Version May 2024
INTRODUCTION — Antimicrobial stewardship consists of systematic measurement and coordinated interventions designed to promote the optimal use of antimicrobial agents, including their choice, dosing, route, and duration of administration [1,2]. The primary goal of antimicrobial stewardship is to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use (including toxicity, selection of pathogenic organisms such as Clostridioides difficile, and the emergence of antimicrobial resistance) [3]. Additional benefits include improving susceptibility rates to targeted antimicrobial agents and optimizing resource utilization [1].
The majority of antimicrobial use in humans occurs in outpatient settings, making this a critical target of antimicrobial stewardship. In the United States in 2021, more than 211 million courses of antimicrobials were prescribed in the outpatient setting (estimated to be 636 antibiotic prescriptions per 1000 persons) [4]. Infections of the respiratory tract, skin and skin structure, and urinary tract are the most frequent diagnoses for which antimicrobials are prescribed.
Issues related to outpatient antimicrobial stewardship are reviewed here. General principles regarding antimicrobial stewardship and issues related to antimicrobial stewardship in hospital settings are discussed separately. (See "Antimicrobial stewardship in hospital settings".)
BACKGROUND — Inappropriate antimicrobial use in outpatient settings is common [5-10]. The CDC estimates that up to 30 percent of antibiotics prescribing in clinics are unnecessary, and many more prescriptions are suboptimal (wrong choice, wrong dose, wrong duration) [11]. Inappropriate outpatient antibiotic use is linked to emergence of multidrug-resistant organisms, patient harm (eg, adverse drug events) and increased health care cost [12].
Antimicrobial prescribing in outpatient settings across the US is highly variable [13]. In one study of a pediatric primary care network, the probability of being prescribed a non-first-line antimicrobial for community-acquired pneumonia ranged from 0.22 to 0.88 [14]. In a review of outpatient visits for acute respiratory infection (ARI), the 10 percent of providers who prescribed antimicrobials most frequently did so for 95 percent of ARI visits, while the 10 percent of providers who prescribed the least frequently did so for <40 percent of ARI visits [15]. Prescribing rates also vary geographically, with reports of increased inappropriate antibiotic prescribing in the southern US and in rural settings [16,17].
In 2017, the Joint Commission required that all hospitals and nursing care centers have antimicrobial stewardship programs; this regulation also applies to all outpatient facilities associated with the hospital or center, including clinics and ambulatory surgical centers.
CORE ELEMENTS OF OUTPATIENT STEWARDSHIP — Core elements of outpatient antimicrobial stewardship (outlined by the United States Centers for Disease Control and Prevention) include [2]:
●Commitment
●Action for policy and practice (stewardship program interventions)
●Tracking and reporting
●Education and expertise
The AHRQ Safety Program for Improving Antibiotic Use in Ambulatory Care was developed to assist programs in establishing outpatient antimicrobial stewardship programs according to CDC guidelines and requirements [18,19].
Commitment — Clinicians can commit to antimicrobial stewardship by displaying a public statement in patient care areas describing adherence to appropriate antimicrobial use; this approach also provides an opportunity to educate patients about the issue. In one randomized trial including more than 950 adult visits for acute respiratory infection, displaying commitment letters reduced inappropriate antimicrobial prescribing by nearly 20 percent [20].
Clinic and health care system leadership can demonstrate commitment to antimicrobial stewardship by identifying a leader to direct stewardship activities, including such activities in job descriptions or promotion criteria, and by communicating with all clinic staff members to set appropriate patient expectations regarding antimicrobial prescribing practices.
Stewardship program interventions — One or more interventions should be implemented to promote the optimal use of antimicrobials. Interventions for outpatient settings are discussed below; some stewardship interventions commonly used in hospitals are also applicable to the outpatient setting. (See "Antimicrobial stewardship in hospital settings".)
Identify high-priority condition(s) — High-priority conditions are those for which clinicians commonly deviate from best practices for antimicrobial prescribing; they include conditions for which antimicrobial are overprescribed, under-prescribed, or mis-prescribed (with the wrong antimicrobial agent, dose, or duration).
Examples include:
●Conditions for which antimicrobials are not indicated (examples include acute bronchitis, the common cold, other nonspecific upper respiratory infection or viral pharyngitis, and asymptomatic urinary tract infection) [21,22]
●Conditions for which antimicrobials might be indicated but are over-diagnosed, such as a condition that is diagnosed without fulfilling diagnostic criteria (for example, prescribing antimicrobials for streptococcal pharyngitis without testing for group A Streptococcus) [21]
●Conditions for which antimicrobials might be indicated but for which the wrong antimicrobial class, agent, dose or duration is often selected [23-25]
●Conditions for which watchful waiting or delayed prescribing is appropriate but underused (examples include acute otitis media and acute uncomplicated sinusitis) [24,26,27]
These conditions are discussed further separately:
●(See "The common cold in adults: Treatment and prevention" and "The common cold in children: Management and prevention".)
●(See "Acute bronchitis in adults".)
