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Objective: To determine the proportion of hospitals that implemented 6 leading practices in their antimicrobial stewardship programs (ASPs). Design: Cross-sectional observational survey. Setting: Acute-care hospitals. Participants: ASP leaders. Methods: Advance letters and electronic questionnaires were initiated February 2020. Primary outcomes were percentage of hospitals that (1) implemented facility-specific treatment guidelines (FSTG); (2) performed interactive prospective audit and feedback (PAF) either face-to-face or by telephone; (3) optimized diagnostic testing; (4) measured antibiotic utilization; (5) measured C. difficile infection (CDI); and (6) measured adherence to FSTGs. Results: Of 948 hospitals invited, 288 (30.4%) completed the questionnaire. Among them, 82 (28.5%) had Conclusions: Significant variation exists in the adoption of ASP leading practices. A minority of hospitals have taken action to optimize diagnostic testing and measure adherence to FSTGs. Additional efforts are needed to expand adoption of leading practices across all acute-care hospitals with the greatest need in smaller hospitals.

Twenty of 21 health systems and network-based antimicrobial stewardship programs (ASPs) who were invited participated in a questionnaire, a webinar, and focus groups to understand implementation strategies for system-wide antimicrobial stewardship. Four centralized ASPs structures emerged. Of participating organizations, 3 (15%) confirmed classification as collaborative, 3 (15%) as centrally coordinated, 3 (15%) as in between or in transition between centrally coordinated and centrally led, 8 (40%) as centrally led, 2 (10%) as collaborative, consultative network. One (5%) organization considered themselves to be a hybrid. System-level stewardship responsibilities varied across sites and generally fell into 6 major categories: building and leading a stewardship community, strategic planning and goal setting, development of validated data streams, leveraging tools and technology for stewardship interventions, provision of subject-matter expertise, and communication/education. Centralized ASPs included in this study most commonly took a centrally led approach and engaged in activities tailored to system-wide goals.

Background The Joint Commission's hospital antimicrobial stewardship (AS) standards became effective in January 2017. Surveyors' experience to date suggests that almost all hospitals have established AS leadership commitment and organized structures. Thus, The Joint Commission sought to examine advances in AS interventions and measures that hospitals could implement to strengthen their existing AS programs. Methods The Joint Commission and Pew Charitable Trusts sponsored a meeting to bring together experts and key stakeholder organizations from around the country to identify leading practices for AS interventions and measurement. Presenters were asked to summarize the AS activities they thought were most important for the success of their own AS program and leading practices that all hospitals should be able to implement. Results The panel highlighted two interventions as leading practices that go beyond current guidelines and established practices (that is, preauthorization and prospective audit and feedback). The first is diagnostic stewardship. This type of intervention addresses errors in diagnostic decision making that lead to inappropriate antibiotic prescribing. The second is handshake stewardship, a method of engaging frontline providers on a regular basis for education and discussions about barriers to AS from the clinician's perspective. The panel identified days of therapy (or defined daily dose, when days of therapy is not possible), Clostridioides difficile rates, and adherence to facility-specific guidelines as the preferred measures for assessing stewardship activities. Conclusion The practices highlighted should be given greater emphasis by The Joint Commission in their efforts to improve hospital AS, and the Centers for Disease Control and Prevention will be updating the Core Elements of Hospital Antibiotic Stewardship Programs.

