Implementation of Antimicrobial Stewardship Interventions in Primary Care: Acute Bacterial Rhinosinusitis Treatment Strategies

Abstract

Background:

The highest prescribing rates for antibiotics occur in primary care, therefore, ambulatory care pharmacist interventions could play a major role in preventing overuse and misuse of antibiotics. Delegated pharmacists in the SJC primary care setting guided 3 activities with a goal of positively impacting prescribing patterns: monthly webinars provided by Agency for Healthcare Research and Quality (AHRQ), quarterly reporting to physicians of antibiotic prescribing patterns, and development of a clinical decision-making support tool for antibiotic prescribing.

Methods:

Retrospective, observational data was collected to evaluate antibiotic prescribing patterns in patients diagnosed with acute sinusitis both before initiatives were implemented (July 1, 2019 through June 30, 2020) and after the initiatives were implemented (April 1, 2022 through June 30, 2022).

Results:

A total of 675 patients were diagnosed with acute bacterial sinusitis during the specified time frame. Of these, 138 patients were excluded. A total of 279 antibiotics were prescribed in the preintervention group out of 298 patient encounters (93.6%) and 225 antibiotics were prescribed in the post-intervention group out of 244 patient encounters (92.9%) (p = .26). Although the primary outcome was not statistically significant, a significant reduction in patients treated with fluoroquinolones was noted, with 59/298 (20%) of those being prescribed in the pre-intervention group and 20/244 (8%) in the post intervention group (P = .02).

Conclusions:

While pharmacist-led antimicrobial stewardship interventions in primary care did not result in a decrease in the overall prescription of antibiotics for acute sinusitis, our study did reveal a notable reduction in the use of fluoroquinolones. This finding highlights a promising avenue for expanding the role of ambulatory care pharmacists.

Background

According to the World Health Organization, antibiotic resistance is among one of the 10 greatest threats to public health. This public health issue can amplify healthcare costs and lead to increased morbidity and mortality. ¹ In the 2019 antibiotic threats report, the Centers for Disease Control reported more than 2.8 million antibiotic-resistant infections in the United States each year, resulting in more than 35 000 total deaths. ² A significant proportion of these infections are linked to the overuse and misuse of antibiotics, including inappropriate antibiotic prescribing. Addressing this issue is of paramount importance to preserving the efficacy of existing antimicrobial agents and protecting public health.

Overuse and misuse of antibiotics is especially of concern when considering the treatment of acute respiratory infections. Approximately 70% of all inappropriate antibiotic prescriptions are written for the treatment of acute respiratory conditions. ³ Among these conditions, sinusitis stands out as a frequent target for antibiotic overprescribing. Despite evidence indicating that the majority of sinusitis cases stem from viral origin, antibiotics continue to be prescribed unnecessarily in most cases, further exacerbating the already pressing issue of antibiotic resistance. A study conducted by the CDC and Pew Charitable Trusts highlights this problem, revealing that appropriate antibiotic use for upper respiratory conditions, including sinus infections, was observed in adults only 37% of the time over a 1-year period. ⁴

The heart of the issue, though, lies within primary care settings, where the highest rates of antibiotic prescriptions originate. However, despite the prevalence of outpatient antibiotic use, most antibiotic stewardship initiatives remain focused on the inpatient setting. Based on these insights, intervening in primary care settings holds the potential to curb overuse and misuse of antibiotics and thus contribute to a solution for inappropriate antimicrobial prescribing. This is where pharmacists can make a significant impact. Over the past decade, the integration of non-dispensing pharmacists into outpatient settings has seen significant growth. Primary care pharmacists in ambulatory care now play a crucial role in comprehensive medication management and patient care. ⁵ These highly trained professionals, often equipped with post-graduate residency training and board certifications, possess the expertise to optimize medication regimens and promote antimicrobial stewardship. Multiple studies have explored outpatient antimicrobial stewardship efforts led by pharmacists.^14,15 In a study by Burns et al, pharmacists led an antimicrobial stewardship program in a primary care office through audit and feedback, resulting in significant reduction in inappropriate antibiotic prescribing and improvement in duration of therapy for upper respiratory tract infections (URIs) and urinary tract infections (UTIs). Similarly, research by Westerhof et al demonstrated significant improvements in guideline-concordant antibiotic selection, dose, and duration of therapy for URIs, UTIs, and skin and soft tissues infections (SSTIs) after implementation of a pharmacist-led stewardship program within a family medicine resident clinic. However, despite the compelling evidence supporting the positive impact of pharmacist interventions on reducing unnecessary antibiotic prescribing, their full potential in managing and prescribing antimicrobial regimens remains underutilized. ⁶ By harnessing the expertise of pharmacists in primary care settings, we have an opportunity to strengthen antimicrobial stewardship, prevent antibiotic overuse and misuse, and contribute to a sustainable solution for inappropriate antimicrobial prescribing.

