Effectiveness of clinical pathway for upper respiratory tract infections in emergency department

Open AccessPublished:April 30, 2019DOI:https://doi.org/10.1016/j.ijid.2019.04.022

      Highlights

      • Using clinical pathway (CP) for URTI decreased inappropriate antibiotic use.
      • In parallel, using CP increased antiviral use.
      • CP can increase physician awareness of appropriate antibiotic use.

      Abstract

      Objective

      We aimed to demonstrate the benefits of implementing a clinical pathway to decrease the inappropriate use of antibiotics in upper respiratory tract infections (URTI) in an emergency department (ED).

      Methods

      The study was performed in a hospital with 300 beds. All patients who applied with URTI from 1st to 30th of April 2017 were included and the appropriateness of the antibiotics were compared with the patients in the same period in 2016. A checklist for the clinical pathway of URTI was completed by the ED physicians.

      Results

      351 patients were included, 176 these patients were in pre-ASP period and 175 patients were in post-ASP period. The rate of prescriptions including antibiotics was 49% in pre-ASP period and has decreased to 29% in post-ASP period (p < 0.001). Adherence to clinical pathway has increased from 50% to 80% (p < 0.001). In the post-ASP period, clinical pathway was used in 133 out of 175 patients (76%) and the consequently rate of appropriate antibiotic use was 82%.

      Conclusion

      The implementation of clinical pathway for URTI has decreased inappropriate antibiotic use in ED. As the secondary effect, using clinical pathway in ED also has increased the awareness of ED physicians who did not adhere to clinical pathway.

      Keywords

      Introduction

      The Organization for Economic Co-operation and Development (
      Stemming the Superbug Tide: Just A Few Dollars More.
      ) Health Policy Studies reported that Turkey is one of the countries with the highest rates of antimicrobial resistance (2018), therefore control of antibiotic consumption is an urgent need (
      • Isler B.
      • Keske S.
      • Aksoy M.
      • Azap O.K.
      • Yilmaz M.
      • Simsek Yavuz S.
      • et al.
      Antibiotic overconsumption and resistance in Turkey.
      ). Upper respiratory tract infection (URTI) is one of the leading causes of outpatient admission and antibiotic prescription (
      • Shapiro D.J.
      • Hicks L.A.
      • Pavia A.T.
      • Hersh A.L.
      Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09.
      ,
      • Sharma P.
      • Finley R.
      • Weese S.
      • Glass-Kaastra S.
      • McIsaac W.
      Antibiotic prescriptions for outpatient acute rhinosinusitis in Canada, 2007-2013.
      ,
      • Steinman M.A.
      • Gonzales R.
      • Linder J.A.
      • Landefeld C.S.
      Changing use of antibiotics in community-based outpatient practice, 1991-1999.
      ). High rates of antibiotic consumption in URTI increase the risk of adverse events, healthcare costs, and antimicrobial resistance (
      • Grijalva C.G.
      • Nuorti J.P.
      • Griffin M.R.
      Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings.
      ,
      • Jenkins T.C.
      • Irwin A.
      • Coombs L.
      • Dealleaume L.
      • Ross S.E.
      • Rozwadowski J.
      • et al.
      Effects of clinical pathways for common outpatient infections on antibiotic prescribing.
      ). Around half of the antibiotic prescriptions in the emergency department (ED) are either unnecessary or inappropriate (
      • Jenkins T.C.
      • Irwin A.
      • Coombs L.
      • Dealleaume L.
      • Ross S.E.
      • Rozwadowski J.
      • et al.
      Effects of clinical pathways for common outpatient infections on antibiotic prescribing.
      ).
      Unnecessary antibiotic consumption in viral infections and antimicrobial resistance has prompted the implementation of antimicrobial stewardship programs (ASP). The ASPs including implementation of national guidelines (
      • Ouldali N.
      • Bellettre X.
      • Milcent K.
      • Guedj R.
      • de Pontual L.
      • Cojocaru B.
      • et al.
      Impact of implementing national guidelines on antibiotic prescriptions for acute respiratory tract infections in pediatric emergency departments: an interrupted time series analysis.
      ) and pharmacist intervention (
      • Davis L.C.
      • Covey R.B.
      • Weston J.S.
      • Hu B.B.
      • Laine G.A.
      Pharmacist-driven antimicrobial optimization in the emergency department.
      ,
      • Santiago R.D.
      • Bazan J.A.
      • Brown N.V.
      • Adkins E.J.
      • Shirk M.B.
      Evaluation of pharmacist impact on culture review process for patients discharged from the emergency department.
      ,
      • Zhang X.
      • Rowan N.
      • Pflugeisen B.M.
      • Alajbegovic S.
      Urine culture guided antibiotic interventions: a pharmacist driven antimicrobial stewardship effort in the ED.
      ) have been shown to decrease inappropriate antibiotic prescription in the ED. However, more clinical data are needed (
      • Barlam T.F.
      • Cosgrove S.E.
      • Abbo L.M.
      • MacDougall C.
      • Schuetz A.N.
      • Septimus E.J.
      • et al.
      Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.
      ). The Guideline for “Implementing an antibiotic stewardship” by the Infectious Diseases Society of America (IDSA) has suggested facility-specific clinical pathways to optimize prescribing practices for areas of high antibiotic consumption. In this study we have demonstrated the benefit of implementing a clinical pathway by decreasing inappropriate antibiotic prescription among the patients with diagnosis of URTI in an emergency department.

