Final Draft Abx Stewardship Game

Antibiotic stewarship

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WELCOME

BACK

The game is divided into multiple parts. First, you will complete the knowledge builder. Then, you will proceed through the game and complete each mission. Please be sure to complete the survey at the end!

CONTINUE

1. Center for Disease Control. "Outpatient Antibiotic Prescribing in the United States." Antibiotic Prescribing and Use. April 22, 2024. https://www.cdc.gov/antibiotic-use/hcp/data-research/antibiotic-prescribing.html

• The CDC (2024) estimates that close to 30% of antibiotics that are prescribed are prescribed uneccessarily.1
• Close to 90% of antibiotics are prescribed in outpatient settings.1
• Uneccessary antibiotic use can lead to side effects for patients and exacerbate antibiotic resistance rates.1

• Healthcare providers are essential players in decreasing unnecessary antibiotic use.1

BACKGROUND

BACK

CONTINUE

BACK

OBJECTIVES

By the end of the course, clinicians will be able to:

1. Diagnose and distinguish between sinusitis, pharyngitis, bronchitis and upper respiratory infections.
2. Identify red flag symptoms.
3. Appropriately recommend supportive care and first, second, and third line antibiotics.
4. Differentiate circumstances in which antibiotics are appropriate.
5. Determine situations in which a referral is most appropriate.

CONTINUE

Respond to the questions and hit send once a response has been selected.

KNOWLEDGE BUILdER

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CONTINUE

Respond to the question and hit send once a response has been selected.

KNOWLEDGE BUILdER

BACK

CONTINUE

Respond to the question and hit send once a response has been selected.

KNOWLEDGE BUILdER

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CONTINUE

BACK

CONTINUE

wheel health

BEGIN

Click play to begin the game.

URI

Pharyngitis

Sinusitis

Bronchitis

BACK

Bronchitis

bronchitis

BACK

click the YELLOW CIRCLES to review signs and symptoms.

CONTINUE

hover over each card to learn more

BACK

bronchitis TREATMENT

antibitoics are not recommended.

CONTINUE

BACK

hover over each circle to review the red flag symptoms.

bronchitis - RED FLAG SYMPTOMS

CONTINUE

CLICK ACCEPT CONSULT TO PROCEED

BACK

ACCEPT CONSULT

incoming consult

NKDA

1. Where are you today?• Florida
2. Which (if any) of the following symptoms are you experiencing?• Productive cough (whitish colored sputum)• Congestion that has improved
3. Do you have fever, fatigue, chills, hemoptysis, barking cough, wheezing, or dyspnea?• NO
4. Can you tell us more about your symptoms?

• My entire family caught a cold about 12 days ago. My sore throat is gone and the congestion has improved but I can not get rid of the cough. I don't have a fever, just a cough. CLICK CONTINUE TO PROVIDE TREAMENT RECOMMENDATIONS.

Intake Interview

Other seasonal allergies

Conditions

Allergies

BACK

Patient Notes

5555555555

janedoe@patient. com

595 WHEEL LANE MEDICAL CITY, TX 72151

Female, 05/06/2000 24 years old

Jane Doe

visit information

CONTINUE

Review the consult and proceed to the next slide to address it.

REVIEW the consult

BACK

BACK

Thank you. I will prescribe Cephalexin for you. Please feel better soon.

Hello, I am a provider and I am here to care for you. I reviewed your intake and I have an additional question. Were you tested for COVID or the flu?

Hi! Yes, I tested negative for the flu, strep and covid. I have just had the cough for 12 days. I feel the same way I did when I had bronchitis a year ago.

CONTINUE

complete the consult

BACK

Address the scenario and hit submit once a response is selected.

CLICK THE ITEM THAT COMPLETES THE SENTENCE

are not needeed

In the treatment of bronchitis, antibiotics _____________ .

congestion

This symptom is not a red flag symptom of bronchitis _____________ .

