2568. Variability in Pediatric Antibiotic Prescribing for Upper Respiratory Illnesses by Provider Specialty

Abstract Background Antibiotic prescribing varies among providers, contributing to antibiotic resistance and adverse drug reactions. Objective. To evaluate variation in antibiotic prescribing between pediatric and nonpediatric providers for common upper respiratory illnesses. Methods Patient encounters for children aged <18 years from a regional healthcare system were identified. Electronic medical records from 2011 to 2016 were extracted for diagnoses of upper respiratory infection (URI), pharyngitis, acute otitis media (AOM), and sinusitis. Encounters with competing medical diagnoses, recent hospitalization, and antibiotic prescriptions within 30 days were excluded. Adherence to antibiotic guidelines was assessed by provider training (pediatric, nonpediatric physicians, and advance practice providers [APP]). Additional factors assessed included clinic or urgent care setting, calendar year, and patient’s age, gender, insurance status, and number of sick visits in the prior year. Results Across 6 years, 141,361 visits were examined: 43,914 for URI, 43,701 for pharyngitis, 43,925 for AOM, and 9,821 for sinusitis. Pediatricians were more likely than APPs and nonpediatric providers to have guideline-concordant prescribing for pharyngitis (pediatricians 66.7 (54.5, 77.0)%, nonpediatricians 49.1 (36.3, 62.0)%, APPs 52.2(39.4, 64.7)%, P < 0.0001) and sinusitis (pediatricians 70.8(53.8, 83.4)%, nonpediatricians 63.3(46.8, 77.2)%, APPs 62.1(45.1, 76.5)%, P = 0.48) and to withhold antibiotics for URI than APPs and nonpediatric providers (pediatricians 86.6(81.2, 90.6)%, nonpediatricians 80.8(73.0, 86.8)%, APPs 76.8(68.4, 83.5)%, P < 0.0001). Pediatricians were less likely to prescribe antibiotics for pharyngitis without a positive Group A Streptococcus test than APPs and nonpediatric providers (pediatricians 15.1(10.4, 21.6)%, nonpediatricians 29.4(20.8, 39.6)%, APPs 27.2(19.3, 36.9)%, P < 0.0001). First-line antibiotic prescribing for pharyngitis and AOM did not differ between provider specialties. A trend toward more guideline-concordant prescribing was seen for pharyngitis and sinusitis over the study period. Conclusion Pediatricians were more likely to adhere to guidelines for pediatric acute respiratory infections. Pediatric antibiotic stewardship efforts should also target non-pediatricians. Disclosures All authors: No reported disclosures.

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Antibiotic Prescribing in Adults Presenting with Pharyngitis Pre- and Post-Implementation of a Rapid Group A Streptococcus Test

Hospital Pharmacy ◽

10.1177/00185787211032365 ◽

2021 ◽

pp. 001857872110323

Author(s):

Preeyaporn Sarangarm ◽

Timothy A. Huerena ◽

Tatsuya Norii ◽

Carla J. Walraven

Keyword(s):

Group A Streptococcus ◽

Intervention Group ◽

Urgent Care ◽

Antibiotic Prescribing ◽

Care Clinic ◽

Rapid Antigen Detection Test ◽

Appropriate Prescribing ◽

Icd 10 ◽

Group A

Background: Group A Streptococcus (GAS) pharyngitis is the most common bacterial cause of acute pharyngitis and is often over treated with unnecessary antibiotics. The purpose was to evaluate if implementation of a rapid antigen detection test (RADT) for GAS would reduce the number of inappropriately prescribed antibiotics for adult patients presenting with symptoms of pharyngitis. Methods: This was a retrospective cohort study of adult urgent care clinic patients pre- and post-implementation of a GAS RADT. We included patients who had a diagnosis of GAS identified via ICD-10 codes and either a throat culture, GAS RADT, or antibiotic prescribed for GAS. Antibiotic prescribing was assessed as appropriate or inappropriate based on testing and IDSA guideline recommendations. Thirty-day follow-up visits related to pharyngitis or the prescribed antibiotics was also evaluated. Results: A total of 1734 patients were included; 912 and 822 in the pre- and post-implementation groups, respectively. Following implementation of the GAS RADT, there was an increase in the number of antibiotics prescribed for GAS (43.4% vs 59.1%, P < .001) as well as an increase in appropriate prescribing (67.6% vs 77.5%, P < .001). More 30-day pharyngitis-related follow-up visits were seen in the pre-intervention group (12.5% vs 9.3%, P = .03). Conclusion: Implementation of a RADT for GAS pharyngitis was associated with an increase in both the overall number of antibiotic prescriptions for GAS and the proportion of appropriately prescribed antibiotics. There was also a reduction in follow up visits related to GAS pharyngitis, however educational efforts to further increase appropriate prescribing is needed.

