A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings

Acad Emerg Med. 2019 Jul;26(7):719-731. doi: 10.1111/acem.13690. Epub 2019 Jun 19.


Background: Antibiotics are commonly prescribed during emergency department (ED) and urgent care center (UCC) visits for viral acute respiratory infection (ARI). We evaluate the comparative effectiveness of an antibiotic stewardship intervention adapted for acute care ambulatory settings (adapted intervention) to a stewardship intervention that additionally incorporates behavioral nudges (enhanced intervention) in reducing inappropriate prescriptions.

Methods: This study was a pragmatic, cluster-randomized clinical trial conducted in three academic health systems comprising five adult and pediatric EDs and four UCCs. Randomization of the nine sites was stratified by health system; all providers at each site received either the adapted or the enhanced intervention. The main outcome was the proportion of antibiotic-inappropriate ARI diagnosis visits that received an outpatient antibiotic prescription by individual providers. We estimated a hierarchical mixed-effects logistic regression model comparing visits during the influenza season for 2016 to 2017 (baseline) and 2017 to 2018 (intervention).

Results: There were 44,820 ARI visits among 292 providers across all nine cluster sites. Antibiotic prescribing for ARI visits dropped from 6.2% (95% confidence interval [CI] = 4.5% to 7.9%) to 2.4% (95% CI = 1.3% to 3.4%) during the study period. We found a significant reduction in inappropriate prescribing after adjusting for health-system and provider-level effects from 2.2% (95% CI = 1.0% to 3.4%) to 1.5% (95% CI = 0.7% to 2.3%) with an odds ratio of 0.67 (95% CI = 0.54 to 0.82). Difference-in-differences between the two interventions was not significantly different.

Conclusion: Implementation of antibiotic stewardship for ARI is feasible and effective in the ED and UCC settings. More intensive behavioral nudging methods were not more effective in high-performance settings.

Publication types

  • Pragmatic Clinical Trial
  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Ambulatory Care / statistics & numerical data
  • Anti-Bacterial Agents / administration & dosage*
  • Antimicrobial Stewardship*
  • Attitude of Health Personnel
  • Child
  • Emergency Service, Hospital / statistics & numerical data
  • Female
  • Humans
  • Inappropriate Prescribing / prevention & control*
  • Inappropriate Prescribing / statistics & numerical data
  • Logistic Models
  • Male
  • Practice Patterns, Physicians' / statistics & numerical data
  • Program Evaluation
  • Respiratory Tract Infections / drug therapy*


  • Anti-Bacterial Agents