BackgroundThis study reports estimates of the healthcare costs, length of stay, and mortality associated with infections due to multidrug-resistant bacteria among elderly individuals in the United States.MethodsWe conducted a retrospective cohort analysis of patients aged ≥65 admitted for inpatient stays in the Department of Veterans Affairs healthcare system between 1/2007–12/2018. We identified those with positive cultures for multidrug-resistant bacteria and matched each infected patient to ≤10 control patients. We then performed multivariable regression models to estimate the attributable cost and mortality due to the infection. We also constructed multistate models to estimate the attributable length of stay due to the infection. Finally, we multiplied these pathogen-specific attributable cost, length of stay, and mortality estimates by national case counts from hospitalized patients in 2017.ResultsOur cohort consisted of 87 509 patients with infections and 835 048 matched controls. Costs were higher for hospital-onset invasive infections, with attributable costs ranging from $22 293 (95% confidence interval: $19 101–$24 485) for methicillin-resistant Staphylococcus aureus (MRSA) to $57 390 ($34 070–$80 710) for carbapenem-resistant (CR) Acinetobacter. Similarly, for hospital-onset invasive infections, attributable mortality estimates ranged from 14.2% (12.2–16.2%) for MRSA to 24.1% (12.1–36.0%) for CR Acinetobacter. The aggregate cost of these infections was an estimated $1.9 billion ($1.3 billion–$2.5 billion) with 11 852 (8719–14 985) deaths and 448 224 (354 513–541 934) inpatient days in 2017.ConclusionsEfforts to prevent these infections due to multidrug-resistant bacteria could save a significant number of lives and healthcare resources.

Nonguideline antibiotic prescribing for the treatment of pediatric infections is common, but the consequences of inappropriate antibiotics are not well described.To evaluate the comparative safety and health care expenditures of inappropriate vs appropriate oral antibiotic prescriptions for common outpatient pediatric infections.This cohort study included children aged 6 months to 17 years diagnosed with a bacterial infection (suppurative otitis media [OM], pharyngitis, sinusitis) or viral infection (influenza, viral upper respiratory infection [URI], bronchiolitis, bronchitis, nonsuppurative OM) as an outpatient from April 1, 2016, to September 30, 2018, in the IBM MarketScan Commercial Database. Data were analyzed from August to November 2021.Inappropriate (ie, non-guideline-recommended) vs appropriate (ie, guideline-recommended) oral antibiotic agents dispensed from an outpatient pharmacy on the date of infection.Propensity score-weighted Cox proportional hazards models were used to estimate hazards ratios (HRs) and 95% CIs for the association between inappropriate antibiotic prescriptions and adverse drug events. Two-part models were used to calculate 30-day all-cause attributable health care expenditures by infection type. National-level annual attributable expenditures were calculated by scaling attributable expenditures in the study cohort to the national employer-sponsored insurance population.The cohort included 2 804 245 eligible children (52% male; median [IQR] age, 8 [4-12] years). Overall, 31% to 36% received inappropriate antibiotics for bacterial infections and 4% to 70% for viral infections. Inappropriate antibiotics were associated with increased risk of several adverse drug events, including Clostridioides difficile infection and severe allergic reaction among children treated with a nonrecommended antibiotic agent for a bacterial infection (among patients with suppurative OM, C. difficile infection: HR, 6.23; 95% CI, 2.24-17.32; allergic reaction: HR, 4.14; 95% CI, 2.48-6.92). Thirty-day attributable health care expenditures were generally higher among children who received inappropriate antibiotics, ranging from $21 to $56 for bacterial infections and from -$96 to $97 for viral infections. National annual attributable expenditure estimates were highest for suppurative OM ($25.3 million), pharyngitis ($21.3 million), and viral URI ($19.1 million).In this cohort study of children with common infections treated in an outpatient setting, inappropriate antibiotic prescriptions were common and associated with increased risks of adverse drug events and higher attributable health care expenditures. These findings highlight the individual- and national-level consequences of inappropriate antibiotic prescribing and further support implementation of outpatient antibiotic stewardship programs.