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SPECIAL ARTICLE

PEDIATRICS ◽

10.1542/peds.15.3.334 ◽

1955 ◽

Vol 15 (3) ◽

pp. 334-336

Author(s):

Sidney S. Samuels

Keyword(s):

Otitis Media ◽

Respiratory Infections ◽

Acute Otitis Media ◽

Air Travel ◽

Virus Infections ◽

Secretory Otitis Media ◽

Upper Respiratory Infection ◽

Upper Respiratory Infections ◽

Sense Of Security ◽

Upper Respiratory

THE DIAGNOSIS of non-suppurative, secretory otitis media has been made much more frequently in recent years than it was prior to 1950. This increase has been noticed in children many more times than in adults, as pointed out by Robison and Nicholas. The disease is much more commonly found because of increased vigilance some otologists believe, as does Suehs, since the entity was reviewed and clarified by the brilliant work of Hoople in that year. However, there are undoubtedly other factors contributing to the greater incidence of this entity, such as the increased use of antibiotics in upper respiratory infections, including otitis media; an increase in the number of so-called virus infections; the greater prevalence of allergic diathesis; increased air travel; and, as Lindsay states, the swing of time pendulum toward extreme conservatism in recommending removal of tonsils and adenoids, a tendency resulting partly from a sense of security afforded by antibiotic therapy. The condition has received more of the attention it merits lately from that group of practitioners who are first in contact with the patients, namely the pediatrician and general practitioner who attend the acutely ill child. For usually the actual onset of the illness is acute, an otitis media occurring during an acute upper respiratory infection or as an acute otitis media following such an illness. The former need not even reach the stage where it is definitely recognized, its progress being halted by the antibiotic treatment administered. The attention of the attending physiciain is focused upon the middle ear in the younger child, either by the presence of pain in the affected ear, or by the abnormal appearance of the tympanic membrane, or both.

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Intramuscular Corticosteroids for Acute Upper Respiratory Infections Affects Healthcare Utilization

Annals of Otology Rhinology & Laryngology ◽

10.1177/0003489420929717 ◽

2020 ◽

Vol 129 (10) ◽

pp. 988-995 ◽

Cited By ~ 1

Author(s):

Sean M Parsel ◽

Alaa E Mohammed ◽

Daniel Fort ◽

Blair M Barton ◽

Edward D McCoul

Keyword(s):

Healthcare Utilization ◽

Respiratory Infections ◽

Acute Otitis Media ◽

Patient Characteristics ◽

Urgent Care ◽

Upper Respiratory Infections ◽

Regional Health Care ◽

Repeat Visit ◽

Upper Respiratory

Objective: To examine the use of intramuscular corticosteroid (IMCS) injections for treatment of acute upper respiratory infections (URI) and the influence on healthcare utilization. Methods: This retrospective cohort study used patient encounter data from a large multicenter regional health care system between 2013 and 2017. Adult patients diagnosed with acute URI (acute pharyngitis, acute sinusitis, acute otitis media, and URI not otherwise specified) during ambulatory encounters were included. Follow-up encounters for a diagnosis of acute URI within 60 days were identified and patient characteristics, encounter details, and procedure codes were retrieved. Frequency data was used to calculate IMCS injection administration prevalence, utilization trends, and associations with covariates. Follow-up data for return encounters within 60 days for the same diagnosis was examined. Results: Of the 153 848 initial encounters, 34 600 (22.5%) patients received IMCS injection for acute URI. Injection rates varied from 0.85% to 49.1% depending on specialty and practitioner type. Internal medicine, family medicine, urgent care, and otorhinolaryngology clinics most commonly administered IMCS. 3788 patients returned for a second encounter of which 751 (19.8%) received an injection. IMCS injection during the first encounter was associated with increased odds of repeat visit within 60 days (OR: 1.74; 95% CI: 1.61–1.88). Conclusion: IMCS use in the treatment of acute URI is highly prevalent despite lack of evidence for impact and safety. Prevalence is variable across multiple medical and surgical specialties including otorhinolaryngology. Administration of IMCS injection may contribute to the likelihood of a subsequent healthcare visit for the same indication.