      Methods

       Study design and population

      The study was performed in a private foundation hospital in Istanbul with 300 beds. We prepared an URTI clinical pathway (CP) which is one sheet, two pages and implemented it in March 2017 to optimize antibiotic use in ED (Figure 1A and B). In our study design we used the checklist of “Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0).
      Figure 1
      Figure 1(A) Upper respiratory tract infection clinical pathway in adult patients, page 1. (B) Upper respiratory tract infection clinical pathway in adult patients, page 2.
      Figure 1
      Figure 1(A) Upper respiratory tract infection clinical pathway in adult patients, page 1. (B) Upper respiratory tract infection clinical pathway in adult patients, page 2.
      The charts of the patients who applied to the ED with diagnosis of URTI from 1 st to 30th of April 2017 were evaluated for adherence to CP, prospectively. The findings were compared with the data obtained during the same term in 2016. Assessment of the appropriateness of antibiotic prescriptions was evaluated with the same infection control team and we have utilized the same CP during evaluation phase in two parts. The patients who were hospitalized because of various other comorbidities were excluded.

       Definition of clinical pathway

      The URTI clinical pathway was created based on a modified CENTOR score that was developed for acute tonsillitis/pharyngitis (
      • Choby B.A.
      Diagnosis and treatment of streptococcal pharyngitis.
      ) and deduced from the recommendation of Centers for Disease Control and Prevention (CDC) and Infectious Diseases Society of America (IDSA). Clinical pathway was applied for acute tonsillitis / pharyngitis, acute rhinosinusitis, common cold, non-specific URTI and bronchitis (
      • Chow A.W.
      • Benninger M.S.
      • Brook I.
      • Brozek J.L.
      • Goldstein E.J.
      • Hicks L.A.
      • et al.
      IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults.
      ,
      • Shulman S.T.
      • Bisno A.L.
      • Clegg H.W.
      • Gerber M.A.
      • Kaplan E.L.
      • Lee G.
      • et al.
      Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.
      ) (Figure 1A and B).
      According to the clinical pathway; patients with CENTOR score results of ≤0 were to be discharged without antibiotic order and further laboratory tests. If the CENTOR score was equal to one, the patients could be discharged without antibiotic therapy and laboratory tests, but if needed, further laboratory tests such as throat culture, respiratory virus panel test or Group A streptococcal rapid antigen test was requested. For patients with CENTOR score of two or three, further laboratory tests were to be done. If the results were negative, patients should be monitored without antibiotic therapy. If the results were positive, the physicians should prescribe an appropriate antibiotic that was listed in the CP. The patients with CENTOR score of four were prescribed an appropriate antibiotic from the CP list.