Background Outpatient antibiotic stewardship is needed to reduce inappropriate prescribing and minimize the development of resistant bacteria. We assessed primary care physicians’ perceptions of antibiotic resistance, antibiotic use, and the need for stewardship activities. Methods We conducted a national online survey of 1550 internal, family, and pediatric medicine physicians in the United States recruited from an opt-in panel of healthcare professionals. Descriptive statistics were generated for respondent demographics and question responses. Responses were also stratified by geographic region and medical specialty, with a χ 2 test used to assess for differences. Results More respondents agreed that antibiotic resistance was a problem in the United States (94%) than in their practice (55%) and that inappropriate antibiotic prescribing was a problem in outpatient settings (91%) than in their practice (37%). In addition, 60% agreed that they prescribed antibiotics more appropriately than their peers. Most respondents (91%) believed that antibiotic stewardship was appropriate in office-based practices, but they ranked antibiotic resistance as less important than other public health issues such as obesity, diabetes, opioids, smoking, and vaccine hesitancy. Approximately half (47%) believed they would need a lot of help to implement stewardship. Respondents indicated that they were likely to implement antibiotic stewardship efforts in response to feedback or incentives provided by payers or health departments. Conclusions Primary care physicians generally did not recognize antibiotic resistance and inappropriate prescribing as issues in their practice. This poses a challenge for the success of outpatient stewardship. Healthcare stakeholders will need to explore opportunities for feedback and incentive activities to encourage stewardship uptake., US primary care physicians recognize the threat of antibiotic resistance and inappropriate antibiotic prescribing nationally but not in their own practices. Healthcare stakeholders need to explore effective strategies for incentivizing stewardship implementation in these critical healthcare settings.

The prevalence of pediatric antimicrobial stewardship programs (ASPs) is increasing. We review strategies for ASPs to adapt and report standardized metrics, expand activities to specialized populations, and implement novel diagnostics for continued progress in improving antibiotic use and patient outcomes., The prevalence of pediatric antimicrobial stewardship programs (ASPs) is increasing in acute care facilities across the United States. Over the past several years, the evidence base used to inform effective stewardship practices has expanded, and regulatory interest in stewardship programs has increased. Here, we review approaches for established, hospital-based pediatric ASPs to adapt and report standardized metrics, broaden their reach to specialized populations, expand to undertake novel stewardship initiatives, and implement rapid diagnostics to continue their evolution in improving antimicrobial use and patient outcomes.

The overuse and misuse of antibiotics affect patients in many ways, including by driving antibiotic resistance, a serious public health threat in the United States and around the world. To improve patient safety and address rising rates of resistance, an increasing number of health care facilities have created antibiotic stewardship programs (ASPs). ASPs have been successful in slowing the emergence of resistance and improving patient outcomes. However, there are serious geographic and resource barriers to ASP adoption in small community hospitals and critical access hospitals. Fortunately, many barriers can be overcome by using collaborative models to bring together key stakeholders, including large hospitals and health systems and academic medical centers; hospital associations; federal, state, and local public health organizations; and federal and state offices of rural health. These stakeholders are ideally positioned to assist with stewardship efforts in small community and critical access hospitals and, in doing so, can improve patient safety while stemming the spread of resistant bacteria.

Using the 2014 IBM MarketScan commercial database, we compared antibiotic selection for pharyngitis, sinusitis, and acute otitis media in retail clinics, emergency departments, urgent care centers, and offices. Only 50% of visits for these conditions received recommended first-line antibiotics. Improving antibiotic selection for common outpatient conditions is an important stewardship target.