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A Learning Collaborative to Improve Antibiotic Prescribing in Primary Care Pediatric Practices

Clinical Pediatrics ◽

10.1177/00099228211001623 ◽

2021 ◽

Vol 60 (4-5) ◽

pp. 230-240

Author(s):

Chuck Norlin ◽

Katherine Fleming-Dutra ◽

Jeff Mapp ◽

Jennifer Monti ◽

Allison Shaw ◽

...

Keyword(s):

Primary Care ◽

Patient Education ◽

High Performance ◽

Acute Otitis Media ◽

Safety Net ◽

Antibiotic Prescribing ◽

Learning Collaborative ◽

Upper Respiratory Infection ◽

Upper Respiratory ◽

Improve Patient

An American Academy of Pediatrics State Chapter organized a 6-month, mostly online quality improvement learning collaborative to improve antibiotic prescribing and patient education for upper respiratory infection (URI) and acute otitis media (AOM). Practices submitted data on quality measures at baseline, monthly, and 4 months post-project. Fifty-three clinicians from 6 independent, private primary care pediatric practices participated. Use of first-line antibiotics for AOM increased from 63.5% at baseline to 80.4% 4 months post-project. Use of safety-net antibiotic prescriptions (SNAP) for AOM increased from 4.5% to 16.9%. Educating patients about management for URI increased from 66.1% to 88.0% and for AOM from 20.4% to 85.6%. Practices maintained high performance for not prescribing antibiotics for URI (94.4% to 96.2%). Leveraging local relationships and national resources, this replicable antibiotic stewardship project engaged independent private practices to improve patient education for URI and AOM and prescribing and use of SNAP for AOM.

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Incidence of Pharyngitis, Sinusitis, Acute Otitis Media, and Outpatient Antibiotic Prescribing Preventable by Vaccination Against Group A Streptococcus in the United States

Clinical Infectious Diseases ◽

10.1093/cid/ciaa529 ◽

2020 ◽

Cited By ~ 1

Author(s):

Joseph A Lewnard ◽

Laura M King ◽

Katherine E Fleming-Dutra ◽

Ruth Link-Gelles ◽

Chris A Van Beneden

Keyword(s):

United States ◽

Otitis Media ◽

Group A Streptococcus ◽

Acute Otitis Media ◽

The United States ◽

Incidence Rates ◽

World Health ◽

Antibiotic Prescribing ◽

Outpatient Visits ◽

Group A

Abstract Background Group A Streptococcus (GAS) is a leading cause of acute respiratory conditions that frequently result in antibiotic prescribing. Vaccines against GAS are currently in development. Methods We estimated the incidence rates of healthcare visits and antibiotic prescribing for pharyngitis, sinusitis, and acute otitis media (AOM) in the United States using nationally representative surveys of outpatient care provision, supplemented by insurance claims data. We estimated the proportion of these episodes attributable to GAS and to GAS emm types included in a proposed 30-valent vaccine. We used these outputs to estimate the incidence rates of outpatient visits and antibiotic prescribing preventable by GAS vaccines with various efficacy profiles under infant and school-age dosing schedules. Results GAS pharyngitis causes 19.1 (95% confidence interval [CI], 17.3–21.1) outpatient visits and 10.2 (95% CI, 9.0–11.5) antibiotic prescriptions per 1000 US persons aged 0–64 years, annually. GAS pharyngitis causes 93.2 (95% CI, 82.3–105.3) visits and 53.2 (95% CI, 45.2–62.5) antibiotic prescriptions per 1000 children ages 3–9 years, annually, representing 5.9% (95% CI, 5.1–7.0%) of all outpatient antibiotic prescribing in this age group. Collectively, GAS-attributable pharyngitis, sinusitis, and AOM cause 26.9 (95% CI, 23.9–30.8) outpatient visits and 16.1 (95% CI, 14.0–18.7) antibiotic prescriptions per 1000 population, annually. A 30-valent GAS vaccine meeting the World Health Organization’s 80% efficacy target could prevent 5.4% (95% CI, 4.6–6.4%) of outpatient antibiotic prescriptions among children aged 3–9 years. If vaccine prevention of GAS pharyngitis made the routine antibiotic treatment of pharyngitis unnecessary, up to 17.1% (95% CI, 15.0–19.6%) of outpatient antibiotic prescriptions among children aged 3–9 years could be prevented. Conclusions An efficacious GAS vaccine could prevent substantial incidences of pharyngitis infections and associated antibiotic prescribing in the United States.

