January 20, 2020
3 min read

Small, practical steps can improve antibiotic stewardship in the outpatient setting

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Although the CDC’s Core Elements of Outpatient Antibiotic Stewardship provide a framework for outpatient antibiotic use, researchers are calling for more practical strategies and tools that are straightforward, highly effective and sustainable in a letter to the editor published in Infection Control & Hospital Epidemiology.

“The use of unnecessary antibiotics or unnecessarily broad antibiotics can result in an increase in antibiotic-resistant organisms and adverse drug events,” Holly Frost, MD, pediatrician at Denver Health and assistant professor of pediatrics at the University of Colorado School of Medicine, told Healio. “Most antibiotics in the United States are prescribed in the outpatient setting, yet we have a very limited understanding of how to practically implement the CDC’s Core Elements of Outpatient Antibiotic Stewardship into clinical practice. We felt it was important to share our experiences and lessons learned from implementing outpatient antimicrobial stewardship interventions at eight Colorado pediatric practices.”

Frost and colleagues used surveys and semi-structured phone interviews with physicians to evaluate the ability of health care practices to maintain the implementation of the Core Elements, as well as tracking and reporting and education and expertise.

Of the eight practices surveyed, seven identified a leader for antibiotic stewardship and five planned to display commitment posters. Six had access to experts in antibiotics and six intended to offer ongoing education about antibiotic use. The survey revealed that only four practices had established systems for ongoing antibiotic stewardship-related duties, five had systems for tracking and three had systems for reporting.

Barriers that “complicated” the practices’ ability to display commitment to the Core Elements included lack of control and competing priorities; barriers to sustaining education about antimicrobial stewardship were scheduling and a shortage of resources, such as regional experts. Additionally, practices were more likely to continue tracking and reporting per the Core Elements if there was stronger information technology support and a nonphysician took on the responsibility.

“Though we have recently seen increased attention on outpatient antibiotic stewardship, we know relatively little about the best and most practical ways to implement antimicrobial stewardship programs in community-based outpatient settings and how to make these interventions sustainable,” Frost said. “We are particularly limited in our understanding of how to do this in small- to mid-sized practices and resource-limited settings.”

Frost explained that the most sustainable interventions are typically the simplest and least time consuming for practices, so that practices do not get “bogged down” implementing them. She also emphasized the importance of specific, streamlined strategies.


“We found success in having a forum for practices to share practical tips with each other and centralizing some processes, such as printing commitment posters,” she said. “We also propose that having a detailed toolkit and step-by-step guide for practices, analogous to what has been created for hospitals, would be useful.”

Sharon Tsay, MD , medical officer in the CDC’s Office of Antibiotic Stewardship, says that although the Core Elements did contribute to a 6% decrease in overall prescribing of antibiotics in the U.S., there is still room for improvement, especially in prescribing to adults, in certain outpatient settings like urgent care clinics and for certain conditions where antibiotics are unnecessary, like viral respiratory infections.

In addition, as more clinicians, facilities and public health agencies initiate antibiotic stewardship in the outpatient setting, new areas for improvement will be identified. Tsay says reducing the use of antibiotic classes of concern — such as fluoroquinolones — could have “far-reaching effects” on reducing the risks for other antibiotic treatment-associated adverse events.

That said, Tsay notes that physicians – and not the CDC alone – are also responsible for stewardship.

“Antibiotic stewardship has often been described as prescribing the right drug at the right time at the right dose for the right duration. Although this may feel like a big task, clinicians can prioritize stewardship even in small ways each time they consider prescribing an antibiotic,” she said.

Physicians can consider a number of questions that may help them put a bigger emphasis on antibiotic stewardship, Tsay continued. First, consider if antibiotics are even indicated by asking: “Is this a viral infection, in which case antibiotics will not help?” Clinicians should also ask themselves if there is a first-line antibiotic for the condition presented to help improve antibiotic selection.

“Reducing unnecessary antibiotic use for conditions that don’t need antibiotics and improving antibiotic selection for common conditions can make a big impact in improving antibiotic use overall,” Tsay concluded. – by Caitlyn Stulpin

Disclosures: Frost and Tsay report no relevant financial disclosures.