Outpatient Antibiotic Stewardship
Maria G. Tanzi, PharmD
Researchers estimate that at least 30% of antibiotics prescribed in the outpatient setting are unnecessary and inappropriate. Outpatient antibiotic use is close to 50% for patients receiving the wrong drug, the wrong dose, and/or the wrong duration. These issues have prompted The Joint Commission to implement new antimicrobial stewardship requirements for ambulatory health care organizations they accredit that routinely prescribe antimicrobial medications. The new requirements, which became effective on January 1, 2020, apply to organizations that provide medical or dental services, episodic care, occupational health, urgent care, and convenient care.
“Antibiotics are commonly prescribed by primary care providers and at urgent care clinics and dental offices, with many of these prescriptions being inappropriate,” said Amy Hanson, PharmD, BCPS AQ-ID, antimicrobial stewardship and infectious disease pharmacist at the Chicago Department of Public Health. “This inappropriate use of antibiotics contributes to antibiotic resistance and places patients at risk for adverse effects such as the potential for Clostridioides difficile infections. Therefore, outpatient practice settings are prime targets for antibiotic stewardship interventions.”
Select antibiotic stewardship interventions
The new Joint Commission requirements focus on key elements such as identifying an antimicrobial stewardship leader, establishing an annual antimicrobial stewardship goal, implementing evidence-based practice guidelines, reporting data related to the goal, and educating clinical staff.
For the annual goal, high-priority conditions in which antibiotics are inappropriately used can be the initial targets. Examples of high-priority conditions are those for which antibiotics are not indicated (e.g., acute bronchitis, nonspecific upper respiratory infection, or viral pharyngitis) or for which watchful waiting or delayed prescribing may be appropriate but underused (e.g., acute otitis media or acute uncomplicated sinusitis). Addressing overuse of a specific antibiotic class may also be a targeted intervention.
Hanson discussed numerous interventions that can be impactful in the outpatient setting. She noted that dermatologic practitioners often prescribe long courses of systemic antibiotics when some dermatologic conditions may be treated with topical agents. She also noted that antibiotics may not be needed for acute dental conditions, such as toothache.
“The American Dental Association (ADA) has recently released a clinical practice guideline on antibiotic use for the urgent management of select acute dental conditions, and the guidelines recommend against the use of antibiotics for most conditions and instead recommends only the use of dental source control and, if needed, OTC pain relievers such as acetaminophen and ibuprofen,” said Hanson. In addition, ADA recommends that antibiotic prophylaxis prior to dental procedures be used only for patients who are at the greatest risk of posttreatment bacterial-related complications.
Other interventions Hanson mentioned include pharmacists helping to determine if a patient is truly allergic to a class of antibiotics (commonly beta-lactams) and the importance of both peer-to-peer and clinician-to-patient education. Community practitioners can be educated on the recent warnings associated with fluoroquinolone use and the need to reserve this class of medications for patients with more complicated infections. Also, providers can be informed of the risks of C. difficile with use of antibiotics such as clindamycin, even after a single dose.
These educational efforts may help decrease prescribing of these agents. Patients can also be educated on appropriate use of antibiotics, potential adverse effects, and recommended durations of therapy (with a trend toward the shorter the better).
Necessary resources
Because many outpatient settings do not have a dedicated clinician who is an expert in antibiotic stewardship, education and appropriate resources for these organizations are essential. Outpatient clinics associated with a hospital may be able to leverage assistance from inpatient staff, and clinicians can obtain specialized training in antibiotic stewardship through certificate programs.
“The Society of Infectious Disease Pharmacists has an antibiotic stewardship training certificate program that can help clinicians initiate a program at their practice,” Hanson said. “CDC also has numerous resources on its website, including a document outlining the core elements of outpatient antibiotic stewardship.”