Antimicrobial stewardship in the outpatient setting: A review and proposed framework

2020 ◽  
Vol 41 (7) ◽  
pp. 833-840 ◽  
Author(s):  
Jasmine R. Marcelin ◽  
Philip Chung ◽  
Trevor C. Van Schooneveld
Keyword(s):  
Primary Care ◽  
Antimicrobial Stewardship ◽  
Outpatient Setting ◽  
Significant Problem ◽  
Implementation Framework ◽  
Inappropriate Use ◽  
Primary Care Settings

AbstractAntimicrobial misuse is still a significant problem, and most inappropriate use occurs in the outpatient setting. In this article, we provide a review of available literature on outpatient antimicrobial stewardship in primary care settings, and we propose a novel implementation framework.

scholarly journals 142. Implementing an Antimicrobial Stewardship Program in the Outpatient Setting

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S82-S82
Author(s):  
Travis B Nielsen ◽  
Maressa Santarossa ◽  
Beatrice D Probst ◽  
Laurie Labuszewski ◽  
Jenna Lopez ◽  
...  
Keyword(s):  
Primary Care ◽  
Antimicrobial Stewardship ◽  
Inappropriate Prescribing ◽  
The United States ◽  
Outpatient Setting ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Antimicrobial Stewardship Program ◽  
Post Intervention ◽  
Stewardship Program

Abstract Background Antimicrobial-resistant infections lead to increased morbidity, mortality, and healthcare costs. Among the most facile modifiable risk factors for developing resistance is inappropriate prescribing. The CDC estimates that 47 million (or ≥30% of) outpatient antibiotic prescriptions in the United States are unnecessary. This has provided impetus for expanding our antimicrobial stewardship program (ASP) into the outpatient setting. Initial goals included the following: continuous evaluation and reporting of antibiotic prescribing compliance; minimize underuse of antibiotics from delayed diagnoses and misdiagnoses; ensure proper drug, dose, and duration; improve the percentage of appropriate prescriptions. Methods To achieve these goals, we first sent a baseline survey to outpatient prescribers, assessing their understanding of stewardship and antimicrobial resistance. Questions were modeled from the Illinois Department of Public Health (IDPH) Precious Drugs & Scary Bugs Campaign. The survey was sent to prescribers at 19 primary care and three immediate/urgent care clinics. Compliance rates for prescribing habits were subsequently tracked via electronic health records and reported to prescribers in accordance with IRB approval. Results Prescribers were highly knowledgeable about what constitutes appropriate prescribing, with verified compliance rates highly concordant with self-reported rates. However, 74% of respondents reported intense pressure from patients to inappropriately prescribe antimicrobials. Compliance rates have been tracked since December 2018 and comparing pre- with post-intervention rates shows improvement in primary care since reporting rates to prescribers in August 2019. Conclusion Reporting compliance rates has been helpful in avoiding inappropriate antimicrobial therapy. However, the survey data reinforce the importance of behavioral interventions to bolster ASP efficacy in the outpatient setting. Going forward, posters modeled off of the IDPH template will be conspicuously exhibited in exam rooms, indicating institutional commitment to the enumerated ASP guidelines. Future studies will allow for comparison of pre- and post-intervention knowledge and prescriber compliance. Disclosures All Authors: No reported disclosures

scholarly journals What Resources Do NHS Commissioning Organisations Use to Support Antimicrobial Stewardship in Primary Care in England?

Antibiotics ◽  
2020 ◽  
Vol 9 (4) ◽  
pp. 158 ◽  
Author(s):  
Rosalie Allison ◽  
Donna M. Lecky ◽  
Elizabeth Beech ◽  
Diane Ashiru-Oredope ◽  
Céire Costelloe ◽  
...  
Keyword(s):  
Primary Care ◽  
Antimicrobial Stewardship ◽  
Professional Education ◽  
Action Planning ◽  
Health Economy ◽  
Medicines Management ◽  
Out Of Hours ◽  
Primary Care Settings ◽  
General Practices ◽  
Primary Care Practitioners

Professional education and public engagement are fundamental components of any antimicrobial stewardship (AMS) strategy. The National Institute for Health and Care Excellence (NICE), Public Health England (PHE), Health Education England (HEE) and other professional organisations, develop and publish resources to support AMS activity in primary care settings. The aim of this study was to explore the adoption and use of education/training and supporting AMS resources within NHS primary care in England. Questionnaires were sent to the medicines management teams of all 209 Clinical Commissioning Groups (CCGs) in England, in 2017. Primary care practitioners in 168/175 (96%) CCGs received AMS education in the last two years. Respondents in 184/186 (99%) CCGs reported actively promoting the TARGET Toolkit to their primary care practitioners; although 137/176 (78%) did not know what percentage of primary care practitioners used the TARGET toolkit. All respondents were aware of Antibiotic Guardian and 132/167 (79%) reported promoting the campaign. Promotion of AMS resources to general practices is currently excellent, but as evaluation of uptake or effect is poor, this should be encouraged by resource providers and through quality improvement programmes. Trainers should be encouraged to promote and highlight the importance of action planning within their AMS training. AMS resources, such as leaflets and education, should be promoted across the whole health economy, including Out of Hours and care homes. Primary care practitioners should continue to be encouraged to display a signed Antibiotic Guardian poster as well as general AMS posters and videos in practice, as patients find them useful and noticeable.

