Outpatient antibiotic stewardship: Opportunities and barriers
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Although antimicrobial stewardship programs are well established in hospitals, they are not common in the outpatient setting, despite the fact that this is where the majority of antimicrobials are prescribed.
Studies have also shown that up to 30% of antimicrobials in the outpatient setting are unnecessary. Unjustified use of antibiotics can lead to complications, including antimicrobial resistance, adverse effects or severe allergic reactions. The CDC reports that 2.8 million antibiotic-resistant infections occur annually, which lead to more than 35,000 deaths. The goal of antimicrobial stewardship programs (ASPs) is to decrease the inappropriate use of antibiotics and optimize their use to improve patient care and decrease health care costs. ASPs in the outpatient setting have been difficult because of limited resources and the impracticality of reviewing each prescription before dispensing it to the patient. Although several interventions have been effective at reducing antibiotic prescribing in this setting, inappropriate use remains high.
Strategies and framework
In January, the Joint Commission released updated accreditation standards specific to outpatient antimicrobial stewardship. They target five specific elements of performance to meet accreditation standards:
- Identify an antimicrobial stewardship leader.
- Establish an annual antimicrobial stewardship goal.
- Implement evidence-based practice guidelines related to the antimicrobial stewardship goal.
- Provide clinical staff with educational resources related to the antimicrobial stewardship goal.
- Collect, analyze and report data related to the antimicrobial stewardship goal.
Even though most outpatient clinics do not seek accreditation by the Joint Commission and are not required to meet these standards, similar goals can be found in the CDC’s core elements of outpatient antibiotic stewardship (see Table). Additionally, the newly released National Action Plan for Combating Antibiotic-Resistant Bacteria 2020-2025 also addresses the issue of outpatient antibiotic use. This plan presents the coordinated actions that the U.S. government will focus on in the next 5 years to change the course of antibiotic resistance. The plan includes five goals, one of which is to improve national outpatient antibiotic use. Specific targets in the outpatient setting include decreasing the rate of outpatient antibiotic dispensing per 1,000 U.S. population, lowering the annual proportion and rate of antibiotic prescriptions for indications in which antibiotics are not needed according to evidence-based guidelines and providing descriptive statistics for trends in unnecessary prescribing patterns.
Trends in outpatient antibiotic prescribing
Recently, there have been some notable trends in antibiotic prescriptions that warrant a closer look. King and colleagues evaluated oral antibiotic prescription rates from 2011 to 2016, and during this period, there was a meager 5% decrease in oral antibiotic use. This was mostly driven by a 13% decrease in antibiotics for pediatric patients, whereas use in adults increased by 2%. A favorable finding in this study was decreased use of fluoroquinolone and macrolide antibiotics. The decrease in macrolide use was likely related to changes in treatment recommendations for sinusitis and acute otitis media secondary to increased resistance among Streptococcus pneumoniae. Reduced fluoroquinolone use was likely driven by FDA safety communications advising against routine use of these agents for uncomplicated infections because of risks for serious adverse effects. Interestingly, the proportion of antibiotic prescriptions written by nurse practitioners (NPs) and physician assistants (PAs) increased during the study period. This is likely because of their increased presence in outpatient clinics. PAs and NPs also were more likely to prescribe broad-spectrum antibiotics. This highlights the need for an interdisciplinary approach to an ASP that includes all aspects of patient care, as well as targeting stewardship efforts toward NPs and PAs.
Barriers and interventions
To accomplish the goals in the national action plan, accurate data for analysis are necessary. A study of the 2015 National Ambulatory Medical Care Survey found that a lack of documented indications could be a barrier to antimicrobial stewardship analysis. There were an estimated 990.8 million ambulatory visits in 2015, with 130 million visits that involved receipt of an antibiotic. Of these, 23.7 million (18%) antibiotic prescriptions were written without a documented indication. Notably, primary care providers were found to be less likely to prescribe antibiotics without a documented indication compared with other specialists.
The attitudes and perceptions of prescribers play a role in the acceptance and success of implementation of outpatient stewardship programs. In a national survey of primary care providers, Zetts and colleagues reported that 91% of those surveyed agreed that inappropriate outpatient prescribing is a problem. However, only 37% agreed that inappropriate prescribing is a problem within their own practice, and 60% agreed that they prescribe antibiotics more appropriately than their peers. Most physicians responded that additional reimbursement from public or private payers would incentivize their adoption of a stewardship program.
Burns and colleagues studied a pharmacist-led intervention with the goal to recognize and reduce inappropriate antibiotic prescription practices. An ambulatory care pharmacist within a primary care office devoted one-half day weekly to auditing and feedback. The pharmacist and physician leader provided initial training and pocket cards on the guidelines for treatment of upper respiratory tract infections and UTIs. The pharmacist then reviewed all antibiotic prescriptions for these indications and provided regular feedback, including both positive remarks and areas to improve adherence to guidelines. This model is notable because the pharmacist was embedded in the practice and had an existing collaborative relationship with the prescriber.
Unfortunately, most primary care clinics do not have a pharmacist on staff. Inpatient antimicrobial stewardship pharmacists are often tasked with spearheading efforts in outpatient clinics. Resources for ASPs are not standardized and often lack sufficient staffing and financial support. Inpatient ASPs are considered self-sufficient financially due to reductions in antimicrobial costs and reduced lengths of stay, but these measures are not applicable to the outpatient setting. As such, outpatient ASP funding and staffing models are undefined, which hinders their development. It will continue to be a challenge to efficiently incorporate outpatient ASPs into most practices until novel provider incentives are adopted to encourage improved antibiotic prescribing practices and funding for ASP initiatives in this setting.
- References:
- ASPE. National action plan for combating antibiotic-resistant bacteria 2020-2025. https://aspe.hhs.gov/pdf-report/carb-plan-2020-2025. Accessed October 19, 2020.
- Avent ML, et al. BMC Fam Pract. 2020;doi:10.1186/s12875-020-01191-0.
- Burns KW, et al. J Am Pharm Assoc. 2020;doi:10.1016/j.japh.2020.08.003.
- CDC. Antibiotic resistance threats in the United States 2019. https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf. Accessed October 19, 2020.
- Greene MH, et al. Infect Control Hosp Epidemiol. 2020;doi:10.1017/ice.2019.294.
- The Joint Commission. R3 Report Issue 23: Antimicrobial stewardship in ambulatory health care. https://www.jointcommission.org/standards/r3-report/r3-report-issue-23-antimicrobial-stewardship-in-ambulatory-health-care. Accessed October 19, 2020.
- King LM, et al. Clin Infect Dis. 2020;doi:10.1093/cid/ciz225.
- Ray MJ, et al. BMJ. 2019;doi:10.1136/bmj.16461.
- Sanchez GV, et al. MMWR Recomm Rep; 2016;65:1-12.
- Zetts RM, et al. Open Forum Infect Dis. 2020;doi:10.1093/ofid/ofaa244.
- For more information:
- Jeff Brock, PharmD, MBA, BCPS-AQ ID, is an infectious disease pharmacy specialist at Mercy Medical Center in Des Moines, Iowa. He can be reached at jbrock@mercydesmoines.org.
- Kimberly Owen is a PharmD student at Creighton University’s School of Pharmacy and Health Professions.
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