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Evaluation of uncomplicated acute respiratory tract infection management in veterans: A national utilization review

  • Jefferson G. Bohan (a1) (a2), Karl Madaras-Kelly (a2) (a3), Benjamin Pontefract (a2), Makoto Jones (a4) (a5), Melinda M. Neuhauser (a6), Matthew Bidwell Goetz (a7), Muriel Burk (a8), Francesca Cunningham (a8) and for the ARI Management Improvement Group (a1) (a2) (a3) (a4) (a5) (a6) (a7) (a8)...



Antibiotics are overprescribed for acute respiratory tract infections (ARIs). Guidelines provide criteria to determine which patients should receive antibiotics. We assessed congruence between documentation of ARI diagnostic and treatment practices with guideline recommendations, treatment appropriateness, and outcomes.


A multicenter quality improvement evaluation was conducted in 28 Veterans Affairs facilities. We included visits for pharyngitis, rhinosinusitis, bronchitis, and upper respiratory tract infections (URI-NOS) that occurred during the 2015–2016 winter season. A manual record review identified complicated cases, which were excluded. Data were extracted for visits meeting criteria, followed by analysis of practice patterns, guideline congruence, and outcomes.


Of 5,740 visits, 4,305 met our inclusion criteria: pharyngitis (n = 558), rhinosinusitis (n = 715), bronchitis (n = 1,155), URI-NOS (n = 1,475), or mixed diagnoses (>1 ARI diagnosis) (n = 402). Antibiotics were prescribed in 68% of visits: pharyngitis (69%), rhinosinusitis (89%), bronchitis (86%), URI-NOS (37%), and mixed diagnosis (86%). Streptococcal diagnostic testing was performed in 33% of pharyngitis visits; group A Streptococcus was identified in 3% of visits. Streptococcal tests were ordered less frequently for patients who received antibiotics (28%) than those who did not receive antibiotics 44%; P < .01). Although 68% of visits for rhinosinusitis had documentation of symptoms, only 32% met diagnostic criteria for antibiotics. Overall, 39% of patients with uncomplicated ARIs received appropriate antibiotic management. The proportion of 30-day return visits for ARI care was similar for appropriate (11%) or inappropriate (10%) antibiotic management (P = .22).


Antibiotics were prescribed in most uncomplicated ARI visits, indicating substantial overuse. Practice was frequently discordant with guideline diagnostic and treatment recommendations.


Corresponding author

Author for correspondence: Karl Madaras-Kelly, Email:


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ARI Management Improvement Group. Collaborators are listed by VA membership at the time of MUE participation, and some collaborators may no longer be practicing at affiliated locations. Hudson Valley VAMC: Rita Bodine PharmD, Catherine Knapp PharmD; Bronx VA: Michael Gelman MD, PhD, Kirsten Vest PharmD, BCPS, Mei Chang PharmD, BCPS-ID, BCCCP; Anchorage VA: Matthew Kirkland PharmD; James Haley VAMC: Patrick Tu PharmD, Amanda Mercurio PharmD, BCPS, Sullivan Lynch PharmD; Salem VAMC: Katherine Jamison PharmD, BCPS, AAHIVP, Allison Kirstie French PharmD, Nick Weatherton PharmD, BCPS, BCACP, BCGP; Portland VA: Kimberly Tamura Mackay PharmD, Johanna Peragine PharmD; Eisenhower VAMC: Emily Potter PharmD, BCPS; VA Connecticut: Brian Kotansky PharmD, BCPS, Ann Fisher MD, Van Vu PharmD; New Orleans: Ngoc-tuyet Ngo PharmD; St Louis VA: Danielle Skouby PharmD, BCPS; Fargo VA HCS: Jessica Dietz PharmD, BCPS; Albuquerque VA HCS VA: Valeria Ilieva MD, Tara Lindeman PharmD; James A. Quillen VAMC: Marty Vannoy PharmD, BCPS; Wilkes-Barre VAMC: Michael Surdy PharmD, AAHIVP, Jill M. O’Donnell PharmD, BCPS, BCGP, Tyler Young PharmD; VA Puget Sound HCS: Jonathan Casavant PharmD, BCPS; Gainesville VAMC: Joseph Pardo PharmD, BCPS-AQ ID, AAHIVP, Michelle Lee PharmD, Stephen Hare PharmD; Fayetteville VAMC: Brian Leith PharmD, BCPS, BCGP, Penny Peacock PharmD, BCPS, Lindsey Cross PharmD, BCACP; Pittsburgh VAMC: Amanda McQuillan PharmD, BCPS; Cincinnati VAMC: Jason Hiett PharmD, BCPS, Jeremy Hilty PharmD, PhD, BCPS, Victoria Tate PharmD, BCPS, Jesse Brown VAMC; Lisa Young PharmD, BCPS, AQ-ID, Jenna Lopez PharmD; Saginaw VAMC: Kayla J. Houghteling PharmD, BCPS, CDE, Rebecca Meagher PharmD, Eric Szydlowski PharmD; VA Central Iowa HCS: Jenny Phabmixay PharmD, BCPS, Kimberly S. Redeker PharmD, BCACP; Edward Hines VA: Ursula Patel PharmD, BCPS, AAHIVP, Kaitlyn Acosta PharmD, Oluwabunmi Abraham PharmD; Central California VA: Jon Malepsy PharmD, Jerick San Mateo PharmD, Christopher Lam PharmD; Dorn VA: Alyssa M. Grill PharmD, BCPS; VA San Diego Health System: Ariel Ma PharmD, BCPS, AQ-ID, Charisma Urbiztondo PharmD, Scott Johns PharmD, BCPS, Veterans Health Care System of the Ozarks (Arkansas): Jennifer Cole PharmD, BCPS, BCCCP, Carol Allred PharmD, Michele Walker PharmD, BCGP, Sioux Falls VA Health Care System: Andrea Aylward PharmD, BCPS, Mackenzie Schreier PharmD, Cassie Heisinger PharmD.