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969. Antibiotic Prescribing in a Large Retail Health Clinic Chain: Opportunities for Stewardship

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz359.071 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S32-S33

Author(s):

Katherine E Fleming-Dutra ◽

Laura M King ◽

Safia Boghani ◽

Lauri Hicks ◽

John Hou ◽

...

Keyword(s):

Urinary Tract Infection ◽

Urinary Tract ◽

Tract Infection ◽

Respiratory Infections ◽

Acute Otitis Media ◽

Adult Patients ◽

Urgent Care ◽

Health Clinic ◽

Antibiotic Prescribing ◽

First Line

Abstract Background Retail health is a growing outpatient setting. Research using claims data found that antibiotics were linked with 46% of urgent care, 17% of medical office, and 14% of retail health visits for acute respiratory infections (ARIs) for which antibiotics are not needed. We aimed to quantify antibiotic prescribing rates to adult patients in a large retail health clinic chain using electronic health records and to identify future stewardship targets. Methods We included visits by adults ≥18 years to network retail health clinics from 2012 to 2016. We classified diagnoses by ICD codes. We calculated the percent of visits with systemic antibiotics prescribed among all visits, by individual diagnosis, and for ARIs as a group (e.g., pneumonia, sinusitis, pharyngitis, acute otitis media [AOM], bronchitis, and viral upper respiratory infections [URI]). We also assessed the percent of visits for sinusitis and pharyngitis with first-line antibiotics prescribed. Results Of 2,893,413 visits by adults during 2012–2016, 1,866,145 (66%) resulted in antibiotic prescriptions. ARIs accounted for 2,039,423 (72%) of visits and 1,475,069 (79%) of antibiotic prescriptions. The most common diagnoses regardless of antibiotic prescription were sinusitis (31% of visits), pharyngitis (15%, of which 81% were coded as streptococcal pharyngitis), urinary tract infection (9%), viral URI (8%), AOM (7%), and bronchitis (5%). Antibiotics were frequently prescribed for sinusitis, urinary tract infection, pharyngitis, and AOM but not for viral URI and bronchitis (Figure 1). First-line antibiotics were prescribed in the majority of sinusitis and pharyngitis visits (Figure 2). Conclusion ARIs are major drivers of visits by adult patients and of antibiotic prescribing to adults in this retail clinic network. Inappropriate antibiotic use was low in this setting for viral URI and bronchitis and first-line antibiotic selection was high for sinusitis and pharyngitis, although additional opportunities for improvement exist. Future antibiotic stewardship efforts may target examining adherence to guideline-recommended diagnostic criteria for sinusitis, AOM, and pharyngitis and increasing use of watchful waiting for sinusitis and AOM. Disclosures All Authors: No reported Disclosures.

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Naturally Acquired Protection Against Upper Respiratory Symptoms Involving Group A Streptococcus in a Longitudinal Cohort Study

Clinical Infectious Diseases ◽

10.1093/cid/ciaa044 ◽

2020 ◽

Vol 71 (8) ◽

pp. e244-e254 ◽

Cited By ~ 1

Author(s):

Joseph A Lewnard ◽

Lilith K Whittles ◽

Anne-Marie Rick ◽

Judith M Martin

Keyword(s):

Respiratory Symptoms ◽

Group A Streptococcus ◽

Antibiotic Use ◽

The United States ◽

Respiratory Illnesses ◽

School Aged Children ◽

Repeated Sampling ◽

Group A ◽

Natural Protection ◽

Upper Respiratory

Abstract Background Pharyngitis due to group A Streptococcus (GAS) represents a major cause of outpatient visits and antibiotic use in the United States. A leading vaccine candidate targets 30 of the > 200 emm types of GAS. We aimed to assess natural protection conferred by GAS against respiratory symptoms. Methods In a 5-year study among school-aged children in Pittsburgh, Pennsylvania, pharyngeal cultures were obtained from children at 2-week intervals, and active surveillance was conducted for respiratory illnesses. We assessed protection via the relative odds of previous detection of homologous strains (defined by field-inversion gel electrophoresis banding pattern), emm types, and emm clusters at visits where GAS was detected with symptoms, vs visits where GAS was detected without symptoms. We used a cluster bootstrap of children to adjust estimates for repeated sampling. Results At visits where previously detected GAS emm types were identified, we estimated 81.8% (95% confidence interval [CI], 67.1%–91.7%) protection against typical pharyngitis symptoms among children reacquiring the same strain, and 94.5% (95% CI, 83.5%–98.6%) protection among children acquiring a distinct strain. We estimated 77.1% (95% CI, 33.7%–96.3%) protection against typical symptoms among children acquiring partially heterologous emm types belonging to a previously detected emm cluster. Protection was evident after both symptomatic and asymptomatic detections of GAS. We did not identify strong evidence of protection against atypical respiratory symptoms. Conclusions Within a 5-year longitudinal study, previous detection of GAS emm types was associated with protection against typical symptoms when homologous strains were subsequently detected. Naturally acquired protection against partially heterologous types suggests that emm type–based vaccines may have broader strain coverage than what has been previously assumed.

