Antimicrobial Stewardship in an Outpatient Setting

Educational Objectives

The goal of this program is to improve management of antimicrobial stewardship. After hearing and assimilating this program, the clinician will be better able to:

1. Explain elements of outpatient antibiotic stewardship.
2. Implement various strategies to reduce inappropriate antibiotic prescribing.

Summary

Introduction: 85% to 95% of human antibiotic use occurs in the outpatient setting; it is estimated that 30% to 50% of outpatient antibiotic prescriptions are inappropriate (eg, antibiotics are prescribed when they are not indicated, the wrong antibiotic is prescribed, the antibiotic duration of therapy is excessive); a study found that 35% of the antibiotics prescribed for patients being discharged from the emergency department were inappropriate; another study that looked at 38 urgent care units found that 3% to 94% of patients who presented with a respiratory condition received an antibiotic; a United Kingdom study found that over 2 yr, 1.3 million days of excess antibiotics were prescribed in their primary care settings

Antibiotic prescriptions for sinusitis and pharyngitis: study — this assessed the appropriateness of antibiotic prescriptions for sinusitis and pharyngitis; prescriptions were classified as inappropriate if antibiotics were not indicated, or if the antibiotic selection, dose, or duration of therapy was not in concordance with the Infectious Diseases Society of America guidelines; the study found that 81% of prescriptions for sinusitis were inappropriate (most of the prescriptions were not indicated, or the antibiotic was prescribed for an excessive duration of therapy), and ≈50% of antibiotics prescribed for pharyngitis were inappropriate (in many cases, the prescribed doses were too high); Centers for Disease Control and Prevention (CDC) study — this study assessed >3 million prescriptions for sinusitis; despite national guidelines that recommend a duration of antibiotic therapy of 5 to 7 days, >90% of antibiotic prescriptions for sinusitis were for ≥10 days

Elements of outpatient antibiotic stewardship: CDC — commitment; action for policy and practice; tracking and reporting; education and expertise; Joint Commission elements of performance — the organization identifies an individual who is responsible for stewardship efforts in the outpatient setting; the organization sets at least one stewardship-related goal; the organization uses evidence-based practice guidelines; the organization provides clinical staff with education and resources; the organization collects, analyzes, and reports data pertaining to antibiotic use

Demonstrating commitment to antibiotic stewardship: at the clinician level — this includes writing and displaying public commitment posters in support of antibiotic stewardship in the clinic and examination rooms; at the facility level — this involves identifying a single leader to direct antibiotic stewardship efforts; including antibiotic stewardship as part of job duties and performance evaluations; communicating with all staff members so that everyone in the clinic provides the same message to patients; efficacy of public commitment posters — a study assessed 5 primary care clinics and 14 providers to determine the effect of displaying public commitment posters in examination rooms on antibiotic prescribing in acute respiratory infections; the study saw nearly a 10% decrease in inappropriate antibiotic prescribing with the use of commitment posters; in the control arm, where no commitment posters were displayed, inappropriate antibiotic prescribing increased; overall, the study saw nearly a 20% reduction in inappropriate antibiotic prescribing

Actions that support antibiotic stewardship: use evidence-based diagnostic criteria and guidelines; require explicit justification in the medical record for prescribing antibiotics when they are not recommended (eg, when a provider prescribes a fluoroquinolone [eg, ciprofloxacin] for simple cystitis, the provider must justify that decision in the medical record); provide communication skills training for clinicians; provide support for clinical decisions; use delayed prescribing practices (eg, provide a postdated antibiotic prescription to be filled if the patient does not improve after a certain date); use watchful waiting (eg, instruct the patient to call back in a few days if symptoms do not improve); use call centers or nurse lines

Components of clinical care guidelines for sinusitis: signs and symptoms (including symptoms shown to correlate more closely with a bacterial infection than a viral infection); diagnostic tips; most cases of sinusitis are caused by viruses; treatment recommendations with the recommended duration of therapy; helpful for guidelines to be posted on antimicrobial stewardship websites and incorporated into apps

