Antibiotic Stewardship Begins in the Doctor’s Office

Outpatient settings remain a crucial component of antibiotic stewardship in the United States.

Improving antibiotic prescribing in outpatient settings is critical to combating the rise of antibiotic-resistant bacteria. That’s because approximately 60 percent of U.S. antibiotic expenditures for humans are related to care received in outpatient settings.

Educating clinicians and patients about the potential consequences of overprescribing antibiotics, as well as the prudent usage of diagnostic tests, are two powerful tools to curb antibiotic resistance, says the Centers for Disease Control and Prevention in its recently released report, “Core Elements of Antibiotic Stewardship.”

Antibiotic resistance leads to an estimated 2 million infections and 23,000 deaths per year in the United States, says the CDC. Although antibiotics are life-saving drugs, infections with pathogens resistant to first-line antibiotics can require treatment with alternative antibiotics that can be expensive and toxic. Antibiotic-resistant infections can lead to increased healthcare costs and, most important, to increased morbidity and mortality.

The most important modifiable risk factor for antibiotic resistance is inappropriate prescribing of antibiotics, says the CDC. Approximately half of outpatient antibiotic prescribing in humans might be inappropriate, including antibiotic selection, dosing, or duration, in addition to unnecessary antibiotic prescribing. At least 30 percent of outpatient antibiotic prescriptions in the United States are unnecessary.

Steps to stewardship
The CDC defines antibiotic stewardship as the effort to:

• Measure antibiotic prescribing
• Improve antibiotic prescribing by clinicians and use by patients so that antibiotics are only prescribed and used when needed
• Minimize misdiagnoses or delayed diagnoses leading to underuse of antibiotics
• Ensure that the right drug, dose, and duration are selected when an antibiotic is needed

The initial steps toward antibiotic stewardship include recognizing opportunities to improve antibiotic prescribing practices by identifying high-priority conditions, identifying barriers to improving antibiotic prescribing, and establishing standards for antibiotic prescribing.

High-priority conditions are those for which clinicians commonly deviate from best practices for antibiotic prescribing. Examples of types of high-priority conditions for improving antibiotic prescribing include those for which:

• Antibiotics are overprescribed, such as conditions for which antibiotics are not indicated (e.g., acute bronchitis, nonspecific upper respiratory infection, or viral pharyngitis).
• Antibiotics might be appropriate but are overdiagnosed, such as a condition that is diagnosed without fulfilling the diagnostic criteria (e.g., diagnosing streptococcal pharyngitis and prescribing antibiotics without testing for group A Streptococcus).
• Antibiotics might be indicated but for which the wrong agent, dose, or duration is selected, such as selecting an antibiotic that is not recommended (e.g., selecting azithromycin rather than amoxicillin or amoxicillin/ clavulanate for acute uncomplicated bacterial sinusitis).
• Watchful waiting or delayed prescribing is appropriate but underused (e.g., acute otitis media or acute uncomplicated sinusitis).
• Antibiotics are underused or the need for timely antibiotics is not recognized (e.g., missed diagnoses of sexually transmitted diseases or severe bacterial infections such as sepsis).

The practice should identify barriers that lead to deviation from best practices, says CDC. These might include clinician knowledge gaps about best practices and clinical practice guidelines, clinician perception of patient expectations for antibiotics, perceived pressure to see patients quickly, or clinician concerns about decreased patient satisfaction with clinical visits when antibiotics are not prescribed.

In addition, the practice should establish standards for antibiotic prescribing, including implementation of national clinical practice guidelines and, if applicable, developing facility- or system-specific clinical practice guidelines to establish clear expectations for appropriate antibiotic prescribing.

Core elements
It is important that all healthcare team members make a commitment to prescribe antibiotics appropriately and engage in antibiotic stewardship.

Outpatient clinic and health care system leaders can demonstrate their commitment by doing any of the following:

• Identify a 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, 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.
• 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 can improve antibiotic prescribing by using consistent messages when communicating with patients about the indications for antibiotics.
• Use evidence-based diagnostic criteria and treatment recommendations, based, when possible, on national or local clinical practice guidelines informed by local pathogen susceptibilities.
• Use delayed prescribing practices or watchful waiting, when appropriate (e.g., acute uncomplicated sinusitis or mild acute otitis media).
• Provide communications skills training for clinicians, so they can 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.

Patient education
Educating patients about antibiotic resistance is critical to a stewardship program, says the CDC.

Patients should be educated 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. 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).

Practices can write and display public commitments in support of antibiotic stewardship. CDC points out that one practice reduced inappropriate antibiotic prescriptions for acute respiratory infections after displaying, in examination rooms, a letter from the clinician to their patients committing to prescribing antibiotics appropriately. This approach also might facilitate patient communication about appropriate antibiotic use.

Effective communications strategies are essential for patient education. For example, patients should be informed that antibiotic treatment for viral infections provides no benefit. They also should be informed that certain bacterial infections (e.g., mild ear and sinus infections) might improve without antibiotics.

Satisfaction scores among patients who expected but were not prescribed antibiotics can improve if the physician provides recommendations for when to seek medical care if conditions worsen or fail to improve.

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.

To view “Core Elements of Outpatient Antibiotic Stewardship,” go to http://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6506.pdf

Facts about antibiotic prescriptions

• Approximately 60 percent of U.S. antibiotic expenditures for humans are related to care received in outpatient settings

• At least 30 percent of outpatient antibiotic prescriptions in the United States are unnecessary, and at least half might be inappropriate (due to inappropriate selection, dosing or duration).

• During 2013 in the United States, approximately 269 million antibiotic prescriptions were dispensed from outpatient pharmacies.

• Approximately 20 percent of pediatric visits and 10 percent of adult visits in outpatient settings result in an antibiotic prescription.

• Antibiotic resistance leads to an estimated 2 million infections and 23,000 deaths per year in the United States

• Antibiotic treatment is the most important risk factor for Clostridium difficile In 2011, an estimated 453,000 cases of C. difficile infection occurred in the United States, approximately one third of which were community-associated infections (i.e., occurred in patients with no recent overnight stay in a healthcare facility).

• Complications from antibiotics range from common side effects, such as rashes and diarrhea, to less common adverse events, such as severe allergic reactions. These adverse drug events lead to an estimated 143,000 emergency department visits annually and contribute to excess use of healthcare resources

Source: “Core Elements of Outpatient Antibiotic Stewardship,” Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, Nov. 11, 2016, http://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6506.pdf