Urinary tract infections (UTIs) are among the most common bacterial infections, prompting millions of antibiotic prescriptions each year. However, the rise in antibiotic resistance has become an alarming public health concern, necessitating innovative strategies to optimize antimicrobial use. In this light, the development and implementation of the clinical decision support (CDS) tool in a family medicine resident clinic herald a significant advancement in outpatient antimicrobial stewardship, as published in the Journal of the American Pharmacists Association (JAPhA) (DOI: 10.1016/j.japh.2019.03.006).
The study, spearheaded by Sarah T. Eudaley, Alexandra E. Mihm, Rebecca R. Higdon, Julie Jeter, and Shaunta M. Chamberlin, demonstrates the effectiveness of a CDS tool specifically designed for managing uncomplicated UTIs in an outpatient setting. The outcomes indicate a notable shift towards better alignment with prescribing guidelines, especially reflected in the reduced use of fluoroquinolones, following the tool’s implementation.
The Clinical Decision Support Tool: Development and Impact
The interdisciplinary team, including physicians, pharmacists, a quality coordinator, and a coding and billing specialist, developed the CDS tool to be integrated into the clinic’s electronic health record system. Its purpose was to guide diagnosis, documentation, and antibiotic prescribing for uncomplicated UTIs, based on local resistance patterns and national guidelines.
Before the CDS tool’s introduction, fluoroquinolones were prescribed in 42% of relevant cases, a concern given the risk factors associated with their use, such as Clostridioides difficile infection and increasing drug resistance. Post-implementation, fluoroquinolone prescriptions plummeted to 15%. Moreover, when the CDS tool was applied, no empiric fluoroquinolone therapy was reported, highlighting the tool’s effectiveness in influencing prescribing behavior.
The study also observed a decrease in the use of trimethoprim/sulfamethoxazole by 20% and an increase in nitrofurantoin prescriptions for cystitis by 31%. Furthermore, adherence to guideline-directed therapy duration improved by 32%, ensuring that patients received the appropriate length of treatment for their UTIs.
These outcomes spotlight the potential of CDS tools in aiding clinicians to make evidence-based decisions, combat the threat of antimicrobial resistance, and enhance patient outcomes.
The Importance of Outpatient Antimicrobial Stewardship
Outpatient antimicrobial stewardship is a cornerstone in the collective effort to curb antibiotic overuse and resistance. The family medicine resident clinic used in the pilot study serves as a microcosm for the broader healthcare community, illustrating how targeted interventions can yield substantial benefits.
With only a 29% usage rate, the CDS tool’s impact was nevertheless significant. This suggests that even modest adoption of such technology in family medicine and other ambulatory care settings can lead to considerable improvements in antimicrobial prescribing practices.
Challenges and Opportunities
While the results were impressive, the 29% utilization rate of the tool signals an area for improvement. The reasons behind this relatively low uptake could include lack of awareness, resistance to change, or the perceived burden of integrating new tools into clinical workflows. Addressing these barriers is essential for the wider adoption and success of CDS tools in the healthcare setting.
Opportunities to enhance the tool’s adoption could involve ongoing education and training, integrating the tool more seamlessly into the workflow, and demonstrating the measurable benefits of its use to both providers and patients.
Future Directions and Recommendations
The study’s success invites replication and scale-up to other clinics and healthcare systems. A phased approach beginning with education, followed by the integration and tracking of the CDS tool’s adoption and results, could pave the way for improved antibiotic stewardship beyond the pilot clinic.
Further research is needed to assess the long-term impacts of CDS tools on antibiotic resistance patterns and patient health outcomes. Moreover, studying the economic implications can provide additional insights into the cost-effectiveness of such interventions.
Keywords
1. Clinical decision support tool UTI
2. Outpatient antimicrobial stewardship
3. Reduction in fluoroquinolone use
4. Optimizing antibiotic prescribing
5. UTI treatment guidelines
References
1. Eudaley, S. T., Mihm, A. E., Higdon, R. R., Jeter, J., & Chamberlin, S. M. (2019). Development and implementation of a clinical decision support tool for treatment of uncomplicated urinary tract infections in a family medicine resident clinic. Journal of the American Pharmacists Association: JAPhA, 59(4), 579-585. doi:10.1016/j.japh.2019.03.006
2. Centers for Disease Control and Prevention. (2020). Antibiotic resistance threats in the United States.
3. American Urological Association. (2019). Diagnosis and Treatment of Uncomplicated Urinary Tract Infection.
4. Chatterjee, A., Modarai, M., Naylor, N. R., Boyd, S. E., Atun, R., Barlow, J., … Holmes, A. H. (2018). Quantifying drivers of antibiotic resistance in humans: a systematic review. The Lancet Infectious Diseases, 18(12), e368-e378.
5. Gonzales, R., Anderer, T., McCulloch, C. E., Maselli, J. H., Bloom, F. J., Graf, T. R., … Metlay, J. P. (2013). A cluster randomized trial of decision support strategies for reducing antibiotic use in acute bronchitis. JAMA Internal Medicine, 173(4), 267-273.
The integration of CDS tools like the one developed for uncomplicated UTIs offers a hopeful path forward in managing antimicrobial use responsibly. The promising results from this pilot study undeniably support larger-scale adoption and pave the way for future innovations in outpatient care settings. Combating antimicrobial resistance is indeed a multi-faceted challenge, but with targeted strategies and robust clinical tools, significant progress can be made toward safeguarding the efficacy of these vital medications for generations to come.