CDC Report: Core Elements of Outpatient Antibiotic Stewardship

Approximately half of outpatient antibiotic prescribing in humans might be inappropriate, including antibiotic selection, dosing, or duration, in addition to unnecessary antibiotic prescribing (2–4). At least 30% of outpatient antibiotic prescriptions in the United States are unnecessary (5).

Improving antibiotic prescribing in all health care settings is critical to combating antibiotic-resistant bacteria (7). Approximately 60% of U.S. antibiotic expenditures for humans are related to care received in outpatient settings (8).Core Elements of Outpatient Antibiotic Stewardship

The Core Elements of Outpatient Antibiotic Stewardship follow and are summarized in a clinician checklist (Figure 1) and a facility checklist (Figure 2):

• Commitment: Demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety.
• Action for policy and practice: Implement at least one policy or practice to improve antibiotic prescribing, assess whether it is working, and modify as needed.
• Tracking and reporting: Monitor antibiotic prescribing practices and offer regular feedback to clinicians, or have clinicians assess their own antibiotic prescribing practices themselves.
• Education and expertise: Provide educational resources to clinicians and patients on antibiotic prescribing, and ensure access to needed expertise on optimizing antibiotic prescribing.

Commitment

A commitment from all health care team members to prescribe antibiotics appropriately and engage in antibiotic stewardship is critical to improving antibiotic prescribing. Every person involved in patient care, whether directly or indirectly, can act as an antibiotic steward. Each clinician can make the choice to be an effective antibiotic steward during each patient encounter.

Clinicians can demonstrate commitment to appropriate antibiotic prescribing by doing the following:

• Write and display public commitments in support of antibiotic stewardship. For example, inappropriate antibiotic prescriptions for acute respiratory infections were reduced after clinicians displayed, in their examination rooms, a poster showing a letter from the clinician to their patients committing to prescribing antibiotics appropriately (18). This approach also might facilitate patient communication about appropriate antibiotic use.

Outpatient clinic and health care system leaders can commit to promoting appropriate antibiotic prescribing by doing any of the following:

• Identify a single leader to direct antibiotic stewardship activities within a facility. Appointing a single leader who is accountable to senior facility leaders is recommended for hospital stewardship programs (21,22), and this approach also might be beneficial in outpatient settings.
• Include antibiotic stewardship-related duties in position descriptions or job evaluation criteria. These duties can be listed for medical directors, nursing leadership positions, and practice management personnel and will help ensure staff members have sufficient time and resources to devote to stewardship. Although evidence in the outpatient settings is lacking, this type of leadership support has been shown to be important for hospital antibiotic stewardship programs (29).
• Communicate with all clinic staff members to set patient expectations. Patient visits for acute illnesses might or might not result in an antibiotic prescription. All staff members in outpatient facilities, including administrative staff members, medical assistants, nurses, allied health professionals, and medical directors, can improve antibiotic prescribing by using consistent messages when communicating with patients about the indications for antibiotics.

Action for Policy and Practice

Outpatient clinicians and clinic leaders can implement policies and interventions to promote appropriate antibiotic prescribing practices. A stepwise approach with achievable goals can facilitate policy and practice changes and help clinicians and staff members from feeling overwhelmed. Clinicians can implement at least one of the following actions to improve antibiotic prescribing:

• Use evidence-based diagnostic criteria and treatment recommendations. When possible, these criteria and recommendations should be based on national or local clinical practice guidelines informed by local pathogen susceptibilities. This can be accomplished by adhering to recommendations from clinical practice guidelines for common infections published by national professional societies such as the American Academy of Pediatrics and the Infectious Diseases Society of America (30–35).
• Use delayed prescribing practices or watchful waiting, when appropriate. Delayed prescribing can be used for patients with conditions that usually resolve without treatment but who can benefit from antibiotics if the conditions do not improve (e.g., acute uncomplicated sinusitis or mild acute otitis media). Clinicians can apply delayed prescribing practices by giving the patient or parent a postdated prescription and providing instructions to fill the prescription after a predetermined period or by instructing the patient to call or return to collect a prescription if symptoms worsen or do not improve (36–40). Watchful waiting means providing symptomatic relief with a clear plan for follow-up if infection symptoms worsen or do not improve. Watchful waiting and delayed antibiotic prescriptions are evidence-based approaches that can safely decrease antibiotic use when used in accordance with clinical practice guidelines (41–44).

