Assessing Antibiotic Prescribing Patterns in Adult Primary Care Clinics

Adult primary care clinics are a prime target for antimicrobial stewardship efforts, as the levels of inappropriate prescribing are often quite high in this setting.

Tina Zheng, PharmD, a PGY1 pharmacy resident at Maimonides Medical Center in Brooklyn, New York, and colleagues sought to better understand the current antibiotic prescribing patterns at adult primary care clinics affiliated with Maimonides Medical Center. Their results were presented in a poster at the Making a Difference in Infectious Disease (MAD-ID) 2022 annual meeting, held May 18-21, 2022, in Orlando, Florida.

Zheng shared the key takeaways of the poster in a video interview with Contagion®.

This transcript has been edited for clarity and length.

Contagion®: What was the impetus for this study?

Zheng: Recently, there's been a huge movement towards outpatient antimicrobial stewardship. We've made a lot of progress in terms of inpatient antimicrobial stewardship. At our current institution, we've had an inpatient antimicrobial stewardship, otherwise known as AMS, program since 2007. The objective of this project was really to see how are we doing in the outpatient setting with our primary care clinics. I think there have been a lot of articles that have been coming out in Open Forum Infectious Diseases recently regarding how are we doing the outpatient setting? What can we do? What sort of interventions can we implement in order to improve the rates of antibiotic prescribing in these settings?

Contagion®: Why do you think the rates of inappropriate prescribing are so high in the adult primary care setting?

Zheng: I think in terms of primary care settings, a lot of us know that primary care providers have a lot on their plates. There's also a lot of patient preference in terms of coming to the clinics if they have some sort of stuffy nose and wanting an antibiotic because that's what they had when they were kids or whatever worked previously. I think it's that patient demand as well. But additionally, with the newer literature coming out that shorter is better, so shorter durations [as well]. Not all primary care providers have the time to really look into that and summarize all that data. I think by providing resources to our outpatient providers, primary care providers, we can really help them to make the best choices in terms of antibiotic therapy.

Contagion®: Can you summarize the results?

Zheng: This was interesting. This was sort of an initial project where we wanted to first see what our baseline was [and] how are we doing in the clinics and then seeing what problem areas that we have that we could probably improve upon. From our results, we found that our total rate of inappropriate antibiotic prescribing was around 61%. I know the CDC reports that around 50% of antibiotics are [used] inappropriately. We also found that 22% of our antibiotics were unnecessary. Otherwise, meaning that they weren't indicated for that diagnosis at all. We sort of reflect the CDC rate of 28% of all antibiotic prescribing [being] unnecessary.

Then we further broke it down. So from that total, inappropriate antibiotic prescriptions were identified as inappropriate if they were for the wrong indication, if they were for the wrong antibiotic, [or] wrong dose, wrong duration. And so that's what the 61% is.

Then we looked into each category. For the rates of inappropriate antibiotics and inappropriate doses, we found that that was pretty similar at 31%. But we did notice that our biggest problem area was duration of therapy. So that was around 54%, I believe. So very drastic compared to the other ones, obviously, the other ones we can also make more improvements upon. But seeing this duration of therapy, we knew that that's where we had to target our provider education, or at least provide some sort of guidance for them to really make it easier for them in terms of selecting the appropriate antibiotic regimen.

Contagion®: What is the key takeaway for clinicians?

Zheng: The key takeaway currently [is that] I think it kind of reinforces that we have a lot of work to do in the outpatient setting. I think it is interesting. In addition to our primary end points, in terms of the characterization of all these antibiotics, we found that a majority of these antibiotics were for urinary tract infections, which was very interesting. I think we were really expecting more respiratory infections, since the literature really shows the pneumonias or the sinusitis, bronchitis, but we saw a lot of urinary tract infections. So based off of those more common indications, we really strive to create more education around those specific infections.

I think the key takeaway really is that you can definitely help out providers with giving them more specific guidance for appropriate antibiotic dose and duration as well as helping them to differentiate when antibiotics are needed for specific indications such as bronchitis, or pharyngitis, where antibiotics really aren't recommended. I think this just sets the stage for interventions to come in order to improve antibiotic prescribing patterns there.

Contagion®: Are there plans for future research?

Zheng: In terms of future directions with this project, we actually have implemented clinical guidelines to help these providers, as well as give education to the provider. We have actually gone in to meet with the primary care providers to give them education on this and I think what we've been seeing is, in terms of having a bigger success with sort of building that rapport with primary care providers, is to really meet them face-to-face and meet them from where they're coming from and not to take things off on negative spin because obviously, they're doing the best that they can and we're just there to help them in terms of infectious diseases providers. We should work together as a team in order to improve on this effort.