Objective

Our study aimed to determine the proportion of patients who received antibiotics for acute sinusitis in a primary care setting before and after intervention of 3 specific pharmacist-led strategies.

Practice Description

SJ/C Primary Care Physician Network comprises 14 primary care medical groups with 38 providers in the greater Savannah area. Pharmacists are on site a minimum of 50% of operating hours at 6 of the highest-volume practices. Pharmacists for SJ/C Physician Network are residency trained and Board Certified in Ambulatory Care by the Board of Pharmacy Specialties. Pharmacists provide Annual Wellness Visits, Chronic Care Management, Transitional Care Management, and Evaluation and Management services while applying Comprehensive Medication Management under the direct supervision of providers.

To satisfy a 2020 Improvement Activity for the Merit-Based Incentive Payment System (MIPS) St. Joseph’s/Candler (SJC) Primary Care Physician Network chose to adopt a quality measure related to antimicrobial stewardship. MIPS is a component of the Quality Payment Program, an incentive program implemented by CMS as a result of the Medicare Access and CHIP Reauthorization Act (MACRA) requirements. ⁷ MIPS allows physicians to receive payment based on quality and performance. ⁷ The primary care committee at SJC selected the MIPS IA PSPA 15 measure: implementation of an ASP. To meet this measure, the clinic(s) must show “leadership of an Antimicrobial Stewardship Program (ASP) that includes implementation of an ASP that measures the appropriate use of antibiotics for several different conditions to clinical guidelines for diagnostics and therapeutics.” Based on this measure, delegated pharmacists in the SJC primary care setting guided 3 activities with a goal of positively impacting prescribing patterns: monthly webinars provided by Agency for Healthcare Research and Quality (AHRQ), quarterly reporting to physicians of antibiotic prescribing patterns, and development of a clinical decision-making support tool for antibiotic prescribing.

Practice Innovation

Monthly webinars

From July 2020 to April 2021, SJC Primary Care Physician Network participated in the AHRQ Safety Program for Improving Antibiotic Use as an Improvement Activity for MIPS 2020. AHRQ provided 5 separate webinars on a monthly basis to discuss antimicrobial prescribing. These specific webinars included topics regarding treatment of respiratory tract infections, asymptomatic bacteriuria and urinary tract infections, cellulitis and skin abscesses, antibiotic allergies, and sustaining antibiotic stewardship efforts.

Quarterly reporting

In addition to the monthly webinars, practice sites utilized an AHRQ provided data collection and reporting system for antimicrobial prescribing. ¹¹ Quarterly reports were generated for each practice site summarizing results of antibiotic usage at that site compared to national benchmark data. Clinical pharmacists within these primary care sites distributed reports to providers, and were available to discuss report results or questions (Figure 1). It was found that although the total number of antibiotic prescriptions written in SJC outpatient clinics is typically below national average, the number of antibiotics, particularly macrolides written for respiratory tract infections, specifically acute sinusitis, is generally higher than national average.

Figure 1.

Quarterly report.

Order set implementation

To build on knowledge and insight gained during our participation in AHRQ, clinical pharmacists, champion providers, and quality team members developed an evidence-based clinical decision support tool for acute bacterial rhinosinusitis antibiotic prescribing (Figure 2). This protocol was initiated on March 22, 2022 in an effort to influence watch and wait as an alternative to antibiotic prescribing for ABRS. To notify providers of implementation, an email was sent with an acute bacterial rhinosinusitis flowsheet, EMR workflow, and a patient education flier. During the month of April, the quality team met with each practice site to reiterate this information and answer any questions from providers.

