Overutilization of Antibiotics

Texas MedicaidOverutilization of AntibioticsEducational RetroDURMailingInitial StudyFollow – up /RestudyExecutive SummaryPurpose:Why Issue was Selected:Program SpecificInformation:Setting & Population:Types of Intervention:Main Outcome Measures:Anticipated Results:To discourage antibiotic use for viral infections, limit the inappropriate use of broadspectrum antibiotics, and provide prescribers with educational tools to bettercommunicate with their patients regarding treatment of viral infections andantibiotic resistance (see Appendix.1).The Centers for Disease Control and Prevention (CDC) estimates that tens ofmillions of antibiotic prescriptions are written each year for viral infections nottreatable with antibiotics, with prescription rates for viral upper respiratory trackinfections estimated to be between 40 and 75%. 1,2 Unfortunately, the occurrenceof resistance to antibiotics (especially with S. pneumoniae, a common respiratorytract infection pathogen) has increased, while the pharmaceutical pipeline for newclasses of antibiotics has continually declined. 2 Despite these facts, consumerattitudes on the use of antibiotics show a lack of understanding, with 48% ofpatients expecting a prescription for an antibiotic when they are ill from a cold, and58% of patients unaware of potential health dangers associated with antibioticuse. 4 However, studies have shown that patients are receptive when asked todelay filling a new antibiotic prescription or not receiving an antibiotic at all if theyare educated about why antibiotics would not be effective for their illness. 3,5Performance IndicatorsCandidates• High percentage of broad spectrum antibiotic use TBDAll patients.Cover letter which includes recommendations from current treatment guidelines forselect upper respiratory tract infections.Per Member Per Month (PMPM) antibiotic costs for the four months following theintervention will be compared to the PMPM costs for the same time period duringthe previous year.Overall decrease in antibiotic prescribing, particularly broad spectrum antibiotics.Overutilization of Antibiotics TX Antibiotic Overutilization Proposal 7 2013.docx© 2011- 2012 Xerox State Healthcare, LLC. All rights reserved.Xerox® and Xerox and Design® are trademarks of Xerox Corporation in the United States and/or other countries.1

Performance Indicator #1: High percentage of broad spectrum antibiotic useWhy has this indicator beenselected?The excessive use of antibiotics is related to the growing emergence of antibioticresistantbacteria. Provider education has been shown to be one component ofdecreasing the use of antibiotics in cases where they are not warranted.How will the patients beselected ?Candidates (denominator):Exception criteria(numerator):Patients receiving outpatient antibiotics in the past 365 days without a history ofthe following conditions in the past 2 years:• Asthma• Chronic obstructive pulmonary disease (COPD)• Chronic bronchitis• Heart failure• Renal failure• Diabetes mellitus• Immunocompromised patients (i.e., HIV+, cancer, history of organtransplantation)• TuberculosisPhysicians of candidates in the upper percentage of the plan for broad spectrumantibiotic use during the past 365 days. Infectious disease specialists areexcluded if specialist data is available.Overutilization of Antibiotics TX Antibiotic Overutilization Proposal 7 2013.docx© 2011- 2012 Xerox State Healthcare, LLC. All rights reserved.2

References1. CDC. Get Smart: Know when antibiotics work. Available at: http://www.cdc.gov/getsmart/index.html. Accessedon June 13, 2013.2. Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. CochraneDatabase of Systematic Reviews 2005, Issue 4. Art. No.: CD003539. DOI:101002/14561858. CD003539.pub2.3. Rybak MJ. Resistance to antimicrobial agents: an update. Pharmacotherapy 2004;24(12):203S-215S.4. Vaden JE, Marcus R, Hadler JL, et al. Consumer attitudes and use of antibiotics. Emerg Inf Dis Sept2003;9(9):1128-35.5. Pontes MC, Pontes NM. Debiasing effects of education about appropriate antibiotic use on consumers’preferences for physicians. Health Care Manage Rev Jan-Mar 2005;30(1):9-16.6. Snow V, Mottur-Pilson C, Gonzales R, et al. Principles of appropriate antibiotic use for treatment of nonspecificupper respiratory tract infections in adults. Ann Intern Med 2001;134:487-489.7. Wong DM, Blumberg DA, Lowe LG. Guidelines for the use of antibiotics in acute URTI. Am Fam Physician2006:74:956-69.8. CDC. Treatment guidelines for upper respiratory tract infections. Availableat: http://www.cdc.gov/getsmart/campaign-materials/treatment-guidelines.html Accessed on June 13, 2013.9. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis inchildren and adults. Clin Infect Dis 2012;54(8):e72-e112. Available at:http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full. Accessed on June 13, 2013.10. Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acutebacterial sinusitis in children aged 1 to 18 years. Pediatrics 2013;108(3):798-808. Availableat: http://pediatrics.aappublications.org/content/early/2013/06/19/peds.2013-1071. Accessed on June 25, 2013.11. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of groupA streptococcal pharyngitis: A 2012 update by the Infectious Disease Society of America. Clin Infect Dis2012;55(10):e86-e102. Available at: http://cid.oxfordjournals.org/content/early/2012/09/06/cid.cis629.fullAccessed on June 20, 2013.12. Snow V, Mottur-Pilson C, et al. Principles of appropriate antibiotic use for treatment of acute bronchitis. AnnIntern Med 2001;134:518-2.13. Braman SS. Chronic cough due to acute bronchitis. ACCP evidenced-based clinical practiceguidelines. Chest 2006;129;95S-103S.14. CDC. Recommended antimicrobial agents for the treatment and postexposure prophylaxis ofpertussis. MMWR 2005;54 (No. RR-14);1-16.15. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitismedia. Pediatrics 2013;131(3):e964-e999. Available at:http://pediatrics.aappublications.org/content/131/3/e964.full.pdf+html Accessed on June 25, 2013.Overutilization of Antibiotics TX Antibiotic Overutilization Proposal 7 2013.docx© 2011- 2012 Xerox State Healthcare, LLC. All rights reserved.3

