used broad-spectrum antibiotics frequently. We have identified several gaps between current and desired performance to address in practice-based quality improvement interventions.

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    ABSTRACT: The objective of this study was to educate health care providers and patients to reduce overall antibiotic prescription rates for patients with acute respiratory tract infection (ARTI). An interdisciplinary quality improvement team used the Define, Measure, Analyze, Improve, and Control quality improvement process to change patient expectations and provider antibiotic prescribing patterns. Providers received personal and group academic detailing about baseline behaviors, copies of treatment guidelines, and educational materials to use with patients. Get Smart About Antibiotics Week materials educated patients about appropriate antibiotic use. Providers collected demographic and clinical information about a case series of patients with ARTIs and their subsequent provision of antibiotics. In total, 241 patients with ARTIs were accrued. The antibiotic prescribing rate for patients aged 18 years and older was significantly reduced from 69% at baseline to 56% after interventions (95% confidence interval = 49.1%-63.4%; P<.001). Providers' prescribing behaviors significantly improved after multiple quality improvement interventions.
    No preview · Article · Feb 2013 · American Journal of Medical Quality
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    ABSTRACT: Acute bronchitis is an inflammation of the tracheobronchial tree that occurs most commonly during the winter months and is associated with respiratory viruses. The role of bacteria in this infection is controversial, as bronchial biopsies have never demonstrated bacterial invasion. Treatment is generally symptomatic, directed at the relief of troublesome respiratory symptoms, particularly cough. Most of these lower respiratory tract infections are self-limiting and several studies suggest that antimicrobial treatment does not significantly shorten the duration of cough. However, many patients are prescribed antibiotics, mainly when discoloured sputum is present. Approaches to controlling acute cough have included narcotic cough suppressants, expectorants, mucolytics, antihistamines, decongestants, β2-agonists, analgesics, nonsteroidal anti-inflammatory drugs and herbal remedies. Despite the fact that these drugs are widely prescribed, there is little evidence that their routine use is helpful for adults with cough. However, guidelines suggest that a short trial of an antitussivemedication, mainly dextromethorphan, may be reasonable, as well as β2- agonists in adults with bronchial obstruction.
    No preview · Chapter · Jun 2013
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    ABSTRACT: Quality improvement investigators working in field settings, who typically are not trained in epidemiological methods, may not consider all three elements of the epidemiologic triad (person, place and time) when planning their projects. To demonstrate how the epidemiological triad can guide analysis for quality assessment. Predictors of antibiotic use in primary care were analysed to illustrate the approach. This study was a secondary analysis of data previously collected from medical records and a provider survey. A convenience sample of 467 family medicine patients treated in two clinic sites for acute respiratory tract infections was analysed by locating quality variation in person, place and time. Independent variables included patient age, date of clinic visit, and clinic site. The outcome measure was antibiotic prescription (yes or no). Antibiotics were prescribed for 69.2% of patients in the sample. Age group was not related to antibiotic prescribing. Prescription was related to time (P = 0.0344) and clinic site (P = 0.0001) in univariate tests. However, only site was independently related to antibiotic prescription (odds ratio = 0.47, confidence interval = 0.30 to 0.73, P = 0.0008). The epidemiological triad assisted in guiding further post hoc analysis of predictors of antibiotic prescriptions. Further investigations of this quality indicator can be directed at exploring site differences and testing interventions. Studies of other quality indicators in primary care can employ the triad to guide the analysis.
    No preview · Article · Aug 2013 · Quality in primary care
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