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The devil’s in the defaults: An interrupted time-series analysis of the impact of default duration elimination on exposure to fluoroquinolone therapy

Published online by Cambridge University Press:  13 February 2024

Rebekah H. Wrenn*
Affiliation:
Duke University Medical Center, Durham, North Carolina Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
Cara N. Slaton
Affiliation:
Orlando Health Orlando Regional Medical Center, Orlando, Florida
Tony Diez Sr
Affiliation:
Duke University Medical Center, Durham, North Carolina
Nicholas A. Turner
Affiliation:
Duke University Medical Center, Durham, North Carolina
Michael E. Yarrington
Affiliation:
Duke University Medical Center, Durham, North Carolina
Deverick J. Anderson
Affiliation:
Duke University Medical Center, Durham, North Carolina
Rebekah W. Moehring
Affiliation:
Duke University Medical Center, Durham, North Carolina Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
*
Corresponding author: Rebekah H. Wrenn; Email: rebekah.wrenn@duke.edu

Abstract

Objective:

To determine whether removal of default duration, embedded in electronic prescription (e-script), influenced antibiotic days of therapy.

Design:

Interrupted time-series analysis.

Setting:

The study was conducted across 2 community hospitals, 1 academic hospital, 3 emergency departments, and 86 ambulatory clinics.

Patients:

Adults prescribed a fluoroquinolone with a duration <31 days.

Interventions:

Removal of standard 10-day fluoroquinolone default duration and addition of literature-based duration guidance in the order entry on December 19, 2017. The study period included data for 12 months before and after the intervention.

Results:

The study included 35,609 fluoroquinolone e-scripts from the preintervention period and 31,303 fluoroquinolone e-scripts from the postintervention period, accounting for 520,388 cumulative fluoroquinolone DOT. Mean durations before and after the intervention were 7.8 (SD, 4.3) and 7.7 (SD, 4.5), a nonsignificant change. E-scripts with a 10-day duration decreased prior to and after the default removal. The inpatient setting showed a significant 8% drop in 10-day e-scripts after default removal and a reduced median duration by 1 day; 10-day scripts declined nonsignificantly in ED and ambulatory settings. In the ambulatory settings, both 7- and 14-day e-script durations increased after default removal.

Conclusion:

Removal of default 10-day antibiotic durations did not affect overall mean duration but did shift patterns in prescribing, depending on practice setting. Stewardship interventions must be studied in the context of practice setting. Ambulatory stewardship efforts separate from inpatient programs are needed because interventions cannot be assumed to have similar effects.

Type
Original Article
Copyright
© The Author(s), 2024. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

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Footnotes

PREVIOUS PRESENTATION. The preliminary results of this study were presented at IDWeek 2018 on October 3–7, 2018, in San Francisco, California.