Background: Most hospitals have a basic infrastructure in place for antimicrobial stewardship programs (ASPs). Although this is a critical first step, we need to ensure that ASPs are working to implement effective evidence-based approaches nationally. In 2018, a group of leading antibiotic stewardship organizations met and identified specific, effective, and recommended ASP activities based on current scientific evidence and their experience (Baker et al, Joint Comm J Qual Pat Saf 2019;45:517–523). To determine the extent to which hospitals are currently implementing the recommended practices, we conducted an electronic questionnaire–based assessment. Methods: A 50-item questionnaire-based assessment was sent via QualtricsTM to the hospital’s designated ASP leader. The sample comprised 992 Joint Commission accredited hospitals. The practices of interest related to (1) development of facility-specific treatment guidelines, (2) measuring appropriate use and concordance of care with these guidelines, (3) engaging clinicians while the patient is on the unit, (4) diagnostic stewardship, (5) measurement of antimicrobial utilization data, and (6) measuring hospital-acquired Clostridioides difficile infection (CDI) rates. Sampling weights were used to adjust the results for nonresponse using R software. Results: In total, 288 hospitals completed the questionnaire. Small and nonteaching hospitals were significantly less likely to respond (p < 0.005, p=0.01 respectively), however there were no differences by healthcare system membership or urban/rural location. 49% of respondents had the specialist term ASP or infectious disease (ID) in their title. Most hospitals (93.1%) had developed facility-specific treatment guidelines for specific inpatient conditions, often community-acquired pneumonia (85%), sepsis (81%), UTI (75%), and SSTI (69%). However, only 37% had formally assessed compliance with 1 or more of these guidelines. Also, 83% reported having a process for prospective audit and feedback, of which 43% do this 4–5 days per week. Similarly, 49% reported that they review all antimicrobials ordered. Recommendations are commonly given by the ASP pharmacist (69%) via some combination of telephone (78%), face-to-face (69%), text message (54%), and/or EHR alert (36%). Overall, 66% of hospitals had procedures in place to prevent inappropriate diagnostic testing for C. difficile, and 39% of hospitals had similar policies for urine specimens. Furthermore, >80% were routinely measuring days of therapy and CDI rates. Conclusions: Most hospitals have facility-specific treatment guidelines and measure CDI and days of therapy. Practices for active engagement with frontline staff in prospective audit and feedback vary widely. Greater understanding of barriers to assessing adherence to hospitals’ treatment guidelines is critical to improving this practice.Funding: The Pew Charitable TrustsDisclosures: None

This cohort study compares antibiotic prescribing in 2014 among retail clinics, urgent care centers, emergency departments, and traditional medical offices in the United States.

Antibiotic-resistant infections pose a growing threat to public health. Antibiotic use, regardless of whether it is warranted, is a primary factor in the development of resistance. In the United States, the majority of antibiotic health care expenditures are due to prescribing in outpatient settings. Much of this prescribing is inappropriate, with research showing that at least 30% of antibiotic use in outpatient settings is unnecessary. In this State of the Art Review article, we provide an overview of the latest research on outpatient antibiotic prescribing practices in the United States. Although many of the researchers in these studies describe antibiotic prescribing across all patient age groups, we highlight prescribing in pediatric populations when data are available. We then describe the various factors that can influence a physician’s prescribing decisions and drive inappropriate antibiotic use and the potential role of behavioral science in enhancing stewardship interventions to address these drivers. Finally, we highlight the role that a wide range of health care stakeholders can play in aiding the expansion of outpatient stewardship efforts that are needed to fully address the threat of antibiotic resistance.

Antibiotic stewardship programs (ASPs) improve antibiotic prescribing. Seventy-three percent of US hospitals have

Background At least 30% of outpatient antibiotic prescriptions are unnecessary. Outpatient antibiotic stewardship can improve prescribing and minimize the threat of antibiotic resistance. We assessed primary care physicians’ (PCPs) perceptions of antibiotic resistance, inappropriate antibiotic use, and the need for and impact of antibiotic stewardship activities. Methods We conducted a national survey of 1,550 internal and family medicine physicians and pediatricians recruited from a medical market research panel. Quotas were established to recruit participants by geographic region and specialty. For sample representativeness, survey weights were generated according to these characteristics using the American Medical Association’s Masterfile. Results Among respondents, 94% agreed that resistance is a problem in the United States, but only 55% felt it was a problem for their practice; 65% of respondents agreed they had seen an increase in resistant infections in their patients over the past 5 years. Responses about inappropriate antibiotic use were similar: 91% agreed that it was a problem, but 37% agreed that it is a problem in their practice. Additionally, 60% felt they prescribed antibiotics more appropriately than their peers. For antibiotic stewardship, 91% felt it was appropriate for office-based practices, but 53% believed that discussions with patients on the appropriate use of antibiotics is sufficient to address the problem. The majority of respondents indicated they were likely, very likely, or extremely likely to implement stewardship interventions in response to feedback or incentives from payers or health departments. The activities with the strongest likelihood to spur stewardship adoption included the state health department publishing local resistance patterns (82%), a payer creating a stand-alone incentive program for stewardship (80%), or a payer including it in a broader quality incentive program (76%). Conclusion PCPs feel that antibiotic resistance, inappropriate prescribing, and stewardship are important in the United States, but not for their own practices. This disconnect poses a challenge for the success of outpatient stewardship programs. Incentive or data feedback activities may help encourage stewardship uptake. Disclosures All authors: No reported disclosures.