Outpatient clinic and health care system leaders can take at least one of the following actions to improve antibiotic prescribing based on established standards or national clinical practice guidelines:

• Provide communications skills training for clinicians. Communications skills training can be used to promote strategies to address patient concerns regarding prognosis, benefits, and harms of antibiotic treatment; management of self-limiting conditions; and clinician concerns regarding managing patient expectations for antibiotics during a clinical visit (45,46).
• Require explicit written justification in the medical record for nonrecommended antibiotic prescribing. This technique has reduced inappropriate prescribing by holding clinicians accountable in the medical record for their decisions (19).
• Provide support for clinical decisions. Clinical decision support, which provides specific information in electronic or print form during the typical workflow, can facilitate accurate diagnoses and effective management of common conditions (e.g., discouraging antibiotic prescribing for acute bronchitis in healthy adults) (47–52).
• Use call centers, nurse hotlines, or pharmacist consultations as triage systems to prevent unnecessary visits. These resources can be used to reduce unnecessary visits for conditions that do not require a clinic visit (53), such as a common cold.

Tracking and Reporting

Tracking and reporting clinician antibiotic prescribing, also called audit and feedback, can guide changes in practice and be used to assess progress in improving antibiotic prescribing. Both clinicians and clinic leaders can be involved in antibiotic stewardship. Clinicians can track and report their own antibiotic prescribing practices by doing at least one of the following:

• Self-evaluate antibiotic prescribing practices. Clinicians can use self-evaluations to align their antibiotic prescribing practices with updated evidence-based recommendations and clinical practice guidelines.
• Participate in continuing medical education and quality improvement activities to track and improve antibiotic prescribing. Activities can be tailored by clinical specialty if conducted through health professional organizations and also might be used to meet licensure and other education and quality improvement requirements.

Outpatient clinic or health care system leaders can do at least one of the following:

• Implement at least one antibiotic prescribing tracking and reporting system. Outcomes to be tracked can include high-priority conditions that have been identified as opportunities for improvement in that clinic, the percentage of all visits leading to antibiotic prescriptions, and, for health systems, complications of antibiotic use and antibiotic resistance trends (if antibiotic prescribing outcomes are already being tracked). Outcomes can be tracked and reported by individual clinicians (which is preferred) and by facilities.
• Assess and share performance on quality measures and established reduction goals addressing appropriate antibiotic prescribing from health care plans and payers. The National Strategy for Combating Antibiotic-Resistant Bacteria aims to reduce inappropriate antibiotic use by 50% for monitored conditions in outpatient settings by 2020 (61). Current HEDIS measures include quality measures for appropriate testing for children with pharyngitis, appropriate treatment for children with upper respiratory infections (i.e., avoidance of antibiotics), and avoidance of antibiotic treatment in adults with acute bronchitis (62).

Education and Expertise

Education on appropriate antibiotic use can involve patients and clinicians. Education for patients and family members can improve health literacy and augment efforts to improve antibiotic use. Education for clinicians and clinic staff members can reinforce appropriate antibiotic prescribing and improve the quality of care (56,63,64). Clinicians can educate patients and families about appropriate antibiotic use by doing at least one of the following:

