Managing ARI Prescriptions Appropriately for Patients With and Without HIV

The specialty of the prescribing clinician played a role in the appropriateness of the prescribing for managing ARI in patients with and without HIV.

Managing ARI in patients with HIV was more likely to be appropriate and follow recommended guidelines compared to ARI management in patients without HIV, according to a paper published in Open Forum Infectious Diseases.

Investigators from the University of Nebraska Medical Center in Omaha conducted a trial of 209 patients with HIV and 398 patients without HIV in order to evaluate the use of antibiotics for ambulatory acute respiratory infections (ARI) with patients with HIV in comparison to those without HIV. The study authors wrote that people with HIV might be assumed as higher risk for ARI compared to those without HIV but that there has not been an evaluation of the subject. The study began in January 2014 and ran to April 2018.

Within the study period, there were 350 visits for ARI among the 209 patients with HIV, the study authors wrote, compared to 492 visits for 398 patients without HIV. However, the study authors noted the demographics were similar between the groups, nothing that the patients with HIV were immunologically preserved and virologically suppressed. The majority (91 percent) of those with HIV were prescribed ART.

About a third (38 percent) of visits for ARI resulted in an antibiotic prescription, the study authors found, and 66 percent of patients were managed according to guideline recommendations. People with HIV were prescribed antibiotics in 35 percent of cases, compared to 40 percent of people without HIV, and the study authors said that was not a statistically significant difference between the cohorts.

Notably, 11 percent of the antibiotics prescribed were considered appropriate. The study authors said that 66 percent of the antibiotics were considered inappropriate because an antibiotic was not indicated, 18 percent for inappropriate drug choice, 15 percent for too long a duration, and almost 1 percent for too short a duration. People with HIV received slightly more frequent appropriate prescribing, but it was not a statistically significant difference, the study authors wrote.

People without HIV were more likely to receive the wrong drug compared to their HIV counterparts (22 percent vs. 10 percent, respectively), the study authors found. Additionally, those with HIV were more likely to be treated for too long a duration compared to their non-HIV counterparts, they learned (22 percent vs. 12 percent, respectively).

Across both cohorts, antibiotics were prescribed by an attending physician 38 percent of the time, a trainee (resident or fellow) 23 percent of the time, and an advanced practice provider 50 percent of the time, the study authors learned. Managing the ARI was concordant with the guidelines in two-thirds of the attending visits, 83 percent of the trainee visits, and about half (56 percent) of the advanced practice provider visits. Just 11 percent of attending physician prescriptions were considered appropriate, the study authors found, compared to 26 percent of trainee prescriptions and 6 percent of advanced practice provider prescriptions.

“Our study results highlight the need for improved outpatient stewardship, especially for diagnoses that should rarely or never result in an antibiotic prescription such as ARI, and this is certainly not limited to the HIV community,” the study authors concluded. “A majority of patients with HIV in our study were evaluated for ARI by non-HIV clinicians, and discrepancy between duration of antibiotics prescribed by HIV clinicians compared with non-HIV clinicians to patients with HIV was significant. In an era in which more HIV care is conducted in a primary care setting, these findings emphasize the value of HIV specialty care consultation and education of non-HIV clinicians for appropriate antimicrobial stewardship within the HIV community.”