(Re)Moving the needle: a retrospective, quasi-experimental assessment of the impact of a treatment guideline on oral antibiotic prescribing for orthopedic infections

TL;DR

A treatment guideline increased the use of oral antibiotics for bone and joint infections at a US medical center, showing a significant shift in prescribing practices.

Contribution

This study demonstrates that implementing a treatment guideline can effectively change prescribing behavior in favor of oral antibiotics for orthopedic infections.

Findings

Oral antibiotic prescribing increased from 33% to 59% after guideline implementation.

The post-intervention phase was independently associated with a higher likelihood of oral antibiotic use.

Certain patient characteristics and infection types were linked to oral antibiotic prescribing.

Abstract

Despite many reports of similar effectiveness between oral and intravenous antibiotics for bone and joint infections, prescribing practice has been slow to change in the United States. We sought to determine if implementing an intravenous-to-oral treatment guideline could increase prescribing of oral antibiotic regimens at our center.

Retrospective, quasi-experimental study.

Single US academic medical center.

Patients with bone or joint infections managed by Infectious Disease providers from September 2020 to December 2022.

An intravenous-to-oral treatment guideline for patients with bone and joint infections.

The prescribing rates of fully oral antibiotic regimens before and after implementation of the guideline were compared. Additionally, variables independently associated with oral antibiotic prescribing were identified by logistic regression.

There were 450 patients included: 213 before and 237 after implementation of the guideline. Oral antibiotic prescribing significantly increased following implementation of the treatment guideline to 59% from 33% of patients (difference 25.8%, 95% CI [16.7%, 34.4%]. In multivariable analysis, the post-intervention phase was associated with a significantly greater likelihood of oral antibiotic prescribing (aOR 2.89 [1.90, 4.45]). Other variables independently associated with oral antibiotic prescribing included male sex (aOR 1.88 [1.20, 2.98]), prosthetic joint infection (aOR 0.29 [0.17, 0.47]), and infection with Enterobacterales (aOR 2.86 [1.45, 5.92]), methicillin-sensitive Staphylococcus aureus [aOR 0.41 [0.26, 0.65]), or coagulase-negative staphylococci (aOR 0.34 [0.18, 0.62]).

Implementation of a treatment guideline resulted in a significant increase in oral antibiotic prescribing. Antimicrobial stewardship programs should implement similar interventions to improve outpatient antibiotic utilization.

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