Antibiotic Use in the Outpatient Setting. Ryan Bariola, MD FIDSA Visi4ng Clinical Associate Professor of Medicine

Transcription

1 Antibiotic Use in the Outpatient Setting Ryan Bariola, MD FIDSA Visi4ng Clinical Associate Professor of Medicine

2 Nothing to disclose Disclosures

3 Case 43 year old pa4ent schedules appointment for cough x 10 days PMH: Anxiety and atrial fibrilla4on. Receives flu shot annually. Tdap 2 years prior No sick contacts Cough with green sputum produc4on. General malaise. No fever or chills T 37.2 BP 125/76 P 86 R 16 Pox 97% RA No sinus tenderness. Mild pharyngeal erythema. No anterior cervical lymphadenopathy Diffuse end-expiratory wheezes. No crackles, egophony, or fremitus Pa4ent insists on an4bio4cs due to length of symptoms and concern that pneumonia is se^ng in

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5 Outpatient Antibiotic Use $6.5 billion in outpa4ent an4bio4c prescrip4on costs in % of all an4bio4c costs in % of outpa4ent an4bio4c prescrip4ons may be inappropriate or unnecessary 2 1. Suda KJ et al J An%microb Chemother 2013;68: Hicks LA et al N Engl J Med 2013;368:1461-2

6 Outpatient Antibiotic Usage An4bio4cs for Sore Throat An4bio4cs for Adults with Bronchi4s -Linder et al, JAMA Intern Med 2013 Oct 3 -Linder et al, IDWeek 2013, abstract 963

7 -Linder et al, IDWeek 2013 abstract 1022

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11 Antibiotic Resistance If you reproduced every 20 minutes, you would get smart quickly, too. -A.W. Karchmer, MD -Peleg AY and Hooper DC, N Eng J Med 2010

12 Outpatient Antibiotic Use (2015) Na4onal: 838 an4bio4c prescrip4ons dispensed per 1000 popula4on PA: 895 an4bio4c prescrip4ons dispensed per 1000 popula4on WV: 1319 an4bio4c prescrip4ons dispensed per 1000 popula4on OH: 964 an4bio4c prescrip4ons dispensed per 1000 popula4on -hhps://gis.cdc.gov/grasp/psa/aumapview.html

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14 14 Shively N et al. An%microb Agents Chemother 2018 July 62. e

15 15 Shively N et al. An%microb Agents Chemother 2018 July 62. e

16 Acute Respiratory Tract Infections Acute bronchi4s Pharyngi4s Acute rhinosinusi4s Common Cold Ann Intern Med 2016 Mar 164(6):425-34

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18 Tes4ng Treatment An4bio4cs (no penicillin allergy) BronchiMs PharyngiMs SinusiMs Common Cold No tes4ng unless pneumonia suspected or there is concern for B pertussis Symptoma4c treatment (doesn t lessen dura4on) Only in se^ng of pneumonia Test for Group A Streptococcus when there is clinical concern (at least 3 Centor criteria (fever, tonsillar exudates, ant cervical lad, lack of cough). Further workup also for any warning signs (drooling, difficulty swallowing/breathing, etc) Symptoma4c treatment for most cases. An4bio4cs for Group A Streptococcus Oral penicillin or amoxicillin x 10 days Imaging can t dis4nguish viral vs bacterial Symptoma4c treatment. Intranasal steroids. An4bio4cs for >10 days of symptoms, fever >39, facial pain >3 days, worsening aoer improvement Amoxicillin or amoxicillin/ clavulanate none Symptoma4c treatment None 18 Adapted from Ann Intern Med 2016 Mar 164(6):425-34

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20 What Patients Want 65% of providers felt pa4ents presen4ng with URI symptoms are more sa4sfied aoer receiving an an4bio4c 85% of providers said an4bio4cs are prescribed due to pa4ent demands The most common provider reported barriers to improved prescribing were pa4ent demands, uncertain diagnosis, and short visits Kufel WD et al ID Week abstract 1303

21 What Patients Want Adults Presen4ng to Acute Care Clinic with URIs 39% wanted an4bio4cs 43% wanted symptom relief 48% wanted a diagnosis 46% of pa4ents wan4ng an4bio4cs received them 29% of pa4ents not wan4ng an4bio4cs received them (p=0.01) Linder JA and Singer DE J Gen Intern Med 2003;18:

22 What Patients Want 85% reduc4on in an4bio4c prescrip4ons and improved pa4ent sa4sfac4on scores when parents were informed why an4bio4cs weren t needed and how to use symptoma4c relief Mangione-Smith R et al. Ann Fam Med 2015;13:221-7

23 What Patients Want Call it a chest cold or viral URI Be defini4ve Discuss how pa4ent is going to feel over next few days and roles of symptoma4c treatment An4bio4cs will not improve symptoms of viral infec4ons Ann Intern Med 2016 Mar 164(6):425-34

24 24 Gentry E, et al ID Week abstract 1839

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27 27 Thank You