title: A sustainable strategy to prevent misuse of antibiotics for acute respiratory infections.
abstract: BACKGROUND
  Over 50% of antibiotics prescriptions are for outpatients with acute respiratory infections (ARI). Many of them are not needed and thus contribute both avoidable adverse events and pressures toward the development of bacterial resistance. Could a clinical decision support system (CDSS), interposed at the time of electronic prescription, adjust antibiotics utilization toward consensus treatment guidelines for ARI?
  
  
  METHODS
  This is a retrospective comparison of pre- (2002) and post-intervention (2003-2006) periods at two comprehensive health care systems (intervention and control). The intervention was a CDSS that targeted fluoroquinolone and azithromycin; other antibiotics remained unrestricted. 7000 outpatients visits flagged by an ARI case-finding algorithm were reviewed for congruence with the guidelines (antibiotic prescribed-when-warranted or not-prescribed-when-unwarranted).
  
  
  RESULTS
  3831 patients satisfied the case definitions for one or more ARI: pneumonia (537), bronchitis (2931), sinusitis (717) and non-specific ARI (145). All patients with pneumonia received antibiotics. The relative risk (RR) of congruent prescribing was 2.57 (95% CI = (1.865 to 3.540) in favor of the intervention site for the antibiotics targeted by the CDSS; congruence did not change for other antibiotics (adjusted RR = 1.18 (95% CI = (0.691 to 2.011)). The proportion of unwarranted prescriptions of the targeted antibiotics decreased from 22% to 3%, pre vs. post-intervention (p<0.0001).
  
  
  CONCLUSIONS
  A CDSS interposed at the time of e-prescription nearly extinguished unwarranted use targeted antibiotics for ARI for four years. This intervention highlights a path toward sustainable antibiotics stewardship for outpatients with ARI.
authors.affiliation: Veterans Affairs Maryland Health Care System, Baltimore, MD, USA.
authors.forename: Gail B
authors.initials: GB
authors.lastname: Rattinger
authors.forename: C Daniel
authors.initials: CD
authors.lastname: Mullins
authors.forename: Ilene H
authors.initials: IH
authors.lastname: Zuckerman
authors.forename: Eberechukwu
authors.initials: E
authors.lastname: Onukwugha
authors.forename: Loreen D
authors.initials: LD
authors.lastname: Walker
authors.forename: Adi
authors.initials: A
authors.lastname: Gundlapalli
authors.forename: Matthew
authors.initials: M
authors.lastname: Samore
authors.forename: Sylvain
authors.initials: S
authors.lastname: Delisle
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D017723:Drug Utilization Review; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012141:Respiratory Tract Infections / Q000188:drug therapy*; D012189:Retrospective Studies
chemical_list: D000900:Anti-Bacterial Agents