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1.Fleming-Dutra, K, Hersh, A, Shapiro, D, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA 2016;315:18641873.
2.Harris, AM, Hicks, LA, Qaseem, A. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med 2016;164:425434.
3.Shulman, ST, Bisno, AL, Clegg, HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012;55:e86e102.
4.Chow, A, Benninger, M, Brook, I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012;54:e72e112.
5.Rosenfeld, RM, Piccirillo, JF, Chandrasekhar, SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 2015;152:S1S39.
6.Irwin, R, Baumann, M, Bolser, D, et al. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest 2006;129:1S23S.
7.Adult treatment recommendations for outpatient acute respiratory infections. Center for Disease Control and Prevention website. Accessed January 21, 2019.
8.Kelly, AA, Jones, MM, Echevarria, KL, et al. A report of the efforts of the Veterans Health Administration national antimicrobial stewardship initiative. Infect Control Hosp Epidemiol 2017;38:513520.
9.Sanchez, GV, Fleming-Dutra, KE, Roberts, RM, et al. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep 2016;65:112.
10.Jones, B, Sauer, B, Jones, M, et al. Variation in outpatient antibiotic prescribing for acute respiratory infections in the veteran population: a cross-sectional study. Ann Intern Med 2015;163:7380.
11.Drug and therapeutics committees—a practical guide. World Health Organization website. Accessed January 21, 2019.
12.Madaras-Kelly, KJ, Burk, M, Caplinger, C, et al. Total duration of antimicrobial therapy in veterans hospitalized with uncomplicated pneumonia: results of a national medication utilization evaluation. J Hosp Med 2016;11:832839.
13.Spivak, ES, Burk, M, Zhang, R, et al. Management of bacteriuria in Veterans Affairs hospitals. Clin Infect Dis 2017;65:910917.
14.Centers for Medicare Services 2016 ICD9/ICD10 GEMS. Centers for Medicare Services website. Accessed January 21, 2019.
15.VA informatics and computing infrastructure. Corporate Data Warehouse (CDW Database). Health Services Research and Development website. Accessed January 21, 2019.
16.Veterans Health administration handbook. 1058.05: VHA operations activities that may constitute research. Department of Veterans Affairs website. Published 2011. Accessed January 21, 2019.
17.Centor, RM, Witherspoon, JM, Dalton, HP, et al. The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1981;1:239246.
18.Healthcare Analysis and Information Group (HAIG). A field unit of the Office of Strategic Planning and Analysis within the Office of the ADUSH for Policy and Planning. 2016: Page 21. Department of Veterans Affairs website. Published 2016. Accessed January 21, 2019.
19.The Health of America Report. Antibiotic prescription fill rates declining the United States 2017. BlueCross BlueShield website. Published 2017. Accessed January 21, 2019.
20.Madaras-Kelly, KJ, Hruza, H, Pontefract, B, et al. Trends in antibiotic prescribing for acute respiratory tract infections and implementation of a provider directed intervention within the Veterans Affairs healthcare system. Abstract #208. Program and abstracts of the IDWeek 2018, October 3–7, 2018; San Francisco, CA.
21.Havers, FP, Hicks, LA, Chung, JR, et al. Outpatient antibiotic prescribing for acute respiratory infections during influenza seasons. JAMA Network Open 2018;1:e180243.
22.McCullough, AR, Pollack, AJ, Plejdrup-Hansen, M, et al. Antibiotics for acute respiratory infections in general practice: comparison of prescribing rates with guideline recommendations. Med J Aust 2017;207:6569.
23.Hong, SY, Taur, Y, Jordan, MR, et al. Antimicrobial prescribing in the US for adult acute pharyngitis in relation to treatment guidelines. J Eval Clin Pract 2011;17:11761183.
24.Meyer, H, Lund, B, Heintz, B, et al. Identifying opportunities to improve guideline-concordant antibiotic prescribing in veterans with acute respiratory infections or cystitis. Infect Control Hosp Epidemiol 2017;38;724728.
25.Hueston, WJ, Jenkins, R, Mainous, AG. Does drug treatment of patients with acute bronchitis reduce additional care seeking? Evidence from the Practice Partner Research Network. Arch Fam Med 2000;9:9971001.
26.Meeker, D, Linder, J, Fox, C, et al. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. JAMA 2016;315:562570.
27.Dumkow, L, Axford, K, Suda, K, Draper, H, Brandt, K. Impact of a stewardship-focused culture follow-up initiative on the treatment of pharyngitis in the emergency department and urgent care settings. Diagnost Microbiol Infect Dis 2018;92. doi: 10.1016/j.diagmicrobio.2018.05.014.
28.Ferrat, E, Le Breton, J, Guéry, E, et al. Effects 4.5 years after an interactive GP educational seminar on antibiotic therapy for respiratory tract infections: a randomized controlled trial. Fam Pract 2016;33:192199.
29.Gifford, J, Vaeth, E, Richards, K, et al. Decision support during electronic prescription to stem antibiotic overuse for acute respiratory infections: a long-term, quasi-experimental study. BMC Infect Dis 2017;1:528.
30.Linder, JA, Meeker, D, Fox, CR, et al. Effects of behavioral interventions on inappropriate antibiotic prescribing in primary care 12 months after stopping interventions. JAMA 2017;318:13911392.
31.Jones, BE, South, BR, Shao, Y, et al. Development and validation of a natural language processing tool to identify patients treated for pneumonia across VA emergency departments. Appl Clin Inform 2018;9:122128.
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