Figure 2.

Order set chart.

Methods

Retrospective, observational data was collected to evaluate antibiotic prescribing patterns in patients diagnosed with acute sinusitis both before the initiatives were implemented (July 1, 2019 through June 30, 2020) and after the initiatives were implemented (April 1, 2022 through June 30, 2022). A pre-post design was used to compare the primary and secondary outcomes before and after these initiatives. Patients were included if any variation of diagnosis code reflecting acute sinusitis (J01.90) was present during the specified time frame. Exclusion criteria encompassed patients with concurrent infections and those scheduled for follow-up visit with this diagnosis code, as these individuals are subject to varying antibiotic recommendations. Patient prescriptions were also excluded if a reporting error was identified within the EMR. For patients meeting inclusion criteria, data were collected including presence or absence of antibiotic prescription followed by the specific antibiotic prescribed for the specified indication. The SJ/C Institutional Review Board approved procedures for this retrospective chart review. Informed consent was not required due to the retrospective and quality improvement nature of the initiative.

The primary objective of this study was to determine the proportion of patients who received antibiotics for acute sinusitis in a primary care setting before and after intervention. The secondary objective was to evaluate the effect of these initiatives on overall antibiotic prescribing for acute sinusitis, specifically that of fluoroquinolones.

Chi-square tests were used to for test for differences. Data analyses were conducted using SPSS version 28. Findings were considered significant at P < .05 with 2-sided testing.

Results

A total of 589 patients were diagnosed with acute bacterial sinusitis during the specified time frame. Of these, 52 patients were excluded. (20 due to a concurrent infection and 32 due to follow-up visits). Ultimately, 537 patients were included with 298 in the pre-intervention group and 244 in the post-intervention group.

For the primary outcome, a total of 279 antibiotics were prescribed in the pre-intervention group out of 298 patient encounters (93.6%) and 225 antibiotics were prescribed in the post-intervention group out of 244 patient encounters (92.9%) (p = .26). Although the primary outcome was not statistically significant, a significant reduction in patients treated with fluoroquinolones was noted, with 59 (21%) of those being prescribed in the pre-intervention group and 20 (8%) in the post intervention group (p = .02). Data also demonstrated a significant reduction in overall cephalosporin prescribing with 56 (20%) prescribed in the pre-intervention group and 27 (11%) prescribed in the post-intervention group (Table 1).

Table 1.

Results.

Outcome measure	Pre-intervention (294)	Post-intervention (243)	P-value
Abx prescribed	279 (95%)	225 (93%)	.26
Amoxicillin	67	49	.55
Amoxicillin/Clavulanate	54	32	.12
Azithromycin	30	89	<.01
Cephalosporin	56	27	.02
Doxycycline	5	7	.33
Fluoroquinolone	59	20	.01
Sulfamethoxazole/trimethoprim	5	1	.16
Watch and wait	15	18	.27

Practice Implications

Although the pharmacist-led initiatives implemented within St. Joseph’s/Candler Primary Care did not show a reduction in overall number of antibiotics prescribed for acute sinusitis, a significant reduction in the usage of fluoroquinolones was noted. Due to adverse events associated with fluoroquinolone usage and increasing resistance to broad spectrum antibiotics, this is an important and promising finding. Data also revealed a statistically significant reduction in cephalosporin prescribing, which shows congruence with current IDSA guidelines recommending against the use of cephalosporins for the treatment of acute sinusitis given increasing rates of resistance. One aspect that might have enhanced the outcomes of our study is the integration of an audit and feedback system. Notably, in the studies conducted by Burns et al and Westerhof et al, they implemented audit and feedback as a primary intervention strategy for all prescribed antibiotics.^14,15 This approach involved providing feedback to healthcare providers throughout the intervention period, encompassing recommendations concerning antibiotic drug selection, treatment indications, appropriate dosages, and therapy duration, all in accordance with established guidelines. Positive feedback was also employed to reinforce good prescribing habits. These studies demonstrated the effectiveness of this approach, with Westerhof et al reporting a significant improvement in guideline-concordant antibiotic prescribing across infection types (URI, UTI, SSTI) compared to baseline (38.9%vs 57.9%; P = .001), and Burns et al achieving similar results with guideline-concordant agents prescribed for URIs increased from 43.3% to 86.8%.^14,15 Incorporating a similar audit and feedback system may be a promising avenue for any future studies assessing the impact of antimicrobial stewardship efforts in outpatient settings. While our study did incorporate quarterly reports that summarized antibiotic usage results at each site in comparison to national benchmark data, it’s important to note that, unlike the other 2 studies mentioned, there was limited feedback associated with these reports. Our study did not include specific recommendations related to antibiotic selection, treatment indications, dosages, or therapy duration.

