Complicating the Uncomplicated: A Bundled Approach to Reducing Inappropriate Antibiotic Prescribing for Acute Uncomplicated Bronchitis

Approximately 2 million infections and 23,000 deaths annually are presumed attributable to antibiotic resistance, rendering this issue a significant—and considerable—threat to public health. Antibiotic overuse is associated with the emergence of antibiotic resistance and thus is considered a modifiable risk factor for this phenomenon.¹ Historically, the bulk of antimicrobial stewardship (AMS) literature and guidance have centered on improving antibiotic use within inpatient settings. However, given that significant consumption (80%-90%) of antibiotics occurs within the outpatient realm, interventions geared toward optimizing prescribing within this space are essential.² Respiratory tract infections account for a sizable portion of outpatient antibiotic prescriptions, with as many as half of these prescriptions deemed potentially unnecessary.^3,4 Under this umbrella of diagnoses are respiratory conditions such as acute uncomplicated bronchitis (AUB), which tends to be of viral etiology.⁴ AUB represents a diagnosis for which antibiotic prescribing is prevalent but generally not recommended, highlighting the need for focused ambulatory antimicrobial stewardship interventions (ASIs) to address this issue.⁴

A recent study published in Antimicrobial Stewardship & Healthcare Epidemiology sought to assess the impact of a bundled ASI approach on antibiotic prescribing for ambulatory AUB visits. In this quasi- experimental quality improvement study, the proportion of inappropriate antibiotic prescriptions (IAPs) was assessed before and after the implementation of various ASIs.⁵ The preintervention and postintervention periods were January 1 through December 31 for the years 2020 and 2021, respectively.⁵ Interventions employed within the ASI bundle included retrospective auditing, quarterly IAP reporting, provision of educational webinars, and utilization of electronic best practice alerts (TABLE).⁵ In-person and virtual ambulatory encounters with relevant International Classification of Diseases, 10th Revision (ICD-10) codes were included for assessment. These encounters encompassed both urgent care and primary care practice areas.⁵ Pediatric patient encounters, duplicate encounters, and follow-up visits for recurrent illness were noted exclusions.⁵ Ambulatory encounters were deemed appropriate if 2 criteria were met: No antimicrobial orders were prescribed for AUB, nor were antimicrobial orders prescribed for AUB diagnoses with pertinent underlying conditions like chronic lung disease (ie, chronic obstructive pulmonary disease) or other concurrent diagnoses where therapy would likely be warranted (ie, community- acquired pneumonia).⁵ Encounters were coded as inappropriate if none of the aforementioned criteria were met and documented within the electronic medical record (EMR). Descriptive and inferential statistics were utilized for data analysis.⁵ Altogether, 8176 encounters were included for study analysis, encompassing 4694 pre- and 3482 postintervention period encounters, respectively. A decrease in IAPs for AUB was observed from thepreintervention period to the postintervention period (44.9% vs 32.5%; P < .001).5 Notably, statistically significant reductions in IAPs for AUB pre-post intervention were seen in the months of March (48.1%-31.8%; P = .0002), October (42.2%-27.0%; P < .0001), and November (42.2%-27.0%; P < .0001).⁵ When compared across facility type, a higher proportion of IAPs was noted in clinics relative to urgent care areas (41.3% vs 36.5%; P < .0001).⁵

Despite available guidance advising against routine treatment of AUB with antibiotic therapy, it remains a condition for which antibiotics are overprescribed.⁶ For that reason, AUB has been identified as a high-priority condition where opportunity exists to develop and implement strategies to improve antibiotic prescribing practices.¹ Similar to the present study, prior literature exploring the impact of an array of different ASIs on antibiotic prescribing for AUB has also demonstrated declines in IAPs postintervention.⁷ Collectively, these findings support the potential benefits of applying bundled interventions to optimize and facilitate appropriate use of antimicrobials in AUB.

Limitations of this study were primarily related to study design given that data collected were retrospective in nature and dependent on accurate EMR documentation. Additionally, encounters included for analysis were based on provider-selected ICD-10 codes for bronchitis, allowing for the possibility of misclassification bias and/or selection bias. Last, the study did not assess the individual effect of each distinct ASI nor the sustainability of the impact of these interventions on prescribing. Consequently, it remains unclear which intervention was most effective and whether observed reductions in IAPs will be upheld over time. Highlights of this study include its large sample size and its focus on ambulatory ASIs targeting an important disease state where IAPs are commonly prevalent. As outpatient AMS literature continues to emerge, future studies are needed to examine the impact of individual ASIs on antibiotic prescribing in AUB and their durability over time.

References

1.Core elements of outpatient antibiotic stewardship. Centers for Disease Control and Prevention. December 5, 2024. Accessed January 31, 2025. https://www.cdc.gov/antibiotic-use/hcp/core-elements/outpatient-antibiotic-stewardship.html
2.Outpatient antibiotic prescribing in the United States. Centers for Disease Control and Prevention. December 5, 2024. Accessed January 31, 2025. https://www.cdc.gov/antibiotic-use/hcp/data-research/antibiotic-prescribing.html
3.Dobson EL, Klepser ME, Pogue JM, et al; SIDP Community Pharmacy Antimicrobial Stewardship Task Force. Outpatient antibiotic stewardship: interventions and opportunities. J Am Pharm Assoc (2003). 2017;57(4):464-473. doi:10.1016/j.japh.2017.03.014
4.Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864-1873. doi:10.1001/jama.2016.4151
5.Williams S, Engels J, Ogrin S, Rossman N, Olivero R. Reducing inappropriate antibiotic prescribing for acute uncomplicated bronchitis: a systemwide quality improvement project. Antimicrob Steward Healthc Epidemiol. 2024;4(1):e222. doi:10.1017/ash.2024.465
6.Outpatient clinical care for adults. Centers for Disease Control and Prevention. April 16, 2024. Accessed January 31, 2025. https://www.cdc.gov/antibiotic-use/hcp/clinical-care/adult-outpatient.html
7.Pett RG, Silva F, D’Amico C. Audit and feedback: a quality improvement study to improve antimicrobial stewardship. Fed Pract. 2021;38(6):276-281. doi:10.12788/fp.0135