AppendixesRecommendations to consider before prescribing antibiotics for your patients• Usually viral in origin with symptoms lasting 10-14 days, rarely associated withcomplications, and antibiotics offer no benefit.Upper Respiratory• Antibiotics do not shorten the duration of illness or prevent complications.Tract Infections (URTI)(in general) 6-8 • Purulent nasal/throat secretions alone do not predict bacterial infection or benefit fromantibiotics.• Consider influenza and pneumococcal vaccines in high-risk patients.• Most ambulatory care cases are caused by uncomplicated viral URTIs.Acute BacterialRhinosinusitis 9,10(ABRS)Adult• Patients that may benefit from antibiotics include: persistent symptoms lasting > 7-10days without improvement; severe symptoms (i.e., high fever, purulent nasal dischargeor facial pain) lasting for at least 3-4 days at the beginning of an illness; OR onset of newfever, headache, or increase of worsening nasal discharge following a typical URTI thatwere initially improving.• Standard dose amoxicillin/clavulanate or either doxycycline or respiratory quinolone(levofloxacin, moxifloxacin), if penicillin-allergic, are reasonable first-line agents inpatients with uncomplicated ABRS. Macrolides and trimethoprim/sulfamethoxazole areno longer recommended for empiric therapy based on high rates of resistance.• High dose amoxicillin/clavulanate (2 g orally twice daily) is recommended in certainpatients*Children• ABRS is likely when patients with a URTI present with: persistent illness (i.e., nasaldischarge of any quality and/or daytime cough) > 10 days without improvement;worsening or new onset of symptoms after initial improvement; OR severe symptomonset > 3 consecutive days (i.e., fever >102.2°F and purulent nasal discharge).• Antibiotics should be prescribed in patients with severe onset and worsening courseABRS, while antibiotics OR a 3-day additional observation can be offered to children withpersistent illness.• Amoxicillin with or without clavulanate is recommended as first-line therapy. If penicillinallergic,cefdinir, cefuroxime, cepodoxime, a combination of clindamycin (or linezolid)and cefixime, or levofloxacin can be used.• High dose amoxicillin clavulanate (90 mg/kg/d twice daily) is recommended in certainpatients** Patients from regions with high endemic rates of invasive penicillin non-susceptible S.pneumoniae, severe infection, attend daycare, aged < 2 or >65 years, have recenthospitalization or antibiotic exposure, or are immunocompromised.• Antibiotics should be given only to patients with Group A beta-hemolyticstreptococcal (GABHS) pharyngitis; only 5-15% of adult acute pharyngitis casesand 20-30% of pediatric cases are caused by GABHS.• Rapid antigen diagnostic testing and/or culture should be performed because oftenAcute Pharyngitis 11 clinical features alone do not reliably discriminate between GABHS and viral pharyngitis.Acute Bronchitis 8,12-14(Acute Cough Illness)• Penicillin or amoxicillin is preferred treatment. If penicillin-allergic, a first-generationcephalosporin (if not anaphylactically sensitive), clindamycin, clarithromycin, orazithromycin are recommended.• Analgesics, antipyretics, and supportive care should be offered.• Most acute bronchitis cases (> 90%) are caused by viruses; antibiotics are notrecommended regardless of the duration of the cough.• If cough lasts > 3 weeks or the patient has fever, tachypnea, tachycardia, or evidence ofconsolidation on chest exam, consider chest radiography.• Antibiotics are indicated for suspected or confirmed pertussis; first line agents areOverutilization of Antibiotics TX Antibiotic Overutilization Proposal 7 2013.docx© 2011- 2012 Xerox State Healthcare, LLC. All rights reserved.4

macrolides or trimethoprim/sulfamethoxazole.Acute Otitis Media 15(AOM)• Antibiotics should be prescribed for AOM in children > 6 months with severesigns and symptoms (i.e., moderate to severe otalgia for at least 48hrs ortemperature >102.2°F) and for bilateral AOM in children < 24 months withoutsevere signs and symptoms.• Observation with close follow-up may be appropriate for patients with non-severe signsand symptoms and are 6 to 23 months with unilateral AOM or are > 24 months withunilateral or bilateral AOM.• High dose amoxicillin (80-90 mg/kg/day) is the first-line agent. High dose amoxicillin/clavulanate should be used if the patient received amoxicillin within the last 30 days, hasconcurrent conjunctivitis, or if coverage for a β-lactamase positive organism is needed.• If penicillin-allergic, cefdinir, cefpodoxime, cefuroxime or a macrolide may be used.• Antibiotics are not indicated for otitis media with effusion in the absence of clinicalsymptoms.• Prophylactic antibiotics should not be prescribed to reduce the risk of AOM in childrenwith recurrent AOM.Overutilization of Antibiotics TX Antibiotic Overutilization Proposal 7 2013.docx© 2011- 2012 Xerox State Healthcare, LLC. All rights reserved.5