VA Pittsburgh Healthcare System, Infectious Diseases Section, Pittsburgh, Pennsylvania, USA
VA Pittsburgh Healthcare System, Infectious Diseases Section, Pittsburgh, Pennsylvania, USA.
Antimicrob Agents Chemother. 2020 Dec 16;65(1). doi: 10.1128/AAC.01660-20.
Antibiotic prescribing is very common in emergency departments (EDs). Optimal stewardship intervention strategies in EDs are not well defined. We conducted a prospective, observational cohort study in a Veterans Affairs ED in which clinician education and monthly e-mail-based peer comparisons were directed against all oral antibiotic prescribing for discharged patients. Oral antibiotic prescriptions were compared in baseline (June 2016 to December 2017) and intervention (January to June 2018) periods using an interrupted time series regression model. Prescribing appropriateness was compared during January to June 2017 and the intervention period. During the intervention period, antibiotic prescriptions decreased monthly by 10.4 prescriptions per 1,000 ED visits ( = 0.07 [95% confidence interval {CI}, -21.7 to 1.0]). The relative decrease in the trend of antibiotic prescriptions during the intervention period compared to baseline was 9.9 prescriptions per 1,000 ED visits per month ( = 0.07 [95% CI, -20.9 to 1.0]). The intervention was associated with a significant decrease and increase in amoxicillin-clavulanate and cephalexin prescriptions, respectively (0.001, 0.004). Decreasing trends in ciprofloxacin prescriptions during the baseline period were maintained during the intervention. Unnecessary antibiotic prescribing (i.e., antibiotic not indicated) decreased from 55.6% to 38.7% during the intervention (30.4% decrease, 0.003). Optimal antibiotic prescribing (i.e., antibiotics were indicated, and a guideline-concordant agent was prescribed for guideline-concordant duration) increased by 36% (21.6% to 29.3%, 0.12). A peer comparison-based stewardship intervention directed at ED clinicians was associated with reductions in overall and unnecessary oral antibiotic prescribing. There is potential to further improve antibiotic use as suboptimal prescribing remained common.
抗生素在急诊科（ED）的使用非常普遍。ED 中尚未明确最佳的管理干预策略。我们在退伍军人事务部 ED 中进行了一项前瞻性观察队列研究，对所有出院患者的口服抗生素处方进行了临床医生教育和每月基于电子邮件的同行比较。使用中断时间序列回归模型比较基线（2016 年 6 月至 2017 年 12 月）和干预（2018 年 1 月至 6 月）期间的口服抗生素处方。比较 2017 年 1 月至 6 月和干预期间的处方适宜性。在干预期间，每月每 1000 次 ED 就诊的抗生素处方减少 10.4 张（ = 0.07 [95%置信区间 {CI}，-21.7 至 1.0]）。与基线相比，干预期间抗生素处方趋势的相对减少为每月每 1000 次 ED 就诊减少 9.9 张处方（ = 0.07 [95% CI，-20.9 至 1.0]）。干预与阿莫西林-克拉维酸和头孢氨苄处方的显著减少分别相关（0.001，0.004）。在基线期间，环丙沙星处方呈下降趋势，在干预期间仍保持不变。在干预期间，不必要的抗生素处方（即抗生素未被指示）从 55.6%降至 38.7%（减少 30.4%，0.003）。最佳抗生素处方（即抗生素被指示，并且根据指南选择了与指南一致的药物持续时间）增加了 36%（21.6%至 29.3%，0.12）。针对 ED 临床医生的基于同行比较的管理干预与总体和不必要的口服抗生素处方减少相关。由于次优处方仍然很常见，因此仍有进一步改善抗生素使用的潜力。