References

Tamma, PD, Avdic, E, Keenan, JF, Zhao, Y, Anand, G, Cooper, J, et al. What is the more effective antibiotic stewardship intervention: preprescription authorization or postprescription review with feedback? Clin Infect Dis 2017;64:537543.Google ScholarPubMed
Geller, AI, Lovegrove, MC, Shehab, N, Hicks, LA, Sapiano, MRP, Budnitz, DS. National estimates of emergency department visits for antibiotic adverse events among adults—United States, 2011–2015. J Gen Intern Med 2018;33:10601068.CrossRefGoogle ScholarPubMed
Pollack, LA, Srinivasan, A. Core elements of hospital antibiotic stewardship programs from the Centers for Disease Control and Prevention. Clin Infect Dis 2014;59 suppl 3:S97S100.CrossRefGoogle Scholar
Spellberg, B. The new antibiotic mantra—“shorter is better.” JAMA Intern Med 2016;176:12541255.CrossRefGoogle ScholarPubMed
Stevens, DL, Bisno, AL, Chambers, HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014;59:e10e52.CrossRefGoogle ScholarPubMed
Solomkin, JS, Mazuski, JE, Bradley, JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010;50:133164.CrossRefGoogle ScholarPubMed
Mandell, LA, Wunderink, RG, Anzueto, A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44 suppl 2:S27S72.CrossRefGoogle Scholar
Kalil, AC, Metersky, ML, Klompas, M, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016;63:e61e111.CrossRefGoogle Scholar
Jenkins, TC, Stella, SA, Cervantes, L, et al. Targets for antibiotic and healthcare resource stewardship in inpatient community-acquired pneumonia: a comparison of management practices with national guideline recommendations. Infection 2013;41:135144.CrossRefGoogle ScholarPubMed
Jenkins, TC, Knepper, BC, Sabel, AL, et al. Decreased antibiotic utilization after implementation of a guideline for inpatient cellulitis and cutaneous abscess. Arch Intern Med 2011;171:10721079.CrossRefGoogle ScholarPubMed
Gupta, K, Hooton, TM, Naber, KG, Wullt, B, Colgan, R, Miller, LG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52:e103e120.CrossRefGoogle Scholar
Mo, Y, Oonsivilai, M, Lim, C, Niehus, R, Cooper, BS. Implications of reducing antibiotic treatment duration for antimicrobial resistance in hospital settings: a modelling study and meta-analysis. PLoS Med 2023;20:e1004013.CrossRefGoogle ScholarPubMed
Branch-Elliman, W, O’Brien, W, Strymish, J, Itani, K, Wyatt, C, Gupta, K. Association of duration and type of surgical prophylaxis with antimicrobial-associated adverse events. JAMA Surg 2019;154:590598.CrossRefGoogle ScholarPubMed
Moehring, RW, Anderson, DJ, Cochran, RL, Hicks, LA, Srinivasan, A, Dodds Ashley, ES. Expert consensus on metrics to assess the impact of patient-level antimicrobial stewardship interventions in acute-care settings. Clin Infect Dis 2017;64:377383.CrossRefGoogle ScholarPubMed
Barlam, TF, Cosgrove, SE, Abbo, LM, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016;62:e51e77.CrossRefGoogle Scholar
Dyer, AP, Dodds Ashley, E, Anderson, DJ, et al. Total duration of antimicrobial therapy resulting from inpatient hospitalization. Infect Control Hosp Epidemiol 2019;40:847854.CrossRefGoogle ScholarPubMed
Vaughn, VM, Hersh, AL, Spivak, ES. Antibiotic overuse and stewardship at hospital discharge: the reducing overuse of antibiotics at discharge home framework. Clin Infect Dis 2022;74:16961702.CrossRefGoogle ScholarPubMed
Hayashi, Y, Paterson, DL. Strategies for reduction in duration of antibiotic use in hospitalized patients. Clin Infect Dis 2011;52:12321240.CrossRefGoogle ScholarPubMed
Hersh, AL, Newland, JG, Gerber, JS. Pediatric antimicrobial discharge stewardship: an unmet need. JAMA Pediatr 2016;170:191192.CrossRefGoogle ScholarPubMed
Feller, J, Lund, BC, Perencevich, EN, et al. Post-discharge oral antimicrobial use among hospitalized patients across an integrated national healthcare network. Clin Microbiol Infect 2020;26:327332.CrossRefGoogle ScholarPubMed
Krumholz, HM. Post-hospital syndrome—an acquired, transient condition of generalized risk. N Engl J Med 2013;368:100102.CrossRefGoogle ScholarPubMed
Sanchez, GV, Fleming-Dutra, KE, Roberts, RM, Hicks, LA. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep 2016;65:112.CrossRefGoogle ScholarPubMed
Fleming-Dutra, KE, Hersh, AL, Shapiro, DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA 2016;315:18641873.CrossRefGoogle ScholarPubMed