Clinical decision support: provide clinicians with links to references (eg, antibiotic stewardship website), order instructions (eg, common indications, recommendations for dosing and duration of therapy), and national guidelines for particular antibiotics

Reasons health care providers prescribe an antibiotic while knowing it may not be necessary: to meet the patient’s expectation of an antibiotic; to prevent patient satisfaction scores from decreasing; to shorten the length of patient visits

Communication skills training: clinicians must learn how to talk to patients about appropriate antibiotic use and infections that do not improve with antibiotics; resources are available from, eg, the New York State Department of Health, CDC; tips for communicating with patients — provide a specific diagnosis (eg, “You have viral bronchitis”); provide written instructions for symptomatic therapy (eg, ibuprofen); share normal findings during the physical examination; discuss potential side effects of antibiotic use; explain what is to be expected over the next several days; offer a contingency plan in case the patient’s symptoms do not improve; studies show that communication training reduces inappropriate antibiotic prescribing, and the effects appear to last ≥1 yr after training

Tracking and reporting: self-evaluate antibiotic prescribing practices (eg, clinicians can compare their own practices with national guideline recommendations); participate in continuing medical education and quality improvement activities; implement ≥1 antibiotic prescribing tracking and reporting system (eg, tracking how often fluoroquinolones are prescribed in the clinic); assess performance on improving quality measures and goals (eg, decrease fluoroquinolone prescribing by 10% over the next 3 mo); examples of tracked data — the number of antibiotic prescriptions written per month; the percent of visits for a respiratory condition (eg, cough, bronchitis) where an antibiotic was prescribed; overall prescribing practices of a clinic; individual provider prescribing habits

Email-based intervention of peer comparison: study — aimed to determine whether a peer comparison email could reduce inappropriate antibiotic prescribing for acute respiratory infections; providers with the lowest rates of inappropriate prescribing were sent an email that stated that they were a “top performer”; the remaining providers received an email that stated that they were “not a top performer,” and included their prescribing rate for acute respiratory infections, compared with that of top performers; the intervention decreased the rate of antibiotic prescribing for acute respiratory conditions from nearly 20% to ≈4%

Education: educate patients about the potential harms of antibiotics; provide patient education materials; provide face-to-face educational training and continuing education activities for clinicians; clinicians should have timely access to an individual with enhanced knowledge and expertise; patient education posters and modules for antibiotic stewardship training are available on the CDC website; example of an education plan — provide data about inappropriate antibiotic prescribing for sinusitis and pharyngitis; review new sinusitis and pharyngitis guidelines; display public commitment posters; provide patient education materials and resources for communication training; inform clinicians about the ability to track individual prescribing data; provide tracking and reporting data and feedback

Readings

Dobson EL et al. Outpatient antibiotic stewardship: Interventions and opportunities. J Am Pharm Assoc (2003). 2017;57(4):464-473; King LM et al. Advances in optimizing the prescription of antibiotics in outpatient settings. BMJ. 2018;363:k3047.; Meeker D et al. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. JAMA. 2016;315(6):562-570; Sallis A et al. Prescriber commitment posters to increase prudent antibiotic prescribing in English general practice: a cluster randomized controlled trial. Antibiotics (Basel). 2020;9(8):E490; Smith DRM et al. Defining the appropriateness and inappropriateness of antibiotic prescribing in primary care. J Antimicrob Chemother. 2018;73(suppl_2):ii11-ii18.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Shihadeh spoke in Bloomington, MN, at Emerging Infections in Clinical Practice and Public Health, presented November 15, 2019, by the University of Minnesota Medical School, Office of Continuing Professional Development. Visit https://www.cme.umn.edu/ for more information about courses from the University of Minnesota Medical School, Office of Continuing Professional Development sponsor. The Audio Digest Foundation thanks the speakers and the University of Minnesota Medical School for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

IM674502

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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