KNOWLEDGE SUMMARY

BACK

BACK

High fever

Chest Pain

Weight loss

Difficulty breathing

are not needed

are needed

Congestion

CONTINUE

CONTINUE

BACK

Patients should be advised to see their PCP or urgent care provider for worsening or lingering symptoms and visit urgent care or the emergency room for red flag symptoms.

CONTINUE

follow up and er RECOMMENDATIONS

mission 1 completed!

BACK

CONTINUE

Click play to begin the game.

URI

Sinusitis

Bronchitis

Pharyngitis

BACK

wheel health

click the YELLOW circles to learn about the signs and symptoms.

sinusitis

of cases are bacterial

only 0.5-2%

BACK

OVERVIEW

click for more info

CONTINUE

Let's discuss the red flag symptoms of sinusitis!

Sinusitis - RED FLAG SYMPTOMS

BACK

CONTINUE

3 or more sinus infections in 12 months or sinus symptoms for more than 1 month.

High Fever...

Let's guess the red flag symptoms of sinusitis!

Sinusitis - RED FLAG SYMPTOMS

Severe persistent headache, neck stiffness or meningeal signs...

Proptosis, cranial nerve palsies, periorbital edema, inflammation or erythema, vision changes...

Altered mental status, abnormal ocular movements, papilledema or s/s of increased intracranial pressure

BACK

CONTINUE

3. Viral Infections

2. Antibiotic Qualifications

1. Clinical Presentation

click THE PLUS SIGNS TO LEARN MORE.

BACK

5. What did I Learn?

4. Red Flag Symptoms

CONTINUE

sinusitis workflow

Antibiotics ONLY if medically neccessary.

click the PLUS SIGNS to LEARN MORE.

IF AN ANTIBIOTIC IS NEEDED, use A first line antibiotic unless an alternative is medically neccessary.

no antibiotics

sinusitis TREATMENT

BACK

TREATMENT PLAN

THIRD LINE ANTIBIOTICS

SUPPORTIVE CARE

SECOND LINE ANTIBIOTICS

FIRST LINE ANTIBIOTICS

CONTINUE

CLICK ACCEPT CONSULT TO PROCEED

BACK

ACCEPT CONSULT

incoming consult

NKDA

1. Where are you today?• Texas
2. Which (if any) of the following symptoms are you experiencing?• Sinus pressure• Clear nasal drainage• Nasal discharge and congestion
3. Do you have vision changes, neck stiffness, swelling around your eyes, severe persistent headache, high fever, bulging eyes or confusion?• NO
4. Can you tell us more about your symptoms?

• I get sinus infections every fall and I need a z-pack, please. CLICK CONTINUE TO PROVIDE TREAMENT RECOMMENDATIONS.

Intake Interview

Other seasonal allergies

Conditions

BACK

Allergies

Patient Notes

5555555555

joedoe@patient.com

595 WHEEL LANE MEDICAL CITY, TX 72151

Male, 05/06/2001 23 years old

Joe Doe

visit information

CONTINUE

Review the consult and proceed to the next slide to address it.

REVIEW the consult

BACK

Thank you. I have some recommendations for you.

My pain is a 3/10 and this has been going on for about 3 days.

Hello! We can help. How long has this been going on? Can you rate your pain on a scale of 0-10?

Hi there! I don't feel good. I have sinus pressure and pain, congestion and a runny nose.

CONTINUE

Address the consult and hit send once a response is selected.

COMPLETE THE VISIT

BACK

KNOWLEDGE SUMMARY

CLICK THE ITEM THAT COMPLETES THE SENTENCE

are not needed

are not needeed

In the treatment of sinusitis, antibiotics ___________________ unless the patient presents with symptoms of a bacterial infection.

cough

This condition is not a symptom of bacterial sinusitis _____________ .

BACK

BACK

severe sinus pain

severe facial pain

double worsening

are needed

are not needed

cough

CONTINUE

CONTINUE

BACK

Patients should be advised to see their PCP or urgent care provider for worsening or lingering symptoms and visit urgent care or the emergency room for red flag symptoms.