• Use effective communications strategies to educate patients about when antibiotics are and are not needed. For example, patients should be informed that antibiotic treatment for viral infections provides no benefit and thus should not be used for viral infections. Patients also should be informed that certain bacterial infections (e.g., mild ear and sinus infections) might improve without antibiotics. Explanations of when antibiotics are not needed can be combined with recommendations for symptom management; this combination of messages has been associated with visit satisfaction (65). In addition, providing recommendations for when to seek medical care if patients worsen or do not improve (i.e., a contingency plan) has been associated with higher visit satisfaction scores among patients who expected but were not prescribed antibiotics (66).
• Educate patients about the potential harms of antibiotic treatment. Potential harms might include common and sometimes serious side effects of antibiotics, including nausea, abdominal pain, diarrhea, C. difficile infection, allergic reactions, and other serious reactions. Parents of young children, in particular, want to be informed about possible adverse events associated with antibiotics (67). In addition, increasing evidence suggests antibiotic use in infancy and childhood is linked with allergic, infectious, and autoimmune diseases, likely through disturbing the microbiota (i.e., microorganisms within and on the human body) (68).
• Provide patient education materials. These materials might include information on appropriate antibiotic use, potential adverse drug events from antibiotics, and available resources regarding symptomatic relief for common infections. Educational materials on management of common infections are available online from CDC (http://www.cdc.gov/getsmart).

Outpatient clinic and health care system leaders can provide education to clinicians and ensure access to expertise by doing at least one of the following:

• Provide face-to-face educational training (academic detailing). This training can be provided by peers, colleagues, or opinion leaders, including other clinicians and pharmacists, and uses reinforcement techniques and peer-to-peer comparisons to facilitate changes in antibiotic prescribing practices (69–71).
• Provide continuing education activities for clinicians. Relevant continuing education activities include those that address appropriate antibiotic prescribing, adverse drug events, and communication strategies about appropriate antibiotic prescribing that can improve patient satisfaction. In particular, communications training in which clinicians were taught to assess patient expectations, discuss the risks and benefits of antibiotic treatment, provide recommendations for when to seek medical care if worsening or not improving (a contingency plan), and assess the patient’s understanding of the communicated information led to sustained decreases in inappropriate antibiotic prescribing (46,72).
• Ensure timely access to persons with expertise. Persons with expertise might include pharmacists or medical and surgical consultants who can assist clinicians in improving antibiotic prescribing for patients with conditions requiring specialty care. For example, in hospitals, pharmacists with infectious disease training have been effective and important members of antibiotic stewardship programs, and in hospital stewardship programs these types of pharmacists have been associated with improved patient outcomes and overall cost savings for the hospital (73). The expertise needed might differ among outpatient facilities and can be determined by each facility.

Acute respiratory tract infections have been a focus of outpatient stewardship because these are the most common conditions leading to antibiotic treatment. However, additional efforts are needed to optimize stewardship efforts for other situations and syndromes that commonly lead to antibiotic use in the outpatient setting, including ambulatory procedures, dental prophylaxis, genitourinary infections, acne and other skin and soft tissue conditions, and chronic obstructive pulmonary disease.

Conclusion

Although the core elements provide a framework for outpatient antibiotic stewardship, implementing the elements requires a thoughtful and consistent effort to achieve desired outcomes. This includes developing strategies and preparing individuals, facilities, or organizations for change; developing and testing stewardship interventions; identifying and addressing barriers to change; and evaluating progress toward stated goals. Outpatient settings remain a crucial component of antibiotic stewardship in the United States. Establishing effective antibiotic stewardship interventions can protect patients and optimize clinical outcomes in outpatient health care settings.

Acknowledgments

Jonathan A. Finkelstein, MD, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts; Jeffrey S. Gerber, MD, PhD, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Adam L. Hersh, MD, PhD, University of Utah, Salt Lake City, Salt Lake City, Utah; David Y. Hyun, MD, The Pew Charitable Trusts, Washington, DC; Jeffrey A. Linder, MD, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; Larissa S. May, MD, University of California—Davis, Sacramento, California; Daniel Merenstein, MD, Georgetown University Medical Center, Washington, DC; Katie J. Suda, PharmD, Department of Veterans Affairs, University of Illinois at Chicago, Chicago, Illinois; Kelly O’Neill, Austyn Dukes, and Rachel Robb, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, Georgia; Rachel Zetts, The Pew Charitable Trusts, Washington, DC.