Background Antibiotics are frequently prescribed in nursing homes (NH). National data describing facility-level antibiotic use (AU) in NH are lacking. The objectives of this analysis were to use NH electronic health records (EHR) to describe AU in NH and variability in AU rates across NH. Methods We analyzed antibiotic orders for 309,884 residents in 1,664 US NHs using one EHR company in 2016. We calculated AU rates as antibiotic days-of-therapy (DOT) per 1,000 resident-days and compared by the type of stay (short-stay (SS) ≤ 100 days vs. long-stay (LS) >100 days). We also examined prescribing indications and the duration of nursing home-initiated antibiotic orders. We assessed facility-level correlates of AU using resident health and NH facility characteristics publically available through NH Compare and LTCfocus using a univariate linear regression. Results In 2016, 57% of NH residents received at least one systemic antibiotic; overall rate of AU was 90 DOT/1,000 resident-days. The median facility-level AU rate was 64 DOT/1,000 resident-days (IQR 36–104). The median proportion of SS residents at a facility was 74% (IQR 60–84%). The SS and LS AU rates were 241 DOT/1,000 resident-days (IQR 173–342) and 24 DOT/1,000 resident-days (IQR 14–37), respectively. Overall, the three most common antibiotic classes prescribed were fluoroquinolones (18%), cephalosporins (18%), and extended-spectrum β-lactams (10%). Antibiotics were most frequently prescribed for urinary tract infections, and the mean duration of an antibiotic order was 9 days (range 1–365). Higher facility AU rate correlated positively with the following facility characteristics; proportion of SS residents, urban location, proportion of residents with mild cognitive impairment and lower activities of daily living scores, presence of ventilator beds, proportion of LS residents with urinary catheters or pressure ulcers, facility case-mix index, and not-for-profit ownership and multiorganization facilities. Conclusion Significant variability in NH AU rates exist, and SS residents have higher AU rates. Identifying NH with high rates of AU after adjusting for facility-level predictors of AU may identify opportunities for targeting efforts to improve prescribing practices. Disclosures All Authors: No reported Disclosures.

Background The majority of antibiotics in the United States are prescribed in outpatient settings and at least 30% of these antibiotics are unnecessary. Outpatient antibiotic stewardship is needed to minimize the threat of antibiotic resistance (AR). We assessed primary care physicians’ (PCPs) attitudes and perceptions of AR, inappropriate antibiotic use, and outpatient antibiotic stewardship activities. Methods We conducted eight focus groups with outpatient PCPs in four US cities: Philadelphia, PA; Birmingham, AL; Chicago, IL; and Los Angeles, CA. Two focus groups were conducted in each city—one with family medicine and internal medicine physicians and one with pediatricians. All focus groups were audio-recorded, transcribed, and coded for major themes in NVivo 11. Results A total of 26 family medicine/internal medicine physicians and 26 pediatricians participated. Most participants acknowledged that AR is an important public health issue but many considered it to be more of an issue in hospitals and less important in their daily practice when compared with other issues, such as obesity, diabetes, and opioids. PCPs agreed that inappropriate antibiotic use is a problem in outpatient medicine but placed responsibilities on nonprimary care settings such as urgent care and retail clinics, and on patient demand. When discussing possible stewardship activities, participants expressed concerns about measuring inappropriate antibiotic use, questioning the feasibility of assessing prescribing quality while accounting for different patient populations. Participants also argued that other physicians will “game the system” to improve scores. Their perceptions of stewardship were also influenced by their dissatisfaction with quality measurement systems in general and distrust in the accuracy of its tracking and reporting processes. In contrast, participants reacted positively to education efforts for patients and clinicians. Conclusion PCPs recognize the public health importance of AR and inappropriate antibiotic use, but are skeptical about its relative importance and the feasibility and effectiveness of stewardship activities. Addressing these perceptions and skepticism will be integral to the development of outpatient stewardship strategies. Disclosures J. Doctor, The Pew Charitable Trusts: External advisor, Honorarium for time dedicated to research project. Precision Health Economics: Consultant, Consulting fee. University of Pennsylvania Health System: Consultant, Consulting fee. J. S. Gerber, The Pew Charitable Trusts: External advisor, Honorarium for time dedicated to research project. J. A. Linder, The Pew Charitable Trusts: External advisor, Honorarium for time dedicated to research project.

