Outpatient Fluoroquinolone Medication Use Evaluation at an Academic Veterans Affairs Medical Center

Abstract

Background: Fluoroquinolones (FQs) are one of the most commonly prescribed antibiotic classes in the United States. In recent years, their widespread use has come under heightened scrutiny due potential adverse drug reactions including risks of mental health side effects, serious blood sugar disturbances, and Food and Drug Administration (FDA) black-box warnings for tendinopathy, aortic aneurysm, and dissection. These warnings prompted the Department of Veterans Affairs Pharmacy Benefits Management Service to perform a nationwide FQ utilization review, which identified our facility for potential overuse of FQs in the outpatient setting: 82.2 prescriptions per 1,000 unique patients compared to an average of 48 prescriptions per 1,000 unique patients across all VHA facilities. We then embarked on a FQ medication use evaluation (MUE). Objective: To determine appropriateness of FQ prescribing practices in the outpatient setting. Methods: The study setting was a 399-bed tertiary-care Veterans Hospital with >250 affiliated outpatient clinics in Richmond, Virginia. A retrospective chart review was conducted on a convenience sample of consecutive patients prescribed an FQ from each quarter between April 1, 2018, and March 31, 2019. Chart review included patient demographics, location, FQ used, dose, indication, appropriateness, prescriber, and documentation of patient counseling on FDA black box warnings. Appropriate treatment was defined by national and local antimicrobial therapy guidelines. Results: In total, 265 patients were included the study. Among them, 233 patients (88%) were men and the mean age was 68 years. Overall, 127 patients (48%) were prescribed FQs inappropriately. Primary care clinics and the emergency department (ED) had the highest frequency of inappropriate FQ prescriptions (Fig. 1). Moreover, 92 patients (35%) were prescribed FQs for surgical prophylaxis prior to urological procedures. FQs were most commonly inappropriately prescribed for urinary tract infection (UTI, n =74, 84%) and upper respiratory tract infection (URI, n=27, 84%) (Fig. 2). Documented counseling on FDA black box warnings occurred in 82 cases (31%). Conclusions: In our MUE, outpatient prescribing of FQs was inappropriate nearly 50% of the time. The most commonly documented indications for FQs determined to be inappropriate included UTI and URI. Inappropriate prescriptions most commonly originated from primary care and the emergency department. Urology had the highest volume of FQ prescriptions, which were mostly appropriate surgical prophylaxis based on indication (though an alternative agent would be preferred based on local resistance rates). Documentation of patient counseling for FDA black-box warnings on FQs was uncommon.

Funding: None

Disclosures: None