Impact of Education and Data Feedback on Guideline-Concordant Prescribing for Urinary Tract Infections in the Outpatient Setting

Jason R Funaro; Rebekah W Moehring; Beiyu Liu; Hui-Jie Lee; Siyun Yang; Christina B Sarubbi; Deverick J Anderson; Rebekah H Wrenn

doi:10.1093/ofid/ofab214

Impact of Education and Data Feedback on Guideline-Concordant Prescribing for Urinary Tract Infections in the Outpatient Setting

Open Forum Infect Dis. 2021 Apr 28;9(3):ofab214. doi: 10.1093/ofid/ofab214. eCollection 2022 Mar.

Authors

Jason R Funaro¹, Rebekah W Moehring², Beiyu Liu³, Hui-Jie Lee³, Siyun Yang³, Christina B Sarubbi^{1

2}, Deverick J Anderson², Rebekah H Wrenn^{1

2}

Affiliations

¹ Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA.
² Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA.
³ Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA.

Abstract

Background: Urinary tract infections (UTIs) are the most common outpatient indication for antibiotics and an important target for antimicrobial stewardship (AS) activities. With The Joint Commission standards now requiring outpatient AS, data supporting effective strategies are needed.

Methods: We conducted a 2-phase, prospective, quasi-experimental study to estimate the effect of an outpatient AS intervention on guideline-concordant antibiotic prescribing in a primary care (PC) clinic and an urgent care (UC) clinic between August 2017 and July 2019. Phase 1 of the intervention included the development of clinic-specific antibiograms and UTI diagnosis and treatment guidelines, presented during educational sessions with clinic providers. Phase 2, consisting of routine clinic- and provider-specific feedback, began ~12 months after the initial education. The primary outcome was percentage of encounters with first- or second-line antibiotics prescribed according to clinic-specific guidelines and was assessed using an interrupted time series approach.

Results: Data were collected on 4724 distinct patients seen during 6318 UTI encounters. The percentage of guideline-concordant prescribing increased by 22% (95% CI, 12% to 32%) after Phase 1 education, but decreased by 0.5% every 2 weeks afterwards (95% CI, -0.9% to 0%). Following routine data feedback in Phase 2, guideline concordance stabilized, and significant further decline was not seen (-0.6%; 95% CI, -1.6% to 0.4%). This shift in prescribing patterns resulted in a 52% decrease in fluoroquinolone use.

Conclusions: Clinicians increased guideline-concordant prescribing, reduced UTI diagnoses, and limited use of high-collateral damage agents following this outpatient AS intervention. Routine data feedback was effective to maintain the response to the initial education.

Keywords: antibiotics; fluoroquinolones; outpatient antimicrobial stewardship; urinary tract infections.