Background: Judicious prescribing of antibiotics is necessary in addressing the crisis of emerging antibiotic resistance and reducing adverse events. Nearly half of antibiotic prescriptions in the outpatient setting are inappropriate, most for viral upper respiratory infections (URIs). Data outlining the misuse of antibiotics in the outpatient setting provide compelling evidence of the need for more rational use of antimicrobial agents beyond hospital settings. Objectives: We evaluated the effect of a behaviorally enhanced quality improvement (QI) intervention to reduce inappropriate antibiotic prescribing for viral URI in the ambulatory care clinics of a large quaternary care healthcare system serving an urban-rural population. Methods: The outpatient antibiotic stewardship program was implemented in January 2018 at 5 pilot sites. Interventions included identification of a site champion, educational sessions, sharing of clinic and individual provider data, and patient and provider educational materials. In addition, preclinic huddles and resident education sessions for internal medicine resident physicians were conducted with a display of public commitment to prescribe antibiotics appropriately. Site champions collaborated with onsite staff to ensure interventions were consistent with local workflows, policies, and standards. The primary outcome was defined as the provider-level antibiotic prescribing rate for acute URI, defined as patient visits with antibiotic-nonresponsive diagnoses without concomitant diagnostic codes to support antibiotic prescribing (see the public MITIGATE tool kit for a complete list). Results: In total, 116,122 antibiotic prescriptions were dispensed from April 2017 through December 2018 compared to the period from April 2017 to December 2017 during which 9,129 fewer prescriptions were ordered. Inappropriate antibiotic prescribing for viral URI for ambulatory clinic encounters (n ≥ 45,000 visits per month) declined from 14.3% to 7.6%. Academic hospital-based sites showed little seasonality trends and no statistically significant decrease in prescription rates (P = .5176). On the other hand, community-based sites showed strong seasonal fluctuations and a statistically significant decrease in prescription rates after intervention (P = .000189). Conclusions: A multifaceted behaviorally enhanced QI intervention to reduce inappropriate prescribing for URI in ambulatory care encounters at a large integrated health system was successful in reducing both inappropriate prescriptions for presumed viral URI as well as total antibiotic use. Findings suggest that implementing leadership roles, education sessions, and low resource behavioral nudging (peer comparison and public commitment) together can decrease excessive use of antibiotics by physicians. A Hawthorne effect may be an important component of these interventions. Future studies are needed in order to determine the optimal combination of behavioral interventions that are cost-effective in outpatient settings.

Funding: None

Disclosures: Larissa May reports receiving speaking honoraria from Cepheid, research grants from Roche, and consultancy fees from BioRad and Nabriva. She serves on the advisory board for Qvella.