       Implementation and evaluation of ASP

      • 1.
        ED physicians were informed about the CP. The patients who were older than 15 years old with suspected diagnoses of URTI were included.
      • 2.
        In suspected cases of URTI, the checklist for URTI was inserted to the patient folders by the ED physicians.
      • 3.
        The ED physician should complete the checklist according to the subcategory (for acute tonsillitis / pharyngitis, acute rhinosinusitis, common cold, non-specific URTI and bronchitis) of the CP. Prescribed antibiotics which were not compliant with the CP should be justified and noted on the inserted checklist attached to the patient’s folder.
      • 4.
        Assigned ED nurse prepares the list of patients with URTI and shares it with the infection control (IC) nurse on a daily basis.
      • 5.
        Assigned IC nurse reviews the charts of all patients and checks whether the charts have complied with the CP or not.
      • 6.
        Assigned IC nurse and assigned ID physician review the charts and the prescriptions adherence to the CP.

       Statistical analysis

      Mean comparisons for continuous variables were done using independent group t tests. Proportion comparisons for categorical variables were done using Chi-Square tests, although the Fisher’s Exact Test was used, when data were sparse. Significance was set as p < 0.05 using two-sided comparisons. STATA SE/15.0 software package was used in the analysis.

      Results

      We included 351 patients; 176 patients in pre-ASP period and 175 patients in post-ASP period from ED were included. The mean age was 38 (16–90) years and 51% were female. Two groups were similar in terms of age, gender and chronic diseases (Table 1).
      Table 1Characteristics of the patients.
      Total

      n = 351 (%)
      Pre-ASP

      n = 176 (%)
      Post-ASP

      n = 175(%)
      p
      Mean age (sd; min-max)38 (14;16–90)37 (13;16–90)39 (15;16–89)0.132
      Female gender179 (51)101 (57)78 (45)0.15
      Diagnosis
      Upper respiratory infection278 (79)146 (83)132 (75)0.082
      Tonsillitis34 (10)14 (8)20 (11)0.271
      Bronchitis22 (6)7 (4)15 (9)0.076
      Pharyngitis12 (3)7 (4)5 (3)0.564
      Rhinosinusitis5 (1)2 (1)3 (2)0.648
      Comorbidities
       Diabetes mellitus8 (2)3(2)5(3)0.469
       Chronic heart disease11(3)6(3)5(3)0.767
       Other disease19(5)12(7)7(4)0.243
      The rate of prescriptions including antibiotic was 49% in the pre-ASP period. It was decreased to 29% in post-ASP period (p < 0.001). The rate of prescriptions including antiviral drugs was 18% in the pre-ASP period. This was increased to 26% in the post-ASP period (p = 0.04). Adherence to clinical pathway was found at 50% in the pre-ASP period. This was increased to 80% in the post-ASP period (p < 0.001, Table 2). In total, the most commonly prescribed antibiotics were amoxicillin and clavulanic acid (36.8%), cefuroxime (29%) and azithromycin (13%) were similar both in the pre-ASP and in the post-ASP periods. Additional to these outcomes, readmission rate in one week was not significant in both phases (pre-ASP; 14/176 and post-ASP; 11/175, p = 0.543) and no mortality was detected within 30 days in both phases.
      Table 2Number of prescriptions.
      Total n = 351 (%)Pre-ASP

