Implementing Antibiotic Stewardship in a Network of Urgent Care Centers

Abstract Background Most antibiotics are prescribed in outpatient settings, including urgent care clinics (UCCs); however, few UCCs have described implementing antibiotic stewardship. We describe our interventions to reduce total antibiotic and azithromycin use in a UCC network. Methods We conducted a prospective performance improvement project in 5 UCCs in Delaware, with >40 providers and >75,000 visits annually. In April 2017 all providers received in-person education on guideline-recommended management of common infections. The UCC lead physician performed chart audits and provided group and individual feedback. We provided individual antibiotic utilization rates beginning in Feb 2018 and ceased chart audits in May 2018. Patient education included posters in waiting and exam rooms, discharge materials, and external website revisions. We used control charts to analyze trends in prescribing over time, and calculated rate-ratios (RR) between pre/early, mid- and post-intervention periods. Results: Compared to the pre/early intervention study period (54.7 prescriptions per 100 visits), total antibiotic use declined to 40.2 (RR, 0.74, 95% CI 0.72-0.75) in the mid- and to 35.0 (RR, 0.42, 95% CI 0.40, 0.44) in the post-intervention periods. Azithromycin use declined from 8.5 prescriptions/100 visits to 3.5 (RR 0.64, 95% CI 0.63-0.65) and 1.9 (RR 0.22, 95% CI 0.21-0.24), respectively. The control charts indicated decreasing mean antibiotic prescribing rates as well as decreased variability. Conclusion A multifaceted and iterative approach significantly reduced prescribing of all antibiotics, regardless of diagnosis, including azithromycin. While initially resource-intensive, sending prescribing data directly to providers automated the process without an observed rebound in prescribing.