AHRQ Process Cuts Down on Antibiotic Overprescribing

The growth of antibiotic resistant pathogens, the so-called Superbugs, has long been a concern for healthcare professionals. One of the main causes has been the overprescribing for antibiotics.

There are 4 “moments” involved as a healthcare professional at a long-term care facility (LTCF) weighs whether to prescribe an antibiotic to a patient or resident. Those 4 moments, as spelled out by the Agency for Healthcare Research and Quality (AHRQ), an arm of the US Department of Health and Human Resources, are:

• Does the resident have symptoms that suggest an infection?
• What type of infection is it? Have we collected appropriate cultures before starting antibiotics? What empiric therapy should be initiated?
• What duration of antibiotic therapy is needed for the resident’s diagnosis?
• Re-evaluate the resident and review results of diagnostic tests. Can we stop antibiotics? Can we narrow therapy? Can we change to oral antibiotics?

Investigators with Johns Hopkins University and other research institutions, with the aid of an AHRQ grant, set out to find whether having these moments help put the brakes on the overprescribing of antibiotics. The answer seems to be “yes.”

“By targeting both antibiotic prescribing culture and knowledge of best practices, the AHRQ safety program led to significant reductions in antibiotic use across a large cohort of LTCFs,” concludes their study (“Outcomes from the AHRQ Safety Program for Improving Antibiotic Use Across 439 Long-term Care Facilities”) unveiled at ID Week.

The investigators launched the AHRQ safety program in 439 LTCFs in the United States from December 2018 to November 2019. “Through webinars held 1-2 times per month and other educational content, the safety program emphasized 1) the science of safety to improve teamwork and identify antibiotic-associated harm and 2) clinical best practices in making antibiotic treatment decisions,” the study states.

Physicians, nurses, and nurse assistants were encouraged to participate. The LTCF recorded antibiotic days of therapy, number of urine cultures ordered, lab results identifying Clostridioides difficile, and the number of new antibiotic prescriptions.

“Generalized linear mixed effects models were used to calculate pre-post intervention changes at bi-monthly intervals for antibiotic DOT, antibiotic starts and UCX, each per 1,000 resident-days (RD), and C. difficile LabID events per 10,000 RD, comparing the beginning (1/2019 and 2/2019) and end (11/2019 and 12/2019) of the safety program,” the study states.

The majority of the 439 LTCFs that completed the safety program the study describes as mid-sized, or 75 to 149 beds (229, 52.2%). Most were not affiliated to a hospital and were owned by a larger healthcare company (246, 56%), and there were even distributions between rural and urban settings. Three hundred and forty-eight (79%) of the LTCFs submitted both beginning and ending results.

“Antibiotic starts decreased from 7.89 to 7.48 starts/1000 RD; P = 0.02),” the study states “Days of therapy for all antibiotics decreased from 64.1 to 61.0 DOT/1,000 RD; P = 0.068) and for fluoroquinolones (an antibiotic targeted in the Safety Program) from 1.49 to 1.28 DOT/1,000RD; P=0.002. UCX decreased from 3.01 to 2.63 orders/1000 RD; P = 0.001). There were no significant differences in C. difficile LabID events.”

In the November issue of Infection Control Today®, Kevin Kavanagh, MD, writes about how COVID-19 has complicated the tracking of antibiotic resistant bacteria. Patients afflicted with COVID-19 have an increased susceptibility to antibiotic resistant infections both from prolonged hospitalizations and the use of immunocompromising agents such as dexamethasone,” writes Kavanagh, who is a member of ICT®’s Editorial Advisory Board. Kavanagh points out that patients with COVID-19 have longer hospital stays than patients with flu-like symptoms who have not been infected by the coronavirus. He also writes that COVID patients are much more likely to be hit by a healthcare-acquired infection, than non-COVID patients.

Kavanagh writes that preliminary data by the US Centers for Disease Control and Prevention “found that during the pandemic, total hospitalizations in the United States decreased by approximately 25%. However, inpatient antibiotic usage did not markedly change. The most common types of antibiotics prescribed were ceftriaxone for presumptive community acquired pneumonia, which increased by 22% in April and then fell during the summer, and azithromycin, possibly used in conjunction with hydroxychloroquine, the rate of which increased by 55% in April and then also fell. It was evident to me that in both cases the usage pattern represents changes in both diagnostic ability and treatment recommendations.”