      n = 176(%)
      Post-ASP

      n = 175(%)
      p
      The number of the prescriptions including antibiotics137 (39)85 (49)52 (29)<0.001
      The number of the prescriptions including antivirals78 (22)31 (18)47 (26)0.04
      Adherence to clinical pathway226 (64)87 (50)139 (80)<0.001
      In the post-ASP period, the CP was applied to 133 out of 175 patients (76%), which resulted in 82% of appropriate antibiotic usage. However, among 42 out of 175 patients (24%) the CP was not applied by ED physicians and in this case the rate of appropriate antibiotic use was 73% (Figure 2).
      Figure 2
      Figure 2The evaluated patients with URTI in pre-ASP and post-ASP period.
      We also analyzed rapid antigen test in both terms, and the rate of using Group A Streptococcal rapid antigen test increased from 2% to 26% (p < 0.001) in the post-ASP period. However, the increase in the rate of using rapid influenza diagnostic test with PCR was not significantly different (in pre-ASP; 16%, in post-ASP; 19%). The use of molecular respiratory panel test was limited (Table 3).
      Table 3Laboratory Tests.
      Total

      n = 351 (%)
      Pre-ASP

      n = 176 (%)
      Post-ASP

      n = 175 (%)
      p
      Group A Streptococcal rapid antigen test48 (14)3 (2)45 (26)<0.001
      Rapid Influenza A-B Test62 (18)29 (16)33 (19)0.559
      Rapid Respiratory Tract Virus Test3 (1)1 (1)2 (1)0.559

      Discussion

      Antibiotic consumption is high among the patients with respiratory tract infections in ED (
      • Donnelly J.P.
      • Baddley J.W.
      • Wang H.E.
      Antibiotic utilization for acute respiratory tract infections in U.S. emergency departments.
      ,
      • McKay R.
      • Mah A.
      • Law M.R.
      • McGrail K.
      • Patrick D.M.
      Systematic review of factors associated with antibiotic prescribing for respiratory tract infections.
      ,
      • Timbrook T.T.
      • Caffrey A.R.
      • Ovalle A.
      • Beganovic M.
      • Curioso W.
      • Gaitanis M.
      • et al.
      Assessments of opportunities to improve antibiotic prescribing in an emergency department: a period prevalence survey.
      ). Turkey was reported as having the highest rate of antibiotics in OECD countries and it was also shown that the highest number of antibiotics were prescribed in primary health care facilities (
      • Isler B.
      • Keske S.
      • Aksoy M.
      • Azap O.K.
      • Yilmaz M.
      • Simsek Yavuz S.
      • et al.
      Antibiotic overconsumption and resistance in Turkey.
      ). Inappropriate antibiotic use in URTI has forced us to administer a clinical pathway in ED to decrease antibiotic prescription. In this study, we demonstrated the significant beneficial effect of a clinical pathway for decreasing inappropriate antibiotic use among patients with URTI in ED. Prescriptions including at least one antibiotic were decreased, while antiviral use was increased and adherence to clinical pathway was increased in the post-ASP period when compared with pre-ASP period (Table 2).
      The clinical pathway specific for the patients with febrile neutropenia was shown to decrease inappropriate antimicrobial use (
      • Madran B.
      • Keske S.
      • Tokca G.
      • Donmez E.
      • Ferhanoglu B.
      • Cetiner M.
      • et al.
      Implementation of an antimicrobial stewardship program for patients with febrile neutropenia.