A surprising finding noted during this study was progressively increasing azithromycin use. IDSA guidelines recommend against the usage of macrolides for acute sinusitis due to growing antibiotic resistance. ⁸ At first glance, this reveals a potential opportunity for guideline education; however, a possible explanation for this finding is the COVID-19 pandemic, which occurred in the midst of our study. During the initial stages of the pandemic, some medical practitioners and institutions considered azithromycin as a potential adjunct treatment due to its anti-inflammatory properties. ¹² Although we would have ideally excluded all patients with COVID-19, diagnosing the virus was challenging in the early days of the pandemic. Unfortunately, healthcare providers might have used a non-specific upper respiratory tract infection diagnosis code as a catch all, thus leading to inclusion of patients with viral infections, including COVID-19, for which azithromycin was considered as a treatment option at that time based on available data. ¹³

It’s important to highlight that our study compares a 12-month pre-intervention period to a much shorter post-intervention period, which may have some limitations. Since sinus infections tend to be more prevalent in the winter months and the post-intervention period took place during spring and summer, this seasonal variation could influence prescribing patterns. Additionally, the duration of the post-intervention period may not have captured the full impact of the pharmacist-led strategies, and a longer-term follow-up may have helped to assess sustained effects. Another limitation of our study is the impact of the COVID-19 pandemic. The evolving landscape of medical practice during this time, including the potential use of azithromycin in COVID-19 management, may have influenced prescribing patterns. Since the pre-implementation stage took place early in the pandemic and the post-implementation period was nearly 2 years later, it’s possible this contributed to differences in prescribing between the 2 stages. While we acknowledge, the impact of the pandemic on our findings, it is challenging to precisely quantify its effect on antibiotic prescribing rates. Finally, perhaps the largest limitation to this study was related to overall participation in the antimicrobial stewardship initiative. Providers were not required to attend monthly webinars related to antibiotic prescribing thus may not have reviewed important information that could have possibly improved overall prescribing. While each provider received a report of individual antibiotic prescribing, confirming their review of this information was not required. Due to limited capabilities of the electronic medical record, utilization of the order set created based on IDSA guidelines was not required or standardized.

In 2022, an article published in JAMA by Katz et al et al evaluated an AHRQ educational initiative (Safety Program for Improving Antibiotic Use) on overall antibiotic prescribing patterns in long-term care facilities. ⁹ The initiative included 15 webinars over the course of a year accompanied by tools, activities, posters, and pocket cards. The results of this study were similar to ours with fluoroquinolones prescriptions showing the greatest reduction. ⁹ This trial included antibiotic prescriptions for all infection types and did not report specific usage of macrolides. Craddock et al evaluated antibiotic prescribing for upper respiratory infections in the ambulatory care setting before and after implementation of educational and antimicrobial stewardship initiatives and found a significantly reduced rate of inappropriately prescribed antibiotics for upper respiratory infections. ¹⁰ This reinforces the potential utility of an educational initiative and how stewardship positively impacts antibiotic prescribing in the primary care setting.

Conclusions

Our study explored the impact of pharmacist-led interventions on antibiotic prescribing for acute sinusitis in a primary care setting. While we did not observe a statistically significant reduction in the overall antibiotic prescribing rate, our findings revealed significant reductions in the use of fluoroquinolones and cephalosporins, which are important steps toward optimizing antibiotic use. These results underscore the potential of pharmacist-led initiatives to positively influence antibiotic prescribing practices in outpatient settings. As the role of ambulatory care pharmacists continues to grow and evolve, this study outlines a potential avenue for pharmacists in this setting to bring additional value to the clinics they serve.