CONTINUE

follow up and er RECOMMENDATIONS

mission 2 completed!

BACK

CONTINUE

URI

Sinusitis

Bronchitis

Pharyngitis

BACK

CONTINUE

wheel health

BACK

CONTINUE

click the purple circles to learn about the signs and symptoms.

pharyngitis

Antibiotics only if the patient meets Centor score criteria.

supportive care

Use honey to relieve cough for adults and children at least 1 year of age or older.

symptom control

BACK

OTC analgesics including NSAIDS or acetaminophen and topical treatments such as lozenges or sprays.

supportive care

Use a humidifier or cool mist vaporizer. Gargle with salt water. Drink warm beverages and plenty of fluids.

patients with severe penicillin allergy

Azithromycin 250 mg tablet

patients with mild penicillin allergy

Cephalexin 500 mg tablet

first line antibiotics

Penicillin V 500 mg tabletAmoxicillin 500 mg tablet

CONTINUE

PHARYNGITIS TREATMENT PLAN

Drooling

Peritonsillar abscess

High fever or rigors

Inability to swallow

Stiff neck, pain or swelling

3 or more infections in 1 year

Muffled or hot potato voice

Signs of deep neck space infections

BACK

CONTINUE

RED FLAG symptoms of PHARYNGITIS

Inability to swallow

Stiff neck, pain/swelling

Drooling

Muffled or hot potato voice

Signs of deep neck space infections

High fever and rigors

3 or more infections in 1 year

BACK

Tonsillar exudate

SELECT THE SYMPTOM THAT IS NOT A RED FLAG symptom of PHARYNGITIS?

CONTINUE

CLICK ACCEPT CONSULT TO PROCEED

BACK

ACCEPT CONSULT

incoming consult

NKDA

1. Where are you today?• Texas
2. Which (if any) of the following symptoms are you experiencing?• Sore throat• White patches on tonsils• Nasal discharge and congestion
3. Do you have drooling, difficulty swallowing, high fever, rigors, a muffled sounding voice stiff neck or neck swelling?• NO
4. Can you tell us more about your symptoms?

• My throat started hurting 2 days ago. It gets better when I take Tylenol but then hurts again once the Tylenol wears off. CLICK CONTINUE TO PROVIDE TREAMENT RECOMMENDATIONS.

Intake Interview

Other seasonal allergies

Conditions

BACK

Allergies

Patient Notes

5555555555

joedoe@patient.com

595 WHEEL LANE MEDICAL CITY, TX 72151

Male, 05/06/1990 34 years old

Joe Doe

visit information

CONTINUE

Review the consult and proceed to the next slide to address it.

BACK

BACK

REVIEW the consult

Thank you. I have a few recommendations for you.

Hello, I am a provider and I am here to care for you. I reviewed your intake and I have an additional question. Have you been exposed to anyone with strep?

Hi! I don't think I have been exposed to anyone with strep. I work from home so I don't interact with many people.

CONTINUE

Address the scenario and hit send once a response is selected.

COMPLETE THE VISIT

BACK

CONTINUE

KNOWLEDGE SUMMARY

CLICK THE ITEM THAT COMPLETES THE SENTENCE

centor score

patent's name

patients name

red flag symptoms

patient's ame

antibiotic class

patient's name

patient's nam

when

centor score

pharyngitis.

prescribing

Document

the

antibiotics

for

BACK

CONTINUE

BACK

Patients should be advised to see their PCP or urgent care provider for worsening or lingering symptoms and visit urgent care or the emergency room for red flag symptoms.

CONTINUE

follow up and er RECOMMENDATIONS

mission 3 completed!

BACK

CONTINUE

ALMOST THERE!

BACK

CONTINUE

URI

Pharyngitis

Sinusitis

Bronchitis

BACK

wheel health

click the circle to learn about the signs and symptoms.

