Outpatient Antibiotic Stewardship: Intervention and Opportunities

Outpatient Antibiotic Stewardship: Intervention and Opportunities
Lauren Turner, Pharm.D., Fairview Pharmacy Services 

Background: Antibiotic overuse and misuse has become a concern across health care. The federal government has mandated this issue a national priority. This has lead to the expansion of antibiotic stewardship programs (ASPs) across the continuum of care, including outpatient practice settings. However, best practices for outpatient ASPs are yet to be defined due to unique factors that drive inappropriate antibiotic use in this clinical setting.   

Objective: To combat these challenges, evidence-based antibiotic stewardship (AS) interventions and opportunities have been identified to enhance AS in the outpatient setting.

Interventions: Several strategies that have demonstrated success in enhancing AS include: [1] auditing and feedback, [2] education, [3] clinical decision support (CDS) tools, [4] delayed prescribing, [5] guideline implementation, and [6] point-of-care (POC) testing. Each intervention is summarized to highlight opportunities for outpatient ASPs. 

[1] Auditing and Feedback: Provider audit and feedback methods are important to motivate change in prescriber patterns. In order to provide feedback on antibiotic prescribing patterns, clinical practices could consider adding antibiotic use metrics to other clinical metrics. Evidence has shown that sustained quarterly provider feedback and education has vastly reduced broad-spectrum antibiotic prescribing. 

[2] Education: A comprehensive education plan directed towards health care professionals and patients is imperative to the AS initiative, and to drive change within practice. Communication training for prescribers, as well as shared decision making between the patient and prescriber, have been found to demonstrate success in antibiotic use reduction. Additional patient education should focus on promoting wellness, vaccinations, and community pharmacy-based disease management to minimize unnecessary office visits and reduce antibiotic misuse. 

[3] CDS Tools: CDS tools, created from electronic health records, offer assistance with AS during antibiotic prescribing.  Through electronic alerts, antibiotic order sets, and cascading questions, antibiotic drug therapy selection is guided more appropriately. CDS tools can also require prescriber justification when prescribing a non-recommended antibiotic. This will ensure guideline-driven antibiotic use. 

[4] Delayed Prescribing: Also referred to as watchful waiting, delayed prescribing is an effective strategy to reduce antibiotic use. This can be completed by requesting the patient delay filling the antibiotic prescription for 24-48 hours, postdating the prescription, or contacting the patient after the encounter to re-evaluate the patient’s clinical status and appropriateness of treating with an antibiotic.   

[5] Guideline Implementation: Health care system-specific antibiotic use guidelines should be implemented for common outpatient infectious diseases. This will minimize unnecessary or inappropriate antibiotic use and combat antibiotic-resistant bacteria. These guidelines should take into account local resistance patterns, prescribing trends, and cost. Evidence has shown that prescribing guidelines are associated with improved antibiotic outcomes in the outpatient setting. 

[6] POC Testing: An ideal opportunity to enhance AS and to influence appropriate antibiotic use is through POC testing. POC testing has been identified as one of the leading innovations to promote AS in the outpatient setting by identifying patients with a disease of interest, providing timely treatment with the recommended antimicrobial agents, and delivering supportive care when antibiotics are not warranted.

Conclusions: Antibiotic resistance is a tremendous public health issue and improving antibiotic use is a national priority. To address these concerns, driving ASPs across the continuum of care will lead to continual progression towards appropriate antibiotic use to counteract antibiotic resistance. Outpatient AS initiatives should be strategized, developed, and piloted to further enhance the ASP care model.

References:

Dobson EL, Klepser ME, Pogue JM, et al. Outpatient antibiotic stewardship: Interventions and opportunities. J Am Pharm Assoc 2017;57(4):464-473.