Improving Antibiotic Use in Acute Care Setting
Joshua P. Metlay MD PhD
Philadelphia VA Medical Center, Philadelphia, PA
Philadelphia, PA
Funding Period: July 2003 - June 2007

BACKGROUND/RATIONALE:
The emergence and rapid rise in antibiotic resistance among common bacteria are adversely affecting the clinical course and health care costs of community-acquired infections. Because antibiotic resistance rates are strongly correlated with antibiotic use patterns, multiple organizations have declared reductions in unnecessary antibiotic use to be critical components of efforts to combat antibiotic resistance. Among humans, the vast majority of unnecessary antibiotic prescriptions are used to treat acute respiratory tract infections (ARIs) that have a viral etiology. Although the rate of antibiotic prescribing for ARIs by office-based physicians in the US has decreased about 16% from its peak in 1997, the rate of antibiotic prescribing in acute care settings (eg, emergency departments and urgent care centers), which account for 1 in 5 ambulatory antibiotic prescriptions in the US, has shown only a modest decline (6%) during this period. Translation of lessons from intervention studies in office-based practices is needed to improve antibiotic use in acute care settings.

OBJECTIVE(S):
Specific Aim 1: To evaluate the impact of a multidimensional (patient, system, clinician) intervention on appropriate antibiotic use for adults with acute respiratory tract infections-- identifying factors that influence successful translation across VA hospital and non-VA hospital acute care. Specific Aim 2: To evaluate the impact of a rapid diagnostic test for c-reactive protein on antibiotic use for adults with acute cough illness when added to a multidimensional intervention.

METHODS:
We conducted a randomized controlled trial of a quality improvement program consisting of physician education (educational seminar, practice guidelines, performance feedback, and decision support tools) and patient education (waiting room print and audiovisual materials) in 8 VA hospital and 8 non-VA hospital emergency departments. Non VA study sites were identified from an existing research network of hospital emergency departments--EMNet. VA hospital sites were selected among academically affiliated hub facilities. Phase one involved a hospital-level randomized trial of a multidimensional intervention to translate existing evidence based guidelines for antibiotic use in ARIs vs. usual care. In phase two we originally planned to involve a second hospital-level randomized trial of antibiotic use guidelines that incorporate a CRP-based diagnostic algorithm vs. the original guidelines. During a pilot study of the CRP-based guidelines at two of the study sites, it was determined that implementing these guidelines on a larger scale would not be beneficial to the end goal of improving appropriate antibiotic prescriptions for adults with acute respiratory tract infections. The results of the pilot study indicated that a CRP guided algorithm did not lead to reductions in antibiotic prescribing for acute respiratory tract infections. In the final phase of the project, we provided educational components to all participating sites and undertook a qualitative evaluation of intervention implementation at all sites. In addition, interviews were conducted with the Site PIs, ED Nurse Managers, Quality Improvement Officers and focus groups were held with ED nursing staff at the sites as part of a process evaluation of the implementation of the interventions.

FINDINGS/RESULTS:
At control sites, adjusted antibiotic prescribing for URI/acute bronchitis remained stable at 47% of visits in both years. At intervention sites, antibiotic prescribing for the same diagnoses declined from 54% in the baseline year to 43% in the intervention year (p=.06 for the comparison of the change in antibiotic prescribing). . There was no difference between intervention and control sites in the change in antibiotic use for antibiotic-responsive ARIs (e.g., sinusitis, pneumonia, and acute exacerbations of chronic bronchitis) (p = 0.42). The effect of the intervention was not significantly different at VA and non-VA hospitals. However, there was substantial site to site variation in the impact of the intervention. An ongoing process evaluation demonstrated that sites with the greatest level of reduction in inappropriate antibiotic prescribing had the strongest local champions for the intervention.

IMPACT:
Results to date have emphasized local organizational effects on the quality of antibiotic prescribing in EDs. The successful intervention trial demonstrates that relatively inexpensive educational interventions can achieve modest reductions in inappropriate antibiotic prescribing. Disseminating results from this study will help individual VA and non-VA hospital emergency departments identify opportunities to improve the quality of antibiotic use in the management of patients with acute respiratory tract infections.

PUBLICATIONS:

