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Acad Emerg Med. 2019 Jul;26(7):719-731. doi: 10.1111/acem.13690. Epub 2019 Jun 19.

A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings.

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Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA.
Los Angeles Biomedical Research Institute, Torrance, CA.
Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA.
Department of Pediatrics, Section of Emergency Medicine, Children's Hospital of Colorado, Aurora, CO.
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
Department of Emergency Medicine, University of California-Davis, Sacramento, CA.
Department of Psychiatry and Behavioral Sciences, University of California-Davis, Sacramento, CA.



Antibiotics are commonly prescribed during emergency department (ED) and urgent care center (UCC) visits for viral acute respiratory infection (ARI). We evaluate the comparative effectiveness of an antibiotic stewardship intervention adapted for acute care ambulatory settings (adapted intervention) to a stewardship intervention that additionally incorporates behavioral nudges (enhanced intervention) in reducing inappropriate prescriptions.


This study was a pragmatic, cluster-randomized clinical trial conducted in three academic health systems comprising five adult and pediatric EDs and four UCCs. Randomization of the nine sites was stratified by health system; all providers at each site received either the adapted or the enhanced intervention. The main outcome was the proportion of antibiotic-inappropriate ARI diagnosis visits that received an outpatient antibiotic prescription by individual providers. We estimated a hierarchical mixed-effects logistic regression model comparing visits during the influenza season for 2016 to 2017 (baseline) and 2017 to 2018 (intervention).


There were 44,820 ARI visits among 292 providers across all nine cluster sites. Antibiotic prescribing for ARI visits dropped from 6.2% (95% confidence interval [CI] = 4.5% to 7.9%) to 2.4% (95% CI = 1.3% to 3.4%) during the study period. We found a significant reduction in inappropriate prescribing after adjusting for health-system and provider-level effects from 2.2% (95% CI = 1.0% to 3.4%) to 1.5% (95% CI = 0.7% to 2.3%) with an odds ratio of 0.67 (95% CI = 0.54 to 0.82). Difference-in-differences between the two interventions was not significantly different.


Implementation of antibiotic stewardship for ARI is feasible and effective in the ED and UCC settings. More intensive behavioral nudging methods were not more effective in high-performance settings.


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