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143. Initial Impact of COVID-19 on Ambulatory Antibiotic Prescribing for Respiratory Viral Infections

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.188 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S82-S82

Author(s):

Zahra Kassamali Escobar ◽

Todd Bouchard ◽

Jose Mari Lansang ◽

Scott Thomassen ◽

Joanne Huang ◽

...

Keyword(s):

Primary Care ◽

Viral Infections ◽

Respiratory Infections ◽

Urgent Care ◽

Antibiotic Prescribing ◽

Specific Rate ◽

Inclusion Criteria ◽

Diagnosis Codes ◽

Control And Prevention ◽

Viral Respiratory Infections

Abstract Background Between 15–50% of patients seen in ambulatory settings are prescribed an antibiotic. At least one third of this usage is considered unnecessary. In 2019, our institution implemented the MITIGATE Toolkit, endorsed by the Centers for Disease Control and Prevention to reduce inappropriate antibiotic prescribing for viral respiratory infections in emergency and urgent care settings. In February 2020 we identified our first hospitalized patient with SARS-CoV(2). In March, efforts to limit person-to-person contact led to shelter in place orders and substantial reorganization of our healthcare system. During this time we continued to track rates of unnecessary antibiotic prescribing. Methods This was a single center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. We provided monthly individual feedback to urgent care prescribers, (Sep 2019-Mar 2020), primary care, and ED providers (Jan 2020 – Mar 2020) notifying them of their specific rate of unnecessary antibiotic prescribing and labeling them as a top performer or not a top performer compared to their peers. The primary outcome was rate of inappropriate antibiotic prescribing. Results Pre toolkit intervention, 14,398 patient visits met MITIGATE inclusion criteria and 12% received an antibiotic unnecessarily in Jan-April 2019. Post-toolkit intervention, 12,328 patient visits met inclusion criteria and 7% received an antibiotic unnecessarily in Jan-April 2020. In April 2020, patient visits dropped to 10–50% of what they were in March 2020 and April 2019. During this time the unnecessary antibiotic prescribing rate doubled in urgent care to 7.8% from 3.6% the previous month and stayed stable in primary care and the ED at 3.2% and 11.8% respectively in April compared to 4.6% and 10.4% in the previous month. Conclusion Rates of inappropriate antibiotic prescribing were reduced nearly in half from 2019 to 2020 across 3 ambulatory care settings. The increase in prescribing in April seen in urgent care and after providers stopped receiving their monthly feedback is concerning. Many factors may have contributed to this increase, but it raises concerns for increased inappropriate antibacterial usage as a side effect of the SARS-CoV(2) pandemic. Disclosures All Authors: No reported disclosures

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Association of Receipt of Antibiotics with Patient Satisfaction for Caregivers of Children Presenting to Urgent-Care Settings

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.647 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s134-s135

Author(s):

Diane Liu ◽

NORA FINO ◽

Benjamin Haaland ◽

Adam Hersh ◽

Emily Thorell ◽

...

Keyword(s):