Background Antibiotics are frequently prescribed inappropriately in nursing homes (NHs); however, national estimates of NH antibiotic use are limited. We aimed to describe antibiotic prescribing in US NHs to identify potential targets for antibiotic stewardship. Methods A descriptive analysis was conducted using the 2014 proprietary IQVIA long-term care (LTC) Xponent database, which captures oral and intravenous antibiotic prescription transactions from sampled LTC pharmacies representing 70–85% of the LTC market. The data are projected to 100% of the US LTC market. Denominators for rate calculations were captured from the 2014 Minimum Data Set as the number of residents with at least one resident day in an NH in 2014. Antibiotic transaction counts and rates were calculated by resident gender, age, US census region, route of administration, antibiotic class and agent, and total transaction counts were summarized by provider type. Prescribing patterns for antibiotic classes and agents stratified by resident age were also calculated. Results In 2014, there were over 14 million antibiotic transactions in LTC pharmacies, for a rate of 3,302 per 1,000 residents. Female residents accounted for 62% of antibiotic transactions at a rate of 3,305 transactions per 1,000 residents compared with 3,240 per 1,000 male residents. Antibiotic prescribing was highest in the South at 3,752 transactions per 1,000 residents (vs. 2,601 per 1,000 residents in the West). Oral antibiotics accounted for 85% of transactions. Fluoroquinolones were the most frequently prescribed antibiotic class (22%; 723 transactions per 1,000 residents) and the most common agents were levofloxacin, ciprofloxacin, and sulfamethoxazole–trimethoprim. Stratified by age, the percent change in prescribing rates among residents aged Conclusion A potential antibiotic stewardship target in NHs is fluoroquinolone prescribing. Targeting states in the South for interventions may have the largest impact. Figure. Antibiotic prescribing rates in long-term care by U.S. census regions Disclosures All authors: No reported disclosures.

Background At least 30% of antibiotic courses prescribed in physician offices’ and emergency departments (EDs) are unnecessary, but little is known about other ambulatory settings. The study aimed to assess antibiotic prescribing for acute respiratory conditions across U.S. EDs, urgent care centers (UCs), and retail health clinics (RHs). Methods We included visits to EDs, UCs and RHs based on claims from individuals < 65 years old with medical and pharmacy benefits captured in the 2014 Truven MarketScan Commercial Claims and Encounters Database, a convenience sample of employer-based health insurance. Claims for dispensed systemic antibiotics were linked to the most recent ED, UC and RH visit within 3 days for oral antibiotics and on the same day for parenteral antibiotics. Diagnoses were assigned to each visit based on a previously-described tiered system to assign the most likely indication for antibiotics. Antibiotic-inappropriate respiratory conditions (i.e., viral respiratory infections, asthma, and allergy) were identified, and the percent of visits leading to antibiotics were calculated with 95% confidence intervals (CI) by setting. Results In 2014, antibiotics were prescribed in 13.8% (95% CI 13.7–13.8) of 4,954,084 included ED visits, 38.8% (38.8–38.9) of 2,831,950 UC visits, and 36.3% (35.9–36.6) of 59,599 RH visits. Antibiotic-inappropriate respiratory conditions accounted for 5.4% of ED visits, 16.4% of UC visits, and 17.2% of RH visits. UCs had the highest percent of antibiotic prescriptions for all antibiotic-inappropriate respiratory conditions (45.3%, 95% CI 45.2–45.5), followed by EDs (24.5%, 24.3–24.6) and then RHs (14.4%, 13.8–15.1). This pattern persisted when examined by diagnosis (figure). Conclusion Antibiotic prescribing for antibiotic-inappropriate respiratory infections was common in these settings. UCs are a particularly important target for antibiotic stewardship. Figure. Percent of visits for antibiotic-inappropriate respiratory conditions leading to antibiotic prescriptions according to diagnosis by setting — United States, 2014. Disclosures All authors: No reported disclosures.