      ). In a recent study conducted in a tertiary university hospital in France, several ASPs including local treatment guidelines were implemented in ED and unnecessary antimicrobial prescriptions were decreased after implementation of these ASPs (
      • Dinh A.
      • Duran C.
      • Davido B.
      • Bouchand F.
      • Deconinck L.
      • Matt M.
      • et al.
      Impact of an antimicrobial stewardship programme to optimize antimicrobial use for outpatients at an emergency department.
      ).
      We observed that the rate of appropriate antibiotic use was increased in the second phase, despite the fact that CP was not applied among the patients (Figure 2). This observation could be related to the influence of the clinical pathway to all the physicians, despite lack of their full adherence to the CP.
      Rapid microbiological diagnostic tests including Group A Streprococcal rapid antigen test in ED are practical to discriminate bacterial and viral URTI. In our study, Group A Streprococcal rapid antigen test was a component of our clinical pathway and its increased usage may have contributed to decreasing antibiotic consumption. The rapid influenza diagnostic test was not used frequently. This could be due to its lower sensitivity. Molecular based tests were shown to decrease inappropriate antibiotic use in patients with respiratory tract infection in recent studies (
      • Branche A.R.
      • Walsh E.E.
      • Vargas R.
      • Hulbert B.
      • Formica M.A.
      • Baran A.
      • et al.
      serum procalcitonin measurement and viral testing to guide antibiotic use for respiratory infections in hospitalized adults: a randomized controlled trial.
      ,
      • Keske S.
      • Ergonul O.
      • Tutucu F.
      • Karaaslan D.
      • Palaoglu E.
      • Can F.
      The rapid diagnosis of viral respiratory tract infections and its impact on antimicrobial stewardship programs.
      ). In a study conducted in our center, the impact of molecular rapid diagnostic test on ASP was assessed in cases of URTI. It was shown that the rapid molecular test decreased inappropriate antibiotic use in viral URTIs (
      • Keske S.
      • Ergonul O.
      • Tutucu F.
      • Karaaslan D.
      • Palaoglu E.
      • Can F.
      The rapid diagnosis of viral respiratory tract infections and its impact on antimicrobial stewardship programs.
      ). However, implementing this test in ED may not be practical and cost effective.
      The control group in our study was retrieved retrospectively; this could be one of the limitations of our study, but a prospective design would not be possible while we were improving the system. In our algorithm, we suggested amoxicillin-clavulanic, although amoxicillin was suggested in the IDSA guideline. This was because of considering the acceptance rate of physicians. But, in the future, amoxicillin-clavulanic acid could be replaced by amoxicillin. Our study has shown the beneficial effects of implementing a clinical pathway for URTI in decreasing antibiotic consumption; however, long term follow-up is necessary.
      In conclusion, the implementation of a clinical pathway for URTI has significantly decreased inappropriate antibiotic use in ED. The implementation of the ASP in ED has increased the awareness of ED physicians who did not use the clinical pathway.