Patient Satisfaction ◽

Otitis Media ◽

Respiratory Infections ◽

Otitis Media With Effusion ◽

Multivariable Analysis ◽

Acute Otitis Media ◽

Skewed Distribution ◽

Urgent Care ◽

Provider Type ◽

Patient Dissatisfaction

Background: The Press Ganey (PG) Medical Practice Survey is a commonly used questionnaire for measuring patient experience in healthcare. Our objective was to evaluate the PG surveys completed by caregivers of children presenting for urgent care evaluation of acute respiratory infections (ARIs) to determine any correlation with receipt of antibiotics during their visit. Methods: We evaluated responses to the PG urgent-care surveys for encounters of children <18 years presenting with ARIs (ie, sinusitis, bronchitis, pharyngitis, upper respiratory infection, acute otitis media, or serous otitis media with effusion) within 9 University of Utah urgent-care centers. Scores could range from 0 to 100. Because the distributions of scores followed right- skewed distribution with a high ceiling effect, we defined scores as dissatisfied with their care (≤25th percentile) and satisfied with their care (scores >25th percentile). Univariate and multivariable generalized mixed-effects logistic regression was used to assess correlates of patient dissatisfaction. Random intercepts were included for each provider to account for correlation within the same provider. Separate models were used for each PG component score. Multivariable models adjusted for receipt of antibiotics, age, gender, race, ethnicity, and provider type. Results: Overall, 388 of 520 responses (74.6%) indicated satisfaction and 132 responses (25.4%) indicated dissatisfaction. Among patients who did not receive antibiotics, 87 of 284 responses (30.6%) indicated dissatisfaction versus 45 of 236 (19.1%) who did receive antibiotics. Among patients who were dissatisfied with their clinician, raw clinician PG scores were higher among patients who received antibiotics (mean, 64.5; standard deviation [SD], 16.9) versus those who did not receive antibiotics (mean, 54.7; SD, 24.4; P = .015) (Table 1). In a multivariable analysis, receipt of antibiotics was associated with a reduction in patient dissatisfaction overall (odds ratio, 0.55; 95% CI, 0.36–0.85). Conclusions: Overall, most responses for patients seen for ARIs in pediatric urgent care were satisfied. However, a significantly higher proportion of responses for patients who did not receive antibiotics were dissatisfied than for those patients who received antibiotics. Antibiotic stewardship strategies to communicate appropriate prescribing while preserving patient satisfaction are needed in pediatric urgent-care settings.Funding: NoneDisclosures: None

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23. Regional Variation in Outpatient Antibiotic Prescribing in a Commercially-insured Population, United States, 2017

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa417.022 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S12-S12

Author(s):

Destani J Bizune ◽

Danielle Palms ◽

Laura M King ◽

Monina Bartoces ◽

Ruth Link-Gelles ◽

...

Keyword(s):

United States ◽

Otitis Media ◽

Acute Otitis Media ◽

Urgent Care ◽

Antibiotic Prescribing ◽

Tier 2 ◽

Regional Variability ◽

Patient Age ◽

Patient Âgé ◽

Tier 3

Abstract Background Studies have shown that the Southern United States has higher rates of outpatient antibiotic prescribing compared to other regions in the country, but reasons for this variation are unclear. We aimed to determine whether the regional variability in outpatient antibiotic prescribing for respiratory diagnoses can be explained by differences in patient age, care setting, comorbidities, and diagnosis in a commercially-insured population. Methods We analyzed the 2017 IBM® MarketScan® Commercial Database of commercially-insured individuals aged < 65 years. We included visits with acute respiratory tract infection (ARTI) diagnoses from retail clinics, urgent care centers, emergency departments, and physician offices. ARTI diagnoses were categorized as: Tier 1, antibiotics are almost always indicated (pneumonia); Tier 2, antibiotics are sometimes indicated (sinusitis, acute otitis media, pharyngitis); and Tier 3, antibiotics are not indicated (asthma, allergy, bronchitis, bronchiolitis, influenza, nonsuppurative otitis media, viral upper respiratory infections, viral pneumonia). We calculated risk ratios and 95% confidence intervals (CI) stratified by US Census region and ARTI tier using log-binomial models controlling for patient age, comorbidities (Elixhauser and Complex Chronic Conditions for Children), and setting of care, with Tier 3 visits in the West, the strata with the lowest antibiotic prescription rate, as the reference for all strata. Results A total of 100,104,860 visits were analyzed. In multivariable modeling, ARTI visits in the South and Midwest were highly associated with receiving an antibiotic for Tier 2 conditions vs. patients in other regions (Figure 1). Figure 1. Multivariable model comparing risk of receiving an antibiotic for an ARTI by region and diagnostic tier in urgent care, retail health, emergency department, and office visits, MarketScan® 2017, United States Conclusion Regional variability in outpatient antibiotic prescribing for Tier 2 and 3 ARTIs remained even after controlling for patient age, comorbidities, and setting of care. It is likely that this variability is in part due to non-clinical factors such as regional differences in clinicians’ prescribing habits and patient expectations. Targeted and enhanced public health stewardship interventions are needed to address cultural factors that affect antibiotic prescribing in outpatient settings. Disclosures All Authors: No reported disclosures

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