Infectious disease/original researchCluster-Randomized Trial to Improve Antibiotic Use for Adults With Acute Respiratory Infections Treated in Emergency Departments
Introduction
In recent years, there has been a growing concern about the emergence of antibiotic resistance among bacterial pathogens.1, 2 Because antibiotic resistance patterns are strongly correlated with antibiotic use patterns, multiple organizations have identified reductions in unnecessary outpatient antibiotic use as a critical component of efforts to combat antibiotic resistance.3 Targeting unnecessary antibiotic use is important because such use also confers unnecessary individual risk of adverse drug reactions, which are not uncommon with antibiotics.
At the center of campaigns to reduce unnecessary antibiotic use are efforts to understand and improve on management strategies for patients with acute respiratory tract infections.4, 5 Acute respiratory tract infections, which include nonspecific upper respiratory tract infections, acute bronchitis, sinusitis, pharyngitis, otitis media, and pneumonia, account for the majority of outpatient antibiotic use,6 even though available evidence strongly demonstrates that the majority of acute respiratory tract infections, specifically upper respiratory tract infections and acute bronchitis, are not bacterial in origin and, therefore, are unlikely to benefit from antibiotic treatment.5 To date, most interventions to reduce unnecessary antibiotic use for acute respiratory tract infections have focused on primary care settings7, 8, 9 and have demonstrated that combined patient and clinician educational strategies can successfully reduce the use of antibiotics for acute respiratory tract infections. In addition, recent time trend analyses have demonstrated that broader awareness of these issues has resulted in national downward trends in the use of antibiotics for acute respiratory tract infections in primary care settings.10, 11
Unfortunately, levels of antibiotic use for acute respiratory tract infections managed in the emergency department (ED) have not decreased to the same extent as that observed in primary care settings,12 and overall levels of antibiotic prescribing remain high.13 The ED setting is distinct from the primary care setting in a number of ways, having a greater acuity of illness, the need for rapid triage and treatment, and limited previous and subsequent contact with patients. As a result, established methods for reducing antibiotic overuse for acute respiratory tract infections in primary care settings may not readily translate into ED settings.
The Improving Antibiotic Use in Acute Care Treatment (IMPAACT) project is examining the impact of interventions on antibiotic use for acute respiratory tract infections among a national sample of Veterans Administration (VA) and non-VA hospitals. The specific aim of the present study was to test the impact of a multidimensional patient and clinician educational program on reducing unnecessary antibiotic use for acute respiratory tract infections. Our primary endpoint was the proportion of antibiotics prescribed for patients with upper respiratory tract infections and acute bronchitis evaluated in the ED. Our secondary endpoints included antibiotic prescribing for antibiotic-responsive acute respiratory tract infection diagnoses (including community-acquired pneumonia, sinusitis, and acute exacerbations of chronic bronchitis), the frequency of return ED visits and hospital admissions within 2 weeks of the index visit, and overall visit satisfaction. We evaluated the program in VA and non-VA hospital EDs to test whether distinct health care structures modified the impact of the program.
Section snippets
Study Design
The IMPAACT randomized controlled trial involves EDs at 8 VA medical centers and 8 non-VA academic medical centers. The trial was conducted as part of a joint Agency for Healthcare Research and Quality and VA Health Services Research and Development Service Award to compare the translation of research into practice across VA and non-VA settings. Details of the hospital sampling strategy have been previously described.14 In brief, we surveyed all 135 major VA medical centers and all US non-VA
Characteristics of Study Sites
We examined a total of 2,659 visits for acute respiratory tract infection diagnoses at control sites and 3,006 visits for acute respiratory tract infection diagnoses at intervention sites across the year 1 and year 2 winter periods. Table 1 summarizes the final specific acute respiratory tract infection discharge diagnoses documented in the medical record, comparing intervention and control sites during year 1 and year 2. Overall, nonspecific upper respiratory tract infection and acute
Limitations
Hawthorne effects are always of concern in trials intended to modify physician or patient behaviors. As such, clinician coding of diagnoses could be driven by treatment decisions such that physicians would be more likely to code for more antibiotic-responsive acute respiratory tract infections after deciding to prescribe an antibiotic. Indeed, we did observe a relative increase in the diagnosis of pharyngitis at intervention compared to control sites, which may have accounted for some of the
Discussion
We found that a multidimensional educational intervention targeting patients and clinicians appears to reduce antibiotic prescribing for patients diagnosed with upper respiratory tract infection or acute bronchitis in the ED, 2 common conditions for which antibiotics are frequently overprescribed.18 The reduction in antibiotic prescribing for upper respiratory tract infections or acute bronchitis was not associated with any apparent increase in the frequency of return visits or delayed
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2021, Clinical Microbiology and InfectionCitation Excerpt :Several have focused on conditions where antimicrobials are not indicated, such as non-specific upper respiratory tract infections or acute bronchitis. For example, Metlay et al. [35] conducted a clinical trial in 16 hospitals. In the eight intervention sites they implemented clinician feedback and clinical and patient educational materials.
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Supervising editor: Gregory J. Moran, MD
Author contributions: JPM, CAC, TM, CM, and RG were responsible for study conception and design. JPM, JM, SKL, AK, and RG were responsible for acquisition of data and administrative, technical, or material support. JPM, CAC, TM, CM, JM, and RG conducted analysis and interpretation of data. JPM, CAC, CM, JM, and RG were responsible for drafting of the article and statistical analysis. JPM, CAC, TM, and RG obtaining funding. All authors provided critical revision of the manuscript. JPM and RG were responsible for study supervision. JPM and RG takes responsibility for the paper as a whole.
Conflicts of interest: Dr. Metlay has served as a scientific consultant or received unrestricted educational funds from Aventis Pharmaceuticals and Roche Pharmaceuticals. Dr. Gonzales served as a consultant for Abbott Laboratories, Inc. to study C-reactive protein levels as a potential diagnostic test for outpatients with community-acquired pneumonia. Dr. Camargo has received financial support for participation in conferences, consulting, and medical research from the following industry sponsors with an interest in respiratory infections: Abbott, Aventis, Aventis Pasteur, GlaxoSmithKline, MedImmune, and Merck. None of the other authors have any conflicts of interest or financial disclosures.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that may create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This study was funded by the Translating Research into Practice initiative, jointly sponsored by the Agency for Healthcare Research and Quality (1 R01 HS013915) and the Health Services Research and Development Service of the Department of Veterans Affairs (AVA-03-239). The funding agencies had no role in the design and conduct of the study; collection management, analysis, and interpretation of the data; or preparation, review, or approval of the article.
Available online May 23, 2007.
Reprints not available from the authors.