●(See "Asymptomatic bacteriuria in adults".)
●(See "Evaluation of acute pharyngitis in adults" and "Evaluation of sore throat in children".)
●(See "Acute otitis media in adults" and "Acute otitis media in children: Treatment".)
●(See "Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment".)
Clinician interventions — The following interventions may be pursued to improve antimicrobial prescribing [2,28]:
●Identify barriers that lead to deviation from best practices (examples include clinician knowledge gaps about clinical practice guidelines, clinician perception of patient expectations regarding antimicrobials, and perceived pressure to see patients quickly).
Providers' perceptions of patients' desire to receive antimicrobials are often incorrect. In one survey performed by the United States Centers for Disease Control and Prevention, 54 percent of providers believed their patients expected to receive antimicrobials during visits for a cough or cold, while only 26 percent of patients actually had such an expectation [29]. Communication training, including shared decision-making, can help prescribers avoid unnecessary antimicrobial prescribing [30]. As an example, it may be beneficial for clinicians to provide education regarding adverse effects of antimicrobials as well as to offer guidance regarding alternative forms of symptomatic relief [31].
●Establish standards for antimicrobial prescribing; this might include implementation of national guidelines and/or developing facility-specific guidelines (if applicable) to establish clear expectations for appropriate antimicrobial prescribing. As an example, one study noted use of clinical pathways for common outpatient infections was associated with a reduction in antimicrobial prescriptions for acute respiratory infections [32].
Providers frequently prescribe antimicrobials for a longer duration than necessary [33]. Clinical pathways can promote the shortest effective duration of therapy supported by evidence in order to limit unintended consequences of antimicrobial use. Pharmacist review of prescriptions could facilitate adherence to the preferred duration of therapy [34].
Prescriber education is necessary but insufficient to implement the changes required for improved antimicrobial prescribing [35,36]. One survey of primary care physicians, nurse practitioners, and physician assistants noted that providers frequently fail to comply with guidelines even when they are familiar with them [35]. Reasons included belief that nonrecommended antimicrobials were more effective, concern for complications, and patient satisfaction; concern about the general problem of antimicrobial resistance was not routinely factored into decisions about antimicrobial use.
●Use watchful waiting or delayed prescribing for patients with conditions that usually resolve without treatment but who can benefit from antimicrobials if symptoms do not improve; this approach can safely decrease antimicrobial use when used in accordance with clinical practice guidelines. In such cases, symptomatic relief should be provided with a clear plan for follow-up if symptoms worsen or do not improve (for example, the patient may be instructed to call or return for a prescription, or a postdated prescription may be provided with instructions to fill the prescription after a predetermined period).
●Reduce inappropriate diagnostic testing that frequently leads to inappropriate antimicrobial therapy [37,38]. As examples, urine cultures are not warranted in the absence of voiding symptoms or pyuria, and sputum cultures are not warranted for patients with acute bronchitis.
●Issues related to antimicrobial allergy assessment are discussed separately. (See "Antimicrobial stewardship in hospital settings", section on 'Antimicrobial allergy assessment'.)
Leadership interventions — Clinic and health care system leadership can pursue the following interventions to improve antimicrobial prescribing [2]:
●Provide clinician communications skills training to promote strategies for discussing benefits and harms of antimicrobial use, management of self-limiting conditions, patient concerns regarding prognosis, and clinician concerns regarding managing patient expectations for antimicrobials [31,39,40].
●Provide support for antimicrobial decision-making within the clinical workflow [32,41,42].
●Require written justification in the medical record for all antimicrobial prescriptions [43].
Tracking and reporting — Tracking and reporting clinician antimicrobial prescribing (also called audit and feedback) can guide changes in practice and be used to assess progress in improving antimicrobial prescribing. (See "Antimicrobial stewardship in hospital settings", section on 'Antimicrobial oversight'.)
Tracking and reporting for high-priority conditions can be used to assess whether appropriate diagnostic criteria were met, whether an antimicrobial was appropriate for the assigned diagnosis, whether the selected antimicrobial was the recommended agent, and whether the dose and duration were correct. (See 'Identify high-priority condition(s)' above.)
When possible, tracking of individual clinician antimicrobial prescribing (with provision of individualized feedback) is preferred [44]. Comparison of clinicians' performance with that of their top- and bottom-performing peers has been shown to be an effective feedback intervention [43-47].
In addition, tracking and reporting the complications of antimicrobial use (such as C. difficile infections, drug interactions, and adverse drug events) and antimicrobial resistance trends are useful.
Education and expertise — Education on appropriate antimicrobial use should involve patients and clinicians.
Clinicians can educate patients about appropriate antimicrobial use by:
●Educating patients about when antimicrobials are and are not needed – Patients should be informed that use of antimicrobials for viral infections provides no benefit and that certain bacterial infections (such as mild sinus and ear infections) might improve without antimicrobials. In addition, recommendations for symptom management and instructions for when to seek medical if symptoms worsen or do not improve should be provided [31].
