Final Draft Abx Stewardship Game

Antibiotic stewarship

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WELCOME

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!

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BACK

BACKGROUND

• 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

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

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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.

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KNOWLEDGE BUILdER

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

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KNOWLEDGE BUILdER

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

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KNOWLEDGE BUILdER

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

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wheel health

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Sinusitis

Bronchitis

BEGIN

URI

Pharyngitis

Click play to begin the game.

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bronchitis

Bronchitis

click the YELLOW CIRCLES to review signs and symptoms.

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bronchitis TREATMENT

antibitoics are not recommended.

hover over each card to learn more

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bronchitis - RED FLAG SYMPTOMS

BACK

hover over each circle to review the red flag symptoms.

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incoming consult

CLICK ACCEPT CONSULT TO PROCEED

ACCEPT CONSULT

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visit information

Jane Doe

Intake Interview

Female, 05/06/2000 24 years old

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.

595 WHEEL LANE MEDICAL CITY, TX 72151

janedoe@patient. com

5555555555

Patient Notes

Allergies

NKDA

Conditions

Other seasonal allergies

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REVIEW the consult

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

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.

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

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complete the consult

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

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KNOWLEDGE SUMMARY

CLICK THE ITEM THAT COMPLETES THE SENTENCE

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

Weight loss

Chest Pain

Difficulty breathing

High fever

congestion

Congestion

In the treatment of bronchitis, antibiotics _____________ .

are needed

are not needed

are not needeed

CONTINUE

CONTINUE

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follow up and er RECOMMENDATIONS

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.

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mission 1 completed!

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Sinusitis

Bronchitis

wheel health

URI

Pharyngitis

Click play to begin the game.

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sinusitis

OVERVIEW

click for more info

only 0.5-2%

of cases are bacterial

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

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Sinusitis - RED FLAG SYMPTOMS

Let's discuss the red flag symptoms of sinusitis!

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CONTINUE

Sinusitis - RED FLAG SYMPTOMS

Let's guess the red flag symptoms of sinusitis!

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

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

High Fever...

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

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

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CONTINUE

sinusitis workflow

click THE PLUS SIGNS TO LEARN MORE.

1. Clinical Presentation

2. Antibiotic Qualifications

3. Viral Infections

4. Red Flag Symptoms

5. What did I Learn?

Antibiotics ONLY if medically neccessary.

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click the PLUS SIGNS to LEARN MORE.

no antibiotics

sinusitis TREATMENT

SECOND LINE ANTIBIOTICS

FIRST LINE ANTIBIOTICS

TREATMENT PLAN

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

THIRD LINE ANTIBIOTICS

SUPPORTIVE CARE

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incoming consult

CLICK ACCEPT CONSULT TO PROCEED

ACCEPT CONSULT

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visit information

Joe Doe

Intake Interview

Male, 05/06/2001 23 years old

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.

595 WHEEL LANE MEDICAL CITY, TX 72151

joedoe@patient.com

5555555555

Patient Notes

Allergies

NKDA

Conditions

Other seasonal allergies

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REVIEW the consult

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

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

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

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

Thank you. I have some recommendations for you.

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CONTINUE

COMPLETE THE VISIT

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

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KNOWLEDGE SUMMARY

CLICK THE ITEM THAT COMPLETES THE SENTENCE

severe facial pain

This condition is not a symptom of bacterial sinusitis _____________ .

severe sinus pain

double worsening

cough

cough

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

are needed

are not needeed

are not needed

are not needed

CONTINUE

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follow up and er RECOMMENDATIONS

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.

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mission 2 completed!

