The emergence and rapid rise in antibiotic resistance among common bacteria are adversely affecting the clinical course and health care costs of community-acquired infections. Because antibiotic resistance patterns are strongly correlated with antibiotic use patterns, reductions in unnecessary antibiotic use are critical components of efforts to combat antibiotic resistance. Among humans, the vast majority of unnecessary antibiotic prescriptions are used to treat acute respiratory tract infections (ARIs) that have a viral etiology. Although the rate of antibiotic prescribing for ARIs by office-based physicians in the U.S. has decreased about 16% from its peak in 1997, the rate of antibiotic prescribing in acute care settings (e.g., emergency departments and urgent care centers), which account for 1 in 5 ambulatory antibiotic prescriptions in the U.S., has shown only a modest decline (6%) during this period. Translation of lessons from intervention studies in office-based practices is needed to improve antibiotic use in acute care settings. We propose to conduct a randomized controlled trial of a quality improvement program consisting of physician education (educational seminar, practice guidelines, performance feedback, and decision support tools) and patient education (waiting room print and audiovisual materials) in 8 VA hospital urgent care clinics and 8 non-VA hospital emergency departments. Non VA study sites will be identified from an existing research network of hospital emergency departments--EMNet. VA urgent care clinic sites will be selected among academically affiliated hub facilities. Preliminary studies suggest that a rapid, bedside c-reactive protein test on a fingerstick blood specimen can help classify adults at very low risk, and at high risk, for community-acquired pneumonia. In a second phase of the study, we propose to evaluate the incremental impact of a c-reactive protein-based diagnostic algorithm to improve antibiotic prescribing behavior.
Specific Aim 1 : To evaluate the impact of a multidimensional (patient, system, clinician) intervention on appropriate antibiotic use for adults with acute respiratory tract infections-- identifying factors that influence successful translation across VA and non-VA hospital acute care settings.
Specific Aim 2 : To evaluate the impact of a rapid diagnostic test for c-reactive protein on antibiotic use for adults with acute cough illness when added to a multidimensional intervention.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Project (R01)
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Health Research Disssemination and Implementation (HRDI)
Program Officer
White, Jon
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University of California San Francisco
Internal Medicine/Medicine
Schools of Medicine
San Francisco
United States
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Gonzales, Ralph; Aagaard, Eva M; Camargo Jr, Carlos A et al. (2011) C-reactive protein testing does not decrease antibiotic use for acute cough illness when compared to a clinical algorithm. J Emerg Med 41:1-7
Fee, Christopher; Metlay, Joshua P; Camargo Jr, Carlos A et al. (2010) ED antibiotic use for acute respiratory illnesses since pneumonia performance measure inception. Am J Emerg Med 28:23-31
Stearns, Cordelia R; Gonzales, Ralph; Camargo Jr, Carlos A et al. (2009) Antibiotic prescriptions are associated with increased patient satisfaction with emergency department visits for acute respiratory tract infections. Acad Emerg Med 16:934-41
Levin, Sara K; Metlay, Joshua P; Maselli, Judith H et al. (2009) Perceived social support among adults seeking care for acute respiratory tract infections in US EDs. Am J Emerg Med 27:582-7
Steinman, Michael A; Yang, Katherine Y; Byron, Sepheen C et al. (2009) Variation in outpatient antibiotic prescribing in the United States. Am J Manag Care 15:861-8