●Educating patients about the potential harms of antimicrobial treatment; these include nausea, abdominal pain, diarrhea, C. difficile infection, and allergic reactions.
Provision of patient education materials can facilitate this process [48].
Clinic and health care system leaders can facilitate clinician education by providing formal educational training and continuing education opportunities and ensuring timely access to individuals with relevant expertise (such as pharmacists and infectious disease consultants).
SPECIAL SETTINGS
Telemedicine — Telemedicine now plays a key role in the outpatient setting and antimicrobial stewardship has been effectively implemented in this context [49,50]. While variable results have been reported, some have demonstrated that implementation of stewardship principles, including institutional guidelines, during telemedicine encounters can be associated with reductions in unnecessary antibiotic prescriptions [50].
Emergency department — Despite barriers within the emergency department (ED), including the need for rapid decision making and limited availability of diagnostic information, antimicrobial stewardship principles can be successfully implemented in the ED [51,52]. Implementation of the core antimicrobial stewardship elements in Veterans Administration departments was associated with a reduction in inappropriate antibiotic prescribing for upper respiratory tract infections together with a reduction in hospitalizations [53].
An involved pharmacist can assist ED clinicians in antimicrobial choice and dosing as well as in the development and implementation of local guidelines [54,55]. In addition, the ED pharmacist can assist with follow-up microbiology data to verify that discharged patients received appropriate antimicrobial therapy [56,57].
Urgent care centers — Antimicrobial stewardship is being effectively implemented in urgent care centers [9,49,58]. A large health care network reported lower antibiotic prescription rates in their urgent care centers compared with published reports, suggesting that formal programs targeting urgent care settings would be successful [49]. Such programs are multidimensional, introducing multiple antimicrobial stewardship program interventions at once, including electronic medical record changes to promote appropriate antibiotic use, patient education, and provider feedback [59].
Outpatient dialysis units — Parenteral antimicrobial use in dialysis centers is common. In one retrospective study including two dialysis units, approximately 30 percent of prescribed antimicrobial doses were inappropriate [60]. The American Society of Nephrology and the United States Centers for Disease Control and Prevention have published a white paper that addresses a number of strategies for improving antibiotic use in outpatient hemodialysis facilities [61].
Many of the principles of outpatient antimicrobial stewardship can be applied to outpatient dialysis units; however, the high-priority conditions are different. Dialysis units should focus on and develop clinical pathways targeting line-associated bacteremia and vascular access site infections, as well as improving the appropriate use of antimicrobials like vancomycin [62]. Use of antimicrobial lock therapy for line infections may reduce the need for parenteral antimicrobials and, in some cases, the need to replace vascular access devices. (See "Lock therapy for treatment and prevention of intravascular non-hemodialysis catheter-related infection".)
Dentist offices — Dental prescriptions account for approximately 10 percent of outpatient antimicrobial use and a variety of interventions are recommended [63-66]. The American Dental Association has endorsed antimicrobial stewardship and supports more restrictive guidelines for antimicrobial prophylaxis prior to dental procedures in accordance with recent guidelines [67-69].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Antimicrobial stewardship".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (See "Patient education: What you should know about antibiotics (The Basics)".)
SUMMARY
●Definition – Antimicrobial stewardship refers to systematic measurement and coordinated interventions designed to promote optimal use of antimicrobial agents, by advocating selection of appropriate antimicrobial drug regimens (including dosing, duration of therapy, and route of administration).
●Rationale for outpatient stewardship – The majority of antimicrobial use occurs in outpatient settings, making this a critical target of antimicrobial stewardship. (See 'Introduction' above.)
●Core elements – Core elements of outpatient antimicrobial stewardship include commitment, stewardship program interventions, tracking and reporting, and education and expertise. (See 'Core elements of outpatient stewardship' above.)
●Role of leadership – Clinicians can commit to antimicrobial stewardship by displaying a public statement in patient care areas describing adherence to appropriate antimicrobial use. Clinic and health care system leadership can identify a leader to direct stewardship activities and communicate with clinic staff members regarding appropriate patient expectations for antimicrobial prescribing practices. (See 'Commitment' above.)
●Basic components – Initial steps for outpatient antimicrobial stewardship include identifying one or more high-priority condition(s) (ie, those for which clinicians commonly deviate from best practices, including conditions for which antimicrobials are overprescribed, under-prescribed, or mis-prescribed), identifying barriers leading to deviation from best practices, and establishing standards for antimicrobial prescribing. (See 'Stewardship program interventions' above.)
●Providing feedback – Tracking and reporting clinician antimicrobial prescribing (also called audit and feedback) can guide changes in practice and be used to assess progress in improving antimicrobial prescribing. When possible, tracking of individual clinician antimicrobial prescribing (with provision of individualized feedback) is preferred. (See 'Tracking and reporting' above.)
●Educating patients – Clinicians can educate patients about appropriate antimicrobial use by educating patients about when antimicrobials are and are not needed and by educating patients about the potential harms of antimicrobial treatment. (See 'Education and expertise' above.)
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