scholarly journals Decreased Outpatient Fluoroquinolone Prescribing Using a Multimodal Antimicrobial Stewardship Initiative

2020 ◽  
Vol 7 (6) ◽  
Author(s):  
Kevin Lin ◽  
Yorgo Zahlanie ◽  
Jessica K Ortwine ◽  
Norman S Mang ◽  
Wenjing Wei ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Inappropriate Prescribing ◽  
Multidrug Resistant ◽  
Outpatient Setting ◽  
Urgent Care ◽  
Hospital System ◽  
Inappropriate Use ◽  
History Of ◽  
Outpatient Settings ◽  
The Impact

Abstract Background Fluoroquinolones are antibiotics prescribed in the outpatient setting, though they have serious side effects. This study evaluates the impact of stewardship interventions on total and inappropriate prescribing of fluoroquinolones in outpatient settings in a large county hospital and health system. Methods In an effort to decrease inappropriate outpatient fluoroquinolone usage, a multimodal antimicrobial stewardship initiative was implemented in November 2016. Education regarding the risks, benefits, and appropriate uses of fluoroquinolones was provided to providers in different outpatient settings, Food and Drug Administration warnings were added to all oral fluoroquinolone orders, an outpatient order set for cystitis treatment was created, and fluoroquinolone susceptibilities were suppressed when appropriate. Charts from October 2016, 2017, and 2018 were retrospectively reviewed if the patient encounter occurred in primary care clinics, emergency departments, or urgent care centers within Parkland Health & Hospital System and a fluoroquinolone was prescribed. Inappropriate use was defined as a fluoroquinolone prescription for cystitis, bronchitis, or sinusitis in a patient without a history of Pseudomonas aeruginosa or multidrug-resistant organisms and without drug allergies that precluded use of other oral antibiotics. Results Total fluoroquinolone prescriptions per 1000 patient visits decreased significantly by 39% (P < .01), and inappropriate fluoroquinolone use decreased from 53% to 34% (P < .01). More than 90% of inappropriate fluoroquinolone prescriptions were given for cystitis, while bronchitis and sinusitis accounted for only 4.4% and 1.6% of inappropriate indications, respectively. Conclusion A multimodal stewardship initiative appears to effectively reduce both total and inappropriate outpatient fluoroquinolone prescriptions.

scholarly journals 2079. Outpatient Antimicrobial Stewardship Initiative to Reduce Unnecessary Use of Antibiotics in Patients with Upper Respiratory Infections: Findings Shared by a Metropolitan Community Hospital in NYC

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S701-S701
Author(s):  
Jilan Shah ◽  
Dora Izaguirre-Anariba ◽  
Hariprasad Rao ◽  
Yash Patel ◽  
Kyaw Zin Win ◽  
...  
Keyword(s):  
Primary Care ◽  
Respiratory Tract ◽  
Antimicrobial Stewardship ◽  
Respiratory Tract Infections ◽  
Respiratory Infections ◽  
Antibiotic Use ◽  
The United States ◽  
Primary Care Settings ◽  
Tract Infections ◽  
Dedicated Team

Abstract Background Antibiotic-resistant infections are one of the greatest public health issues with more than 2 million infections and 23,000 deaths per year in the United States. Reducing inappropriate antibiotic use is essential to reduce both antibiotic resistance and adverse events. The most important modifiable risk factor for antibiotic resistance is inappropriate prescribing of antibiotics. At least 30% of outpatient antibiotic prescriptions in the United States are unnecessary. We aimed to pilot our outpatient antimicrobial stewardship initiative to track and reduce antibiotic prescriptions among adult patients presenting with common acute respiratory infections in our hospital’s outpatient primary care settings. Methods A retrospective and prospective cohort study from October, 2017 to March, 2019. Implemented a robust outpatient antimicrobial stewardship initiative with a dedicated team and data analyst based on CDC core elements for outpatient antimicrobial stewardship and a prior UHF initiative. Data of common respiratory tract infections and the respective rates of antibiotic prescriptions from 3 adult primary care sites were collected from the EHR. Serials of educational interventions were performed between June, 2018 to September, 2018. We disseminated resources from the CDC and DOH like brochures, posters, viral prescription pads, pocket guidelines, grand rounds and electronic lectures for providers and periodic provider feedback reports. Results Our findings revealed that the physician compliance rate of antibiotics not prescribed for common respiratory tract infections remarkably improved from 72% to 85% after implementing our interventions (Figure 1). The chi-square test showed 40, and P value is 0.000034 which is less than 0.05. Thus, we are 95% confident that there is a significant association between our interventions and reduction of inappropriate antibiotic use (Figure 2). Conclusion Introduction of a robust and multifaceted Outpatient Antimicrobial Stewardship initiative with a dedicated team can substantially decrease outpatient antibiotic prescription rates for respiratory tract infections in metropolitan community hospital-based primary care settings. Disclosures All authors: No reported disclosures.