Journal Articles

1. Metlay JP, Camargo CA, MacKenzie T, McCulloch C, Maselli J, Levin SK, Kersey A, Gonzales R, IMPAACT Investigators. Cluster-randomized trial to improve antibiotic use for adults with acute respiratory infections treated in emergency departments. Annals of Emergency Medicine. 2007 Sep 1; 50(3):221-30.
2. Nolt BR, Gonzales R, Maselli J, Aagaard E, Camargo CA, Metlay JP. Vital-sign abnormalities as predictors of pneumonia in adults with acute cough illness. The American journal of emergency medicine. 2007 Jul 1; 25(6):631-6.
3. Pines JM, Hollander JE, Lee H, Everett WW, Uscher-Pines L, Metlay JP. Emergency department operational changes in response to pay-for-performance and antibiotic timing in pneumonia. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2007 Jun 1; 14(6):545-8.
4. Aspinall SL, Metlay JP, Maselli JH, Gonzales R. Impact of hospital formularies on fluoroquinolone prescribing in emergency departments. The American journal of managed care. 2007 May 1; 13(5):241-8.
5. Vanderweil SG, Pelletier AJ, Hamedani AG, Gonzales R, Metlay JP, Camargo CA. Declining antibiotic prescriptions for upper respiratory infections, 1993-2004. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2007 Apr 1; 14(4):366-9.
6. Gonzales R, Camargo CA, Mackenzie T, Kersey AS, Maselli J, Levin SK, McCulloch CE, Metlay JP. Antibiotic treatment of acute respiratory infections in acute care settings. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2006 Mar 1; 13(3):288-94.
7. Metlay JP, Camargo CA, Bos K, Gonzales R. Assessing the suitability of intervention sites for quality improvement studies in emergency departments. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2005 Jul 1; 12(7):667-70.

Conference Presentations

1. Metlay JP. Is there a relationship between health care quality and appropriate antibiotic use? Paper presented at: National Foundation for Infectious Diseases Annual Conference; 2007 Jun 26; Bethesda, MD.
2. Aspinall S, Metlay JP, Maselli J, Gonzales R. Hospital formulary status affects outpatient fluoroquinolone prescribing in the emergency department. Poster session presented at: AcademyHealth Annual Research Meeting; 2007 Jun 4; Orlando, FL.
3. Metlay JP. Practice guidelines for CAP. Whose outcomes are we optimizing. Paper presented at: International Society of Chemotherapy / Community Acquired Pneumonia Annual Meeting; 2007 Apr 15; Montréal, Canada.
4. Metlay JP. Translating research into group settings: Results from the IMPAACT study. Paper presented at: Association for Surgical Education Annual Meeting; 2007 Apr 11; Washington, DC.
5. Gonzales R, Camargo CA, MacKenzie TD, McCulloch CE, Maselli JH, Kersey AS, Levin SK, Metlay JP. Patient satisfaction with emergency department care is not associated with antibiotic treatment for acute respiratory tract infections. Paper presented at: Society of General Internal Medicine Mid-Atlantic Regional Annual Meeting; 2006 Nov 1; Bethesda, MD.
6. Levin SK, Gonzales R, Stewart AL, Camargo CA, Maselli JH, Kersey AS, Metlay JP. Social support and resolution of acute respiratory illness. Poster session presented at: American Psychosomatic Society Annual Scientific Meeting; 2006 Nov 1; Denver, CO.
7. MacKenzie TD, Gonzales R, Levin SK, Maselli JH, Camargo CA, Kersey AS, Metlay JP. Patterns of use and acceptability of a bilingual interactive computer kiosk designed to teach patients about appropriate antibiotic use for acute respiratory tract infections. Paper presented at: Society of General Internal Medicine Mid-Atlantic Regional Annual Meeting; 2006 Nov 1; Bethesda, MD.
8. Metlay JP, Camargo CA, MacKenzie TD, McCulloch CE, Maselli JH, Levin SK, Kersey AS, Gonzales R. Randomized trial of a multidimensional educational intervention to improve antibiotic use for adults with acute respiratory tract infections managed in the emergency department. Presented at: Society for Academic Emergency Medicine Annual Meeting; 2006 Nov 1; San Francisco, CA.
9. Gonzales R, Camargo CA, Mackenzie TD, Kersey AS, Maselli J, Levin SK, McCulloch CE, Metlay JP. Antibiotic prescribing patterns for acute respiratory tract infections in acute care settings. Paper presented at: Society of General Internal Medicine Annual Meeting; 2005 May 1; New Orleans, LA.
10. Gonzales R, Camargo CA, Mackenzie T, Kersey AS, Maselli J, Levin SK, McCulloch C, Metlay JP. Antibiotic prescribing patterns for acute respiratory tract infections in acute care settings. Poster session presented at: Society for Academic Emergency Medicine Annual Meeting; 2005 May 1; New York, NY.
11. Metlay JP, Maselli J, Camargo CA, Gonzales R. Trustworthiness of different sources of health information. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2005 May 1; New Orleans, LA.
12. Metlay JP. Antibiotic prescribing: impact of outcomes studies and drug resistance. Paper presented at: Interscience Conference on Antimicrobial Agents and Chemotherapy / Infectious Diseases Society of America Joint Meeting; 2004 Oct 31; Washington, DC.
13. Metlay JP, Camargo CA, Bos K, Gonzales R. Assessing the suitability of intervention sites for quality improvement studies in emergency departments. Paper presented at: Agency for Healthcare Research and Quality Translating Research Into Practice and Policy Annual Meeting; 2004 Jul 1; Washington, DC.

DRA: Health Systems, Acute and Combat-Related Injury
DRE: Diagnosis
Keywords: Behavior (provider), Education (patient), Education (provider), Pharmaceuticals
MeSH Terms: Acute Disease