Objective: We evaluated the effect of a behaviorally enhanced quality improvement intervention in reducing the number of antibiotic prescriptions written for antibiotic nonresponsive acute respiratory infections (ARIs). A secondary objective was identifying whether a reduction in inappropriate antibiotic prescriptions, if present, persisted after the immediate implementation of the intervention. Design: Nonrandomized, quasi-experimental study conducted from January 2017 through February 2020. Setting: University of California, Davis Health outpatient clinics. In total, 21 pediatric, family, and internal medicine practices in 10 cities and towns were included. Patients: Patients evaluated by a participating physician at an enrolled practice site during the study period with diagnoses (primary and secondary) from the International Classification of Diseases, Tenth Revision codes consistent with antibiotic nonresponsive ARI diagnoses. Intervention: A behaviorally enhanced quality improvement intervention to reduce inappropriate prescribing for antibiotic nonresponsive ARI. Results: In total, 63,028 eligible patient visits across 21 locations were included in the analysis. The most frequently prescribed antibiotic for antibiotic nonresponsive ARI was azithromycin (n = 3,551), followed by amoxicillin (n = 924). Overall, the intervention was associated with an immediate 46% reduction in antibiotic prescriptions for antibiotic nonresponsive ARI (P = .001) following the intervention. We detected no significant change in the month-to-month trend after the intervention was implemented (P = .87), indicating that the reduction was sustained throughout the postintervention period. Conclusion: Our findings demonstrate that a behaviorally enhanced quality improvement intervention to reduce inappropriate prescribing for antibiotic nonresponsive ARI in ambulatory care encounters was successful in reducing potentially inappropriate prescriptions for presumed antibiotic nonresponsive ARI.

Background: The Centers for Disease Control and Prevention (CDC) estimates that outpatient settings account for 85%–90% of antibiotic prescriptions in the United States, and ~30% of those prescriptions are unnecessary. One of the most common examples of inappropriate prescribing is for viral upper respiratory infections (URIs). Up to 50% of prescriptions written for URIs are deemed inappropriate, making it an important focus for Antibiotic Stewardship programs. In this study, we evaluated the effect of a behaviorally enhanced quality improvement intervention in reducing inappropriate antibiotic prescribing for viral URIs. Methods: A quasi-experimental study assessed the effects of an Antibiotic Stewardship intervention on antibiotic prescribing for viral URIs. The outcome of interest was a change in the number of antibiotics prescribed at each participating clinic over a 1-year preimplementation period and a 2-year postimplementation period. Time trends were analyzed using segmented regression analysis, and a stepped wedge design was used to account for intervention roll-out across clinics. Results: From 2017 to 2020, there were 63,028 patient visits in 21 clinic locations. Antibiotics were prescribed an average of 11.5% and 5.8% of visits during the pre- and postimplementation periods, respectively. The most frequently prescribed antibiotic over the study period was azithromycin (n = 3,551), followed by amoxicillin (n = 924). Overall, the intervention was associated with a 46% reduction in antibiotic prescriptions or 0.54 times (P = .001) as many inappropriate antibiotics prescribed as before the intervention. There was no significant change in the month-to-month trend in inappropriate prescriptions after the intervention was implemented (P = .87). Conclusions: Our study demonstrates that a behaviorally enhanced quality improvement intervention to reduce inappropriate prescribing for URI in ambulatory care encounters was successful in reducing potentially inappropriate prescriptions for presumed viral respiratory infections.Funding: NoDisclosures: None

Background: Judicious prescribing of antibiotics is necessary in addressing the crisis of emerging antibiotic resistance and reducing adverse events. Nearly half of antibiotic prescriptions in the outpatient setting are inappropriate, most for viral upper respiratory infections (URIs). Data outlining the misuse of antibiotics in the outpatient setting provide compelling evidence of the need for more rational use of antimicrobial agents beyond hospital settings. Objectives: We evaluated the effect of a behaviorally enhanced quality improvement (QI) intervention to reduce inappropriate antibiotic prescribing for viral URI in the ambulatory care clinics of a large quaternary care healthcare system serving an urban-rural population. Methods: The outpatient antibiotic stewardship program was implemented in January 2018 at 5 pilot sites. Interventions included identification of a site champion, educational sessions, sharing of clinic and individual provider data, and patient and provider educational materials. In addition, preclinic huddles and resident education sessions for internal medicine resident physicians were conducted with a display of public commitment to prescribe antibiotics appropriately. Site champions collaborated with onsite staff to ensure interventions were consistent with local workflows, policies, and standards. The primary outcome was defined as the provider-level antibiotic prescribing rate for acute URI, defined as patient visits with antibiotic-nonresponsive diagnoses without concomitant diagnostic codes to support antibiotic prescribing (see the public MITIGATE tool kit for a complete list). Results: In total, 116,122 antibiotic prescriptions were dispensed from April 2017 through December 2018 compared to the period from April 2017 to December 2017 during which 9,129 fewer prescriptions were ordered. Inappropriate antibiotic prescribing for viral URI for ambulatory clinic encounters (n ≥ 45,000 visits per month) declined from 14.3% to 7.6%. Academic hospital-based sites showed little seasonality trends and no statistically significant decrease in prescription rates (P = .5176). On the other hand, community-based sites showed strong seasonal fluctuations and a statistically significant decrease in prescription rates after intervention (P = .000189). Conclusions: A multifaceted behaviorally enhanced QI intervention to reduce inappropriate prescribing for URI in ambulatory care encounters at a large integrated health system was successful in reducing both inappropriate prescriptions for presumed viral URI as well as total antibiotic use. Findings suggest that implementing leadership roles, education sessions, and low resource behavioral nudging (peer comparison and public commitment) together can decrease excessive use of antibiotics by physicians. A Hawthorne effect may be an important component of these interventions. Future studies are needed in order to determine the optimal combination of behavioral interventions that are cost-effective in outpatient settings.Funding: NoneDisclosures: Larissa May reports receiving speaking honoraria from Cepheid, research grants from Roche, and consultancy fees from BioRad and Nabriva. She serves on the advisory board for Qvella.