Devin Pinaroc, FNP-C The CDC’s Antibiotic Resistance Threats in the United States, 2019 Report, identified 18 different multi-drug resistant bacteria and fungi that have a widespread prevalence and pose significant threat to the public. More than 2.8 million people in the US develop an antibiotic resistance infection annually and over 35,000 die as a result (2019). Additionally, the annual national cost to treat just 6 of these multi-drug resistant infections was over $4.6 billion dollars (Nelson et al., 2021). The US government’s efforts to reduce inappropriate antibiotic use and implement transmission prevention techniques have effectively decreased the amount of deaths since 2013, but the costs are still too high (CDC, 2019). Inappropriate antibiotic use is seen across all of health care, but the majority of prescriptions result from outpatient settings comprising about 60% of the US’s antibiotic use (Sanchez, 2016). Barriers that lead to inappropriate prescribing include knowledge deficits of clinician and patient, patient expectations and desires, time constraints of a daily clinic, and a misperception of resistance being a future problem. The CDC released a report to guide antibiotic stewardship in outpatient settings, advising clinicians how to overcome barriers and provide optimal care (Sanchez, 2016). Ultimately, improving the way antibiotics are used will maximize the effectiveness of antibiotic treatment and prevent avoidable adverse effects from antibiotic use to individuals and the community. Core Elements of Antibiotic Stewardship The CDC’s Four Core Elements of Outpatient Antibiotic Stewardship report provides a framework on how to practice antibiotic stewardship for clinicians in the outpatient setting. These interventions apply to individual visits during daily clinical practice as well as organizational policy and reports, helping overcome barriers to antibiotic stewardship and reduce inappropriate prescribing throughout all levels of healthcare (Sanchez, 2016). Commitment. Each individual of the healthcare team needs to commit to antibiotic stewardship and promote appropriate antibiotic prescribing daily. Communication by all clinic members that an evaluation might or might not result in antibiotics creates a consistent message from start to finish that helps reduce the expectation that antibiotics are needed for every acute illness. In the exam room, publicly displaying a letter of the clinician’s commitment to antibiotic stewardship was shown to reduce inappropriate antibiotic prescriptions for acute respiratory infections. Ultimately, clinicians must choose to be an antibiotic steward with every patient encounter, utilizing antibiotics only when appropriate as well as the correct drug, dose, and duration, and opposing patient’s desires when necessary (Sanchez, 2016). Action for Policy and Practice. Clinicians should practice evidence-based diagnostic criteria and treatment recommendations from clinical practice guidelines informed by local pathogen susceptibilities. Developing simplified explanations of the research studies behind these treatment guidelines can reassure patients that antibiotics are not always necessary for acute illness. A “watch and wait” or delayed antibiotic prescription are both evidence-based ways to safely decrease antibiotic use while also sustaining satisfaction. This can involve post-dating prescriptions, instructing patients to fill prescriptions after a predetermined date, or providing symptomatic relief with a clear plan to follow up if symptoms worsen or persist (Sanchez, 2016). Clinic leaders can promote antibiotic stewardship by implementing policies to encourage adherence to clinical practice guidelines, like clinic decision support notifications that provide prescribing information during a typical work flow or requiring explicit justification in the EMR when prescribing a non-recommended antibiotic. This keeps accountability and is proven to reduce inappropriate prescribing. A triage or nurse line, especially during the winter months, can provide patients with information about over the counter therapies and supportive care, reducing unnecessary visits for “common colds” (Sanchez, 2016). Tracking and Reporting. Audit and feedback can inform about antibiotic prescribing data for both individual prescribers and the entire organization. This data can be utilized in effective feedback interventions across all levels of the organization. Antibiotic prescribing reports comparison of clinical performance with their peers or against clinical guidelines. This data can help clinicians self-evaluate and determine if they need to seek more information about prescribing guidelines (Sanchez, 2016). Education and Expertise. Clinical education should not only review evidence-based guidelines for clinical knowledge but also address other influences like the concern for patient satisfaction and time constraints of a busy clinic. Misinformation and misunderstanding create incorrect expectations that cause patients to pressure clinicians to provide antibiotics and feel wrongly treated without a prescription. Counseling with an explanation that addresses when antibiotics are not needed, specific symptom management recommendations, and when to seek follow-up care has been shown to increase visit satisfaction. Education about the potential side effects of antibiotics may help patients understand the benefits of avoiding antibiotic use. In a busy clinic day, utilizing patient education materials may be useful for a more complete patient education (Sanchez, 2016). Learn More and Earn CE Earn CE on Antibiotic Stewardship. View our recorded webinar at our Learning Center. Other Resources Adult Outpatient Treatment Recommendations | Antibiotic Use Healthcare Professional Information | Antibiotic Use Antibiotic stewardship targets in the outpatient setting Outpatient antibiotic stewardship: Interventions and opportunities Outpatient Antibiotic Prescribing for Acute Respiratory Infections During Influenza Seasons | Infectious Diseases | JAMA Network Open References CDC. Antibiotic Resistance Threats in the United States, 2019. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2019. CDC. Antibiotic Use in the United States, 2021 Update: Progress and Opportunities. Atlanta, GA: US Department of Health and Human Services, CDC; 2021. Nelson, Richard E, et al. “National Estimates of Healthcare Costs Associated with Multidrug-Resistant Bacterial Infections among Hospitalized Patients in the United States.” OUP Academic, Oxford University Press, 29 Jan. 2021, https://doi.org/10.1093/cid/ciaa1581. Sanchez, G.V., Fleming-Dutra, K.E., Roberts, R.M., Hicks, L.A. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016;65 (No. RR-6):1–12., https://doi.org/10.15585/mmwr.rr6506a1.