UPPER RESPIRATORY INFECTIONS

BACK

CONTINUE

click the purple circles to learn about the signs and symptoms.

BACK

CONTINUE

URI TREATMENT PLAN

Inability to swallow

Dyspnea/Tachypnea

High Fever/Rigors

Cough for greater than 4 weeks

Caution in hepatic or renal impairment

Chest Pain/Palpitations

REVIEW THE RED FLAG SYMPTOMS OF A URI

BACK

Recent hospitalization or antibiotic use.

Dizziness/Confusion/Fainting

Ear Pain

CONTINUE

Severe abdominal pain/abdomen that is tender to palpation

uri RED FLAG SYMPTOMS

Body Aches

Congestion

Chest Pain

Ear pain or pressure

Dyspnea/Tachypnea

Severe abdominal pain

BACK

SOLUTION

CONTINUE

MATCH THE RED FLAG SYMPTOMS OF A URI

RED FLAG SYMPTOMS

CLICK ACCEPT CONSULT TO PROCEED

BACK

ACCEPT CONSULT

incoming consult

NKDA

1. Where are you today?• Texas
2. Which (if any) of the following symptoms are you experiencing?• Sinus pressure• Clear nasal drainage and congestion• Body aches and fatigue
3. Do you have chest pain, dyspnea, wheezing, difficulty breathing, high fever or confusion?• NO
4. Can you tell us more about your symptoms?

• My family member came home with a cold last week and I think I have the same symptoms they have.CLICK CONTINUE TO PROVIDE TREAMENT RECOMMENDATIONS.

Intake Interview

Other seasonal allergies

Conditions

BACK

Allergies

Patient Notes

5555555555

joedoe@patient.com

595 WHEEL LANE MEDICAL CITY, TX 72151

Male, 05/06/2000 34 years old

Joe Doe

visit information

CONTINUE

Review the consult and proceed to the next slide to address it.

REVIEW the consult

BACK

Hello, I am part of the Wheel provider group. It's a pleasure taking care of you. How can I help?

Hi there! I don't feel well. I have been sick for 4 days. My nose is runny, I have a cough, I am tired and I am congested. I don't have a fever. I tested negative for the flu and covid. I just need something to help me feel better. Can you prescribe an antibiotic? A Z-pack always helps.

CONTINUE

Review the consult and proceed to the next slide to address it.

REVIEW the consult

BACK

CONTINUE

Patients should be advised to see their PCP or urgent care provider for worsening or lingering symptoms and visit urgent care or the emergency room for red flag symptoms.

BACK

CONTINUE

follow up and er RECOMMENDATIONS

mission 4 completed!

Back

BACK

CONTINUE

• Do NOT prescribe antibiotics for Bronchitis and Upper respiratory infections.
• Prescribe antibiotics for sinusitis ONLY if THE patient has severe symptoms or symptoms lasting 10 or more days.
• Prescribe antibiotics for pharyngitis ONLY if patient has a Centor score of 4 or a centor score of 3 with known exposure.

Summary

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exit

Please complete the survey:

URI

Sinusitis

Bronchitis

Pharyngitis

BACK

CONTINUE

well done!

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Diagnosis - Utilize Centor Score

• Centor score 4 or higher - limited empiric antibiotic treatment permitted.
• Centor score 2-3 with exposure - antibiotics are NOT recommended unless there is a known at-home exposure to strep.
• Centor score 0-3 with no know exposure - symptomatic treatment and recommendation for testing. NO ANTIBIOTIC USE.
• Documentation of the Centor score is encouraged.

Red Flag Symptoms

• If red flag symptoms are present, refer.

• If no red flag symptoms, proceed.

Hover over the red circles for more information.

• Symptomatic inflammation of the nasal cavity and paranasal cavity for less than 4 weeks.

