Antimicrobial stewardship in outpatient settings
- Marisa Holubar, MD, MS
Marisa Holubar, MD, MS
- Clinical Assistant Professor, Division of Infectious Diseases and Geographic Medicine
- Stanford University
- Stan Deresinski, MD
Stan Deresinski, MD
- Clinical Professor of Medicine, Division of Infectious Diseases and Geographic Medicine
- Stanford University
Antimicrobial stewardship consists of systematic measurement and coordinated interventions designed to promote the optimal use of antibiotic agents, including their choice, dosing, route, and duration of administration [1,2]. The primary goal of antibiotic stewardship is to optimize clinical outcomes while minimizing unintended consequences of antibiotic use (including toxicity, selection of pathogenic organisms such as Clostridium difficile, and the emergence of antibiotic resistance) . Additional benefits include improving susceptibility rates to targeted antibiotics and optimizing resource utilization .
The majority of antibiotic use occurs in outpatient settings, making this a critical target of antimicrobial stewardship. In the United States in 2011, more than 260 million courses of antibiotics were prescribed in the outpatient setting . Infections of the respiratory tract, skin and skin structure, and urinary tract are the most frequent diagnoses for which antibiotics are prescribed in the outpatient setting.
Issues related to outpatient antibiotic stewardship are reviewed here. General principles regarding antibiotic stewardship and issues related to antibiotic stewardship in hospital settings are discussed separately. (See "Antimicrobial stewardship in hospital settings".)
Inappropriate antibiotic use in outpatient settings is common [5-8]. In one study of adult outpatient visits in the United States in 2010 to 2011, approximately 13 percent of visits resulted in an antimicrobial prescription; at least 30 percent of these were inappropriate . Another study including more than 1000 adults with respiratory tract infection seen in outpatient clinics between 2009 and 2011 noted that 77 percent were prescribed antibiotic therapy; antibiotic therapy was inappropriate in 64 percent of cases .
The approach to antibiotic prescribing in United States outpatient settings is highly variable . 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 . In a review of outpatient visits for acute respiratory infection (ARI), the 10 percent of providers who prescribed antibiotics 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 .
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- CORE ELEMENTS OF OUTPATIENT STEWARDSHIP
- Stewardship program interventions
- - Identify high-priority condition(s)
- - Clinician interventions
- - Leadership interventions
- Tracking and reporting
- Education and expertise
- SPECIAL SETTINGS
- Emergency department
- Outpatient dialysis units
- Dentist offices