Glinz, D, Leon Reyes, S, Saccilotto, R, et al. Quality of antibiotic prescribing of Swiss primary-care physicians with high prescription rates: a nationwide survey. J Antimicrob Chemother 2017;72:32053212.CrossRefGoogle ScholarPubMed
Dobson, EL, Klepser, ME, Pogue, JM, et al. Outpatient antibiotic stewardship: interventions and opportunities. J Am Pharm Assoc (2003) 2017;57:464473.CrossRefGoogle ScholarPubMed
Quan, H, Li, B, Couris, CM, et al. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol 2011;173:676682.CrossRefGoogle ScholarPubMed
Antimicrobial use and resistance (AUR) options—January 2023. Centers for Disease Control and Prevention website. https://www.cdc.gov/nhsn/psc/aur/index.html. Accessed January 2024.Google Scholar
Wagner, AK, Soumerai, SB, Zhang, F, Ross-Degnan, D. Segmented regression analysis of interrupted time series studies in medication use research. J Clin Pharm Ther 2002;27:299309.CrossRefGoogle ScholarPubMed
Montoy, JCC, Coralic, Z, Herring, AA, Clattenburg, EJ, Raven, MC. Association of default electronic medical record settings with healthcare professional patterns of opioid prescribing in emergency departments: a randomized quality improvement study. JAMA Intern Med 2020;180:487493.CrossRefGoogle Scholar
Chua, KP, Thorne, MC, Ng, S, Donahue, M, Brummett, CM. Association between default number of opioid doses in electronic health record systems and opioid prescribing to adolescents and young adults undergoing tonsillectomy. JAMA Netw Open 2022;5:e2219701.CrossRefGoogle Scholar
Delgado, MK, Shofer, FS, Patel, MS, et al. Association between electronic medical record implementation of default opioid prescription quantities and prescribing behavior in two emergency departments. J Gen Intern Med 2018;33:409411.CrossRefGoogle ScholarPubMed
Chiu, AS, Jean, RA, Hoag, JR, Freedman-Weiss, M, Healy, JM, Pei, KY. Association of lowering default pill counts in electronic medical record systems with postoperative opioid prescribing. JAMA Surg 2018;153:10121019.CrossRefGoogle ScholarPubMed
van Nieuwkoop, C, van der Starre, WE, Stalenhoef, JE, et al. Treatment duration of febrile urinary tract infection: a pragmatic randomized, double-blind, placebo-controlled noninferiority trial in men and women. BMC Med 2017;15:70.CrossRefGoogle ScholarPubMed
Dinh, A, Davido, B, Etienne, M, et al. Is 5 days of oral fluoroquinolone enough for acute uncomplicated pyelonephritis? The DTP randomized trial. Eur J Clin Microbiol Infect Dis 2017;36:14431448.CrossRefGoogle ScholarPubMed
Peterson, J, Kaul, S, Khashab, M, Fisher, AC, Kahn, JB. A double-blind, randomized comparison of levofloxacin 750 mg once-daily for five days with ciprofloxacin 400/500 mg twice-daily for 10 days for the treatment of complicated urinary tract infections and acute pyelonephritis. Urology 2008;71:1722.CrossRefGoogle ScholarPubMed
Drekonja, DM, Trautner, B, Amundson, C, Kuskowski, M, Johnson, JR. Effect of 7 vs 14 days of antibiotic therapy on resolution of symptoms among afebrile men with urinary tract infection: a randomized clinical trial. JAMA 2021;326:324331.CrossRefGoogle Scholar
Sankar, A, Swanson, KM, Zhou, J, et al. Association of fluoroquinolone prescribing rates with black box warnings from the US food and drug administration. JAMA Netw Open 2021;4:e2136662.CrossRefGoogle ScholarPubMed
Yarrington, ME, Anderson, DJ, Dodds Ashley, E, et al. Impact of FDA black box warning on fluoroquinolone and alternative antibiotic use in southeastern US hospitals. Infect Control Hosp Epidemiol 2019;40:12971300.CrossRefGoogle ScholarPubMed
Dingle, KE, Didelot, X, Quan, TP, et al. Effects of control interventions on Clostridium difficile infection in England: an observational study. Lancet Infect Dis 2017;17:411421.CrossRefGoogle ScholarPubMed
Eudy, JL, Pallotta, AM, Neuner, EA, et al. Antimicrobial stewardship practice in the ambulatory setting from a national cohort. Open Forum Infect Dis 2020;7:ofaa513.CrossRefGoogle ScholarPubMed
Chua, KP, Fischer, MA, Linder, JA. Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross sectional study. BMJ 2019;364:k5092.CrossRefGoogle ScholarPubMed
Jia, J, Linder, JA. Default nudges in medicine-designing the right choice. JAMA Netw Open 2022;5:e222437.CrossRefGoogle ScholarPubMed
Last, BS, Buttenheim, AM, Timon, CE, Mitra, N, Beidas, RS. Systematic review of clinician-directed nudges in healthcare contexts. BMJ Open 2021;11:e048801.CrossRefGoogle ScholarPubMed
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