Lorem Ipsum dolor sit

Lorem Ipsum dolor

CONTINUE

Sinusitis

SECOND LINE ANTIBIOTICS

• Cefixime
• Cefpodoxime

• Doxycycline

Supportive Care

• Analgesic
• Antihistamine/decongestants
• Intranasal steroids
• Saline nasal sprays
• Nasal expectorants
• ANTIBIOTICS ARE NOT RECOMMENDED.

ANTIBIOTICS

• DO NOT PRESCRIBE ANTIBIOTICS UNLESS SEVERE SYMPTOMS ARE PRESENT.

• REFER PATIENTS WITH RED FLAG SYMPTOMS.

• Purulent discharge, nasal obstruction, and/or facial pain/pressure
• Symptoms < 4weeks old?

If so, proceed. If not, consider an alternate diagnosis.

Does the patient present with signs and symptoms of rhinosinusitis?

SUPPORTIVE CARE

• Analgesics
• Antihistamine/decongestants
• Intranasal steroids
• Saline nasal sprays
• Nasal expectorants

• Antibiotics only for severe symptoms (symptoms lasting 10+ days, double worsening, fever or symptoms of severe illness).
• Supportive care first for patients not requiring antibiotics.

LEARNING SUMMARY

FIRST LINE ANTIBIOTICS

• Amoxicillin 500 mg
• Amoxicillin 875 mg
• Amoxicillin/Clavulanate 500 mg
• Amoxicillin/Clavulanate 875 mg

• If the patient does not have signs and symptoms of a bacterial infection, then it is viral.
• Most cases are viral and do NOT require antibiotics.

• For viral infection, implement watchful waiting and supportive care.

Viral Cause

Chest Pain

Ear pain or pressure

Dyspnea/Tachypnea

Severe abdominal pain

BACK

CONTINUE

Solution

Severe abdominal pain

Symptoms

• Sore throat that worsens when swallowing.
• Neck pain or swelling due to regional lymphadenopathy commonly accompanies sore throat.
• Fever, headache, fatigue and malaise are variably present.
• Pharyngitis caused by respiratory virus usually has other S/S of URI such as: fatigue, nasal congestion, cough, coryza, conjunctivitis, sneezing, hoarseness, ear pain, sinus discomfort, and a viral exanthem

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THIRD LINE ANTIBIOTCS

• Levofloxacin
• Moxifloxacin

• Caused by from inflammation of the lower respiratory tract, most frequently due to viral infections.

• Typically self-limiting, resolving in 1-3 weeks.

• Occurs in absence of COPD.

Overview

Symptoms

• Cardinal symptom is cough.
• Cough may be associated with either purulent or non-purulent sputum.

• Wheezing may be present.
• Mild dyspnea may be present.
• During first few days of illness, other symptoms include: headache, nasal congestion, sore throat.
• URI may precede onset.

ANTIBIOTICS

• ANTIBIOTICS ARE NOT RECOMMENDED.
• SUPPORTIVE CARE ONLY.

• Antibiotics are typically not needed.
• Only prescribe it the following criteria are satisfied:

• Symptoms lasting 10 or more days.
• Severe symptoms during the first 3-4 days including fever, purulent nasal discharge and face pain.

• For symptoms between 7-10 days, consider watch and wait antibiotics.

ANTIBIOTICS

Signs and Symptoms of Acute Rhonisinusitis

• Facial pain, pressure and/or fullness
• < 4 weeks of purulent nasal discharge
• Severe nasal obstruction
• Headache
• Patients may also report cough, diminished sense of smell and ear fullness.

Symptoms and Cause

• Congestion, and nasal discharge.
• Sneezing, sore throat and cough.

• Fever, headache, and malaise.
• May present with conjunctival injection, nasal muscosal swelling, adenopathy, and pharyngyeal edema.
• Cause: viral

Characteristics of Bacterial Sinusitis

• Most cases are viral.
• Bacterial infections is suspected with the following:
• severe symptoms including severe illness, fever, purulent nasal drainage and facial pain for 3 or 4 consectuive days at the beginning of the illness).

• Symptoms for greater than or equal to 10 days.