The outcome of patients who were treated with oral trimethoprim-sulfamethoxazole or oral clindamycin after hospitalization at Texas Children's Hospital for community-acquired methicillin-resistant Staphylococcus aureus skin and soft tissue infections was compared. No significant differences were observed in the percentage of patients who returned to the emergency center or clinics because of worsening or incomplete resolution of the infected site.

Antimicrobial stewardship (AS) programs are effective in improving clinical outcomes associated with antimicrobial therapies while improving patient safety by reducing adverse events and development of bacterial resistance. Understanding the basic principles of AS is essential to the successful development and implementation of AS strategies. Identifying and developing strategies to address barriers and challenges to AS can facilitate the establishment of financial, administrative, and organizational support, and agreement and participation by individual prescribers. Review of published outcomes of AS demonstrates the effectiveness in reducing unnecessary antimicrobial use and adverse events such as Clostridium difficile infections. We also illustrate the need for further research and expansion of AS activities to office-based practices and communities by using novel and innovative AS strategies and by influencing regional and national policies.

An adolescent with recently removed ureteral stents and exposure to toilet water contaminated with sink flies developed urinary myiasis after stent removal. Poor hygiene, urinary obstruction and retention and decreased general health are known risk factors for developing urinary myiasis. Good hygiene and sanitation practices should be emphasized to patients with indwelling urogenital foreign bodies such as ureteral stents.

Importance The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotic use by 50% by 2020, but the extent of inappropriate outpatient antibiotic use is unknown. Objective To estimate the rates of outpatient oral antibiotic prescribing by age and diagnosis, and the estimated portions of antibiotic use that may be inappropriate in adults and children in the United States. Design, Setting, and Participants Using the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, annual numbers and population-adjusted rates with 95% confidence intervals of ambulatory visits with oral antibiotic prescriptions by age, region, and diagnosis in the United States were estimated. Exposures Ambulatory care visits. Main Outcomes and Measures Based on national guidelines and regional variation in prescribing, diagnosis-specific prevalence and rates of total and appropriate antibiotic prescriptions were determined. These rates were combined to calculate an estimate of the appropriate annual rate of antibiotic prescriptions per 1000 population. Results Of the 184 032 sampled visits, 12.6% of visits (95% CI, 12.0%-13.3%) resulted in antibiotic prescriptions. Sinusitis was the single diagnosis associated with the most antibiotic prescriptions per 1000 population (56 antibiotic prescriptions [95% CI, 48-64]), followed by suppurative otitis media (47 antibiotic prescriptions [95% CI, 41-54]), and pharyngitis (43 antibiotic prescriptions [95% CI, 38-49]). Collectively, acute respiratory conditions per 1000 population led to 221 antibiotic prescriptions (95% CI, 198-245) annually, but only 111 antibiotic prescriptions were estimated to be appropriate for these conditions. Per 1000 population, among all conditions and ages combined in 2010-2011, an estimated 506 antibiotic prescriptions (95% CI, 458-554) were written annually, and, of these, 353 antibiotic prescriptions were estimated to be appropriate antibiotic prescriptions. Conclusions and Relevance In the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate, supporting the need for establishing a goal for outpatient antibiotic stewardship.