CONTINUE

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Bronchitis

Sinusitis

wheel health

URI

Pharyngitis

CONTINUE

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pharyngitis

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

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PHARYNGITIS TREATMENT PLAN

Antibiotics only if the patient meets Centor score criteria.

patients with severe penicillin allergy

symptom control

first line antibiotics

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

Penicillin V 500 mg tabletAmoxicillin 500 mg tablet

Azithromycin 250 mg tablet

patients with mild penicillin allergy

supportive care

supportive care

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

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

Cephalexin 500 mg tablet

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RED FLAG symptoms of PHARYNGITIS

3 or more infections in 1 year

Peritonsillar abscess

Muffled or hot potato voice

Drooling

Signs of deep neck space infections

Stiff neck, pain or swelling

Inability to swallow

High fever or rigors

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

Tonsillar exudate

3 or more infections in 1 year

Muffled or hot potato voice

Drooling

Signs of deep neck space infections

Inability to swallow

Stiff neck, pain/swelling

High fever and rigors

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incoming consult

CLICK ACCEPT CONSULT TO PROCEED

ACCEPT CONSULT

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visit information

Joe Doe

Intake Interview

Male, 05/06/1990 34 years old

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.

595 WHEEL LANE MEDICAL CITY, TX 72151

joedoe@patient.com

5555555555

Patient Notes

Allergies

NKDA

Conditions

Other seasonal allergies

CONTINUE

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REVIEW the consult

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

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.

Thank you. I have a few recommendations for you.

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COMPLETE THE VISIT

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

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KNOWLEDGE SUMMARY

CLICK THE ITEM THAT COMPLETES THE SENTENCE

when

the

centor score

Document

for

antibiotics

prescribing

pharyngitis.

patient's name

antibiotic class

patient's nam

patient's ame

red flag symptoms

patent's name

patients name

centor score

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follow up and er RECOMMENDATIONS

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.

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mission 3 completed!

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ALMOST THERE!

CONTINUE

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Sinusitis

Bronchitis

wheel health

URI

Pharyngitis

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UPPER RESPIRATORY INFECTIONS

click the circle to learn about the signs and symptoms.

CONTINUE

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URI TREATMENT PLAN

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

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uri RED FLAG SYMPTOMS

REVIEW THE RED FLAG SYMPTOMS OF A URI

Dizziness/Confusion/Fainting

Recent hospitalization or antibiotic use.

Ear Pain

Cough for greater than 4 weeks

High Fever/Rigors

Inability to swallow

Dyspnea/Tachypnea

Chest Pain/Palpitations

Caution in hepatic or renal impairment

Severe abdominal pain/abdomen that is tender to palpation

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RED FLAG SYMPTOMS

SOLUTION

MATCH THE RED FLAG SYMPTOMS OF A URI

Body Aches

Chest Pain

Ear pain or pressure

Dyspnea/Tachypnea

Severe abdominal pain

Congestion

CONTINUE

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incoming consult

CLICK ACCEPT CONSULT TO PROCEED

ACCEPT CONSULT

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visit information

Joe Doe

Intake Interview

Male, 05/06/2000 34 years old

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.

595 WHEEL LANE MEDICAL CITY, TX 72151

joedoe@patient.com

5555555555

Patient Notes

Allergies

NKDA

Conditions

Other seasonal allergies

CONTINUE

BACK

REVIEW the consult

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

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.

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REVIEW the consult

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

CONTINUE

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follow up and er RECOMMENDATIONS

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

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mission 4 completed!

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CONTINUE

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Summary

• 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.

exit

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Sinusitis

Bronchitis

well done!

URI

Pharyngitis

Please complete the survey:

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You’ve successfully completed the education!

Complete the survey

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You'll lose all your progress

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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.

Sinusitis

Lorem Ipsum dolor sit

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

Lorem Ipsum dolor

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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.

Does the patient present with signs and symptoms of rhinosinusitis?

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

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

SUPPORTIVE CARE

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

LEARNING SUMMARY

• 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.

FIRST LINE ANTIBIOTICS

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

Viral Cause

• 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.

Solution

Ear pain or pressure

Dyspnea/Tachypnea

Chest Pain

Severe abdominal pain

Severe abdominal pain

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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

Overview

• 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.

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

• 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.

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.