      Acknowledgement

      Institutional review board of Koc University approved the study with the number of 2018.084.IRB1.013.
      We thank the Hospital Administration and Quality Improvement Department of American Hospital for their support.
      There is no conflict of interest for any authors.

      References

        • Barlam T.F.
        • Cosgrove S.E.
        • Abbo L.M.
        • MacDougall C.
        • Schuetz A.N.
        • Septimus E.J.
        • et al.
        Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.
        Clin Infect Dis. 2016; 62: e51-77
        • Branche A.R.
        • Walsh E.E.
        • Vargas R.
        • Hulbert B.
        • Formica M.A.
        • Baran A.
        • et al.
        serum procalcitonin measurement and viral testing to guide antibiotic use for respiratory infections in hospitalized adults: a randomized controlled trial.
        J Infect Dis. 2015; 212: 1692-1700
        • Choby B.A.
        Diagnosis and treatment of streptococcal pharyngitis.
        Am Fam Physician. 2009; 79: 383-390
        • Chow A.W.
        • Benninger M.S.
        • Brook I.
        • Brozek J.L.
        • Goldstein E.J.
        • Hicks L.A.
        • et al.
        IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults.
        Clin Infect Dis. 2012; 54: e72-e112
        • Davis L.C.
        • Covey R.B.
        • Weston J.S.
        • Hu B.B.
        • Laine G.A.
        Pharmacist-driven antimicrobial optimization in the emergency department.
        Am J Health Syst Pharm. 2016; 73: S49-56
        • Dinh A.
        • Duran C.
        • Davido B.
        • Bouchand F.
        • Deconinck L.
        • Matt M.
        • et al.
        Impact of an antimicrobial stewardship programme to optimize antimicrobial use for outpatients at an emergency department.
        J Hosp Infect. 2017; 97: 288-293
        • Donnelly J.P.
        • Baddley J.W.
        • Wang H.E.
        Antibiotic utilization for acute respiratory tract infections in U.S. emergency departments.
        Antimicrob Agents Chemother. 2014; 58: 1451-1457
        • Grijalva C.G.
        • Nuorti J.P.
        • Griffin M.R.
        Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings.
        JAMA. 2009; 302: 758-766
        • Isler B.
        • Keske S.
        • Aksoy M.
        • Azap O.K.
        • Yilmaz M.
        • Simsek Yavuz S.
        • et al.
        Antibiotic overconsumption and resistance in Turkey.
        Clin Microbiol Infect. 2019;
        • Jenkins T.C.
        • Irwin A.
        • Coombs L.
        • Dealleaume L.
        • Ross S.E.
        • Rozwadowski J.
        • et al.
        Effects of clinical pathways for common outpatient infections on antibiotic prescribing.
        Am J Med. 2013; 126 (e12): 327-335
        • Keske S.
        • Ergonul O.
        • Tutucu F.
        • Karaaslan D.
        • Palaoglu E.
        • Can F.
        The rapid diagnosis of viral respiratory tract infections and its impact on antimicrobial stewardship programs.
        Eur J Clin Microbiol Infect Dis. 2018; 37: 779-783
        • Madran B.
        • Keske S.
        • Tokca G.
        • Donmez E.
        • Ferhanoglu B.
        • Cetiner M.
        • et al.
        Implementation of an antimicrobial stewardship program for patients with febrile neutropenia.
        Am J Infect Control. 2018; 46: 420-424
        • McKay R.
        • Mah A.
        • Law M.R.
        • McGrail K.
        • Patrick D.M.
        Systematic review of factors associated with antibiotic prescribing for respiratory tract infections.
        Antimicrob Agents Chemother. 2016; 60: 4106-4118
        • Ouldali N.
        • Bellettre X.
        • Milcent K.
        • Guedj R.
        • de Pontual L.
        • Cojocaru B.
        • et al.
        Impact of implementing national guidelines on antibiotic prescriptions for acute respiratory tract infections in pediatric emergency departments: an interrupted time series analysis.
        Clin Infect Dis. 2017; 65: 1469-1476
        • Santiago R.D.
        • Bazan J.A.
        • Brown N.V.
        • Adkins E.J.
        • Shirk M.B.
        Evaluation of pharmacist impact on culture review process for patients discharged from the emergency department.
        Hosp Pharm. 2016; 51: 738-743
        • Shapiro D.J.
        • Hicks L.A.
        • Pavia A.T.
        • Hersh A.L.
        Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09.
        J Antimicrob Chemother. 2014; 69: 234-240
        • Sharma P.
        • Finley R.
        • Weese S.
        • Glass-Kaastra S.
        • McIsaac W.
        Antibiotic prescriptions for outpatient acute rhinosinusitis in Canada, 2007-2013.
        PLoS One. 2017; 12e0181957
        • Shulman S.T.
        • Bisno A.L.
        • Clegg H.W.
        • Gerber M.A.
        • Kaplan E.L.
        • Lee G.
        • et al.
        Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.
        Clin Infect Dis. 2012; 55: 1279-1282
        • Steinman M.A.
        • Gonzales R.
        • Linder J.A.
        • Landefeld C.S.
        Changing use of antibiotics in community-based outpatient practice, 1991-1999.
        Ann Intern Med. 2003; 138: 525-533
      1. Stemming the Superbug Tide: Just A Few Dollars More.
        OECD, 2018
        • Timbrook T.T.
        • Caffrey A.R.
        • Ovalle A.
        • Beganovic M.
        • Curioso W.
        • Gaitanis M.
        • et al.
        Assessments of opportunities to improve antibiotic prescribing in an emergency department: a period prevalence survey.
        Infect Dis Ther. 2017; 6: 497-505
        • Zhang X.
        • Rowan N.
        • Pflugeisen B.M.
        • Alajbegovic S.
        Urine culture guided antibiotic interventions: a pharmacist driven antimicrobial stewardship effort in the ED.
        Am J Emerg Med. 2017; 35: 594-598