Why Antibiotic Stewardship is Important in the Ambulatory Care Setting

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Understanding the Issue

“Inappropriate antibiotic use and antibiotic resistance are major public health threats. In the United States, most antibiotic use occurs in ambulatory care and 30% to 50% may be inappropriate. The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotics by 50% by 2020. “    TA Rowe et al

Misuse of antibiotics and antibiotic resistance are major public health threats and it is estimated that more than 30% of antibiotic use in ambulatory areas may be inappropriate. Antibiotic stewardship is the effort to measure and improve antibiotic prescribing and use by patients, so these medications are only prescribed and used when needed. It is an effort to minimize misdiagnoses or delayed diagnoses leading to the inappropriate use or underuse of appropriate antibiotics and thus, ensure that the right drug, dose, and duration are selected when an antibiotic is needed.

Stewardship promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.

Misuse and overuse of antibiotics is one of the world’s most pressing public health problems. Infectious organisms adapt to the antimicrobials designed to kill them, making the drugs ineffective. People infected with antimicrobial-resistant organisms are more likely to have longer, more expensive hospital stays, and may be more likely to die because of an infection.

Antibiotic misuse is not new. Alexander Fleming recognized it as early as the 1940’s, when he remarked on penicillin’s decreasing efficacy, due to its overuse. Then in the 1970’s the first formal evaluation of antibiotic use in children regarding antibiotic choice, dose and necessity of treatment was undertaken.

In the 1980’s, infection control programs were established in hospitals to systematically record and investigate hospital-acquired infections. Evidence-based treatment guidelines and the regulation of antibiotic use surfaced.

In 1996, John McGowan and Dale Gerding from Emory University School of Medicine, coined the term AMS (antimicrobial stewardship). They suggested trials be done to determine the best methods to prevent and control this problem and ensure optimal antimicrobial use stewardship.

Guidelines Recommended

In 1997, the Society of Healthcare Epidemiology in America (SHEA) and the Infectious Diseases Society of America published guidelines to prevent antimicrobial resistance so appropriate antimicrobial stewardship, that included optimal selection, dose, and duration of treatment, as well as control of antibiotic use, would prevent or slow the emergence of resistance among microorganisms.

On September 18, 2014, President Barack Obama issued  Executive Order 13676, “Combating Antibiotic-Resistant Bacteria’. This Executive Order charged a Task Force to develop a 5-Year Action Plan that included steps to reduce the emergence and spread of antibiotic-resistant bacteria and ensure continued availability of effective therapies for infections. Improved antimicrobial stewardship is one of the charges of this Executive Order. The Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria (PACCARB) was formed in response to this Executive Order.

In 2014, the CDC recommended, that all US hospitals have an antibiotic stewardship program. The Joint Commission approved regulations which went into effect January 1, 2017 detailing that hospitals should have an Antimicrobial Stewardship team to write protocols and develop projects focused on the appropriate use of antibiotics. The Joint Commission has now expanded this to ambulatory (outpatient) health care organizations as well.

Despite the efforts to reduce resistance, the CDC estimates that more than 2.8 million antibiotic-resistant infections occur in the United States each year, and more than 35,000 people die as a result. (The Core Elements of Outpatient Antibiotic Stewardship Programs: Centers of Disease Control (2016).

By the Numbers

Improving antibiotic prescribing in all health care settings is critical to combating antibiotic resistant bacteria. Here are some statistics related to overuse of antibiotics in the outpatient setting.

• Approximately 60% of U.S. antibiotic expenditures are related to care received in outpatient settings.
• In other developed countries, approximately 80%–90% of antibiotic use occurs among outpatients.
• During 2013 in the United States, approximately 269 million antibiotic prescriptions were dispensed from outpatient pharmacies.
• Approximately 20% of pediatric visits and 10% of adult visits in outpatient settings result in an antibiotic prescription.

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 health care resources. (The Core Elements of Outpatient Antibiotic Stewardship Programs: Centers of Disease Control (2016).

A Multidisciplinary Initiative

Those involved in making sure that antibiotics are prescribed appropriately are primary care clinicians, emergency department clinicians, dentists, nurse practitioners, physician assistants, outpatient setting clinicians, retail health clinicians, urgent care settings and other health care settings.

Starting an antibiotic stewardship program requires the following steps:

• Recognize opportunities to improve antibiotic prescribing practices by identifying high-priority conditions.
• Identify barriers to improving antibiotic prescribing.
• Establishing standards for antibiotic prescribing.

Additional steps to guide you on the road to a successful Antibiotic Stewardship Program include commitment, action, tracking, reporting, education, and expertise on the part of the clinician(s) and organization. Let’s examine these for further implementation.

1. Commitment
Demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety. This can be achieved when all members of the healthcare team, whether directly or indirectly, prescribe antibiotics appropriately and/or engage in antibiotic stewardship. This is critical to improving patient safety. Each clinician can make the choice to be an effective antibiotic steward during each patient encounter.

2. Action for Policy and Practice
Implement at least one policy or practice to improve antibiotic prescribing, assess whether it is working, and modify as needed. Clinicians and organizations can implement policies and interventions to promote appropriate antibiotic prescribing practices. Assessing and modifying of implemented policies and interventions is critical to improving antibiotic prescribing practices. Action is necessary to transform policy and practice into measurable outcomes to see if there is any break in practice.

3. Tracking and reporting
Monitor antibiotic prescribing practices and offer regular feedback to clinicians, or have clinicians assess their own antibiotic prescribing practices themselves. Tracking and reporting clinician antibiotic prescribing can guide changes in practice and be used to assess progress in improving antibiotic prescribing.

4. Education and Expertise
Provide educational resources to clinicians and patients on antibiotic prescribing and ensure access to needed expertise on optimizing antibiotic prescribing. Education on appropriate antibiotic use can involve patients and clinicians. Education for patients and family members can improve understanding of the appropriate use of antibiotics as well as when they are not necessary. Education for clinicians and clinic staff members can reinforce appropriate antibiotic prescribing and improve the quality of care for patients.

Summary

Rowe recommends that to decrease inappropriate ambulatory antibiotic use, clinicians, pharmacists, practices, and health systems need to collect antibiotic prescribing data, select concrete improvement targets, and implement evidence-based interventions such as peer comparison, accountable justification, precommitment, and communication training.

Identifying an antimicrobial stewardship leader, establishing an annual antibiotic stewardship goal, implementing evidence-based practice guidelines, and providing clinical staff with educational resources sets the stage. Collecting, analyzing, and reporting data related to the antibiotic stewardship goal demonstrates ongoing progress or the need for additional activities to keep the organization on track. Providing ongoing progress checkpoints and support enables organizations to develop an Antibiotic Stewardship Program for their facility that will protect patients and optimize clinical outcomes in the outpatient health care setting.

Checklist to Facilitate Assessment of Antibiotic Stewardship Programs

Facility Checklist for Core Elements of Outpatient Antibiotic Stewardship

References

Joint Commission Comprehensive Accreditation Manual for Hospitals 2020.

The Core Elements of Outpatient Antibiotic Stewardship Programs: Centers of Disease Control (2016).

Rowe TA etal, Expert Rev Anti Infect Ther. Novel approaches to decrease inappropriate ambulatory antibiotic use. doi: 10.1080/14787210.2019.1635455. Epub 2019 Jul 5
Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016;65 (No. RR6):1-12.

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