scholarly journals How Can National Antimicrobial Stewardship Interventions in Primary Care Be Improved? A Stakeholder Consultation

Antibiotics ◽  
2019 ◽  
Vol 8 (4) ◽  
pp. 207 ◽  
Author(s):  
Aleksandra J. Borek ◽  
Marta Wanat ◽  
Anna Sallis ◽  
Diane Ashiru-Oredope ◽  
Lou Atkins ◽  
...  
Keyword(s):  
Primary Care ◽  
Antimicrobial Stewardship ◽  
Online Survey ◽  
Telephone Interview ◽  
Antibiotic Prescribing ◽  
Staff Time ◽  
Healthcare Organizations ◽  
Stakeholder Consultation ◽  
Individual Level ◽  
Primary Care Settings

Many antimicrobial stewardship (AMS) interventions have been implemented in England, facilitating decreases in antibiotic prescribing. Nevertheless, there is substantial variation in antibiotic prescribing across England and some healthcare organizations remain high prescribers of antibiotics. This study aimed to identify ways to improve AMS interventions to further optimize antibiotic prescribing in primary care in England. Stakeholders representing different primary care settings were invited to, and 15 participated in, a focus group or telephone interview to identify ways to improve existing AMS interventions. Forty-five intervention suggestions were generated and 31 were prioritized for inclusion in an online survey. Fifteen stakeholders completed the survey appraising each proposed intervention using the pre-defined APEASE (i.e., Affordability, Practicability, Effectiveness, Acceptability, Safety, and Equity) criteria. The highest-rated nine interventions were prioritized as most promising and feasible, including: quality improvement, multidisciplinary peer learning, appointing AMS leads, auditing individual-level prescribing, developing tools for prescribing audits, improving inductions for new prescribers, ensuring consistent local approaches to antibiotic prescribing, providing online AMS training to all patient-facing staff, and increasing staff time available for AMS work with standardizing AMS-related roles. These prioritized interventions could be incorporated into existing national interventions or developed as stand-alone interventions to help further optimize antibiotic prescribing in primary care in England.

scholarly journals Comparison of Diagnosis and Prescribing Practices Between Virtual Visits and Office Visits for Adults Diagnosed With Sinusitis Within a Primary Care Network

2019 ◽  
Vol 6 (9) ◽  
Author(s):  
Kristen M Johnson ◽  
Lisa E Dumkow ◽  
Kayla W Burns ◽  
Megan A Yee ◽  
Nnaemeka E Egwuatu
Keyword(s):  
Primary Care ◽  
Antimicrobial Stewardship ◽  
Outpatient Setting ◽  
Adult Patients ◽  
Antibiotic Prescribing ◽  
Office Visits ◽  
Care Network ◽  
Virtual Visits ◽  
Tract Infections ◽  
To Receive

Abstract Background Many antibiotics prescribed in the outpatient setting result from upper respiratory tract infections (URTIs); however, these infections are often viral. Virtual visits have emerged as a popular alternative to office visits for URTIs and may be an important target for antimicrobial stewardship programs. Methods This retrospective cohort study evaluated adult patients diagnosed with sinusitis treated within a single primary care network. The primary objective was to compare guideline-concordant diagnosis between patients treated via virtual visits vs in-office visits. Guideline-concordant bacterial sinusitis diagnosis was based on national guideline recommendations. Secondary objectives included comparing guideline-concordant antibiotic prescribing between groups and 24-hour, 7-day, and 30-day revisits. Results A total of 350 patients were included in the study, with 175 in each group. Patients treated for sinusitis were more likely to receive a guideline-concordant diagnosis in the virtual visit group (69.1% vs 45.7%; P < .001). Additionally, patients who completed virtual visits were less likely to receive antibiotics (68.6% vs 94.3%; P < .001). Guideline-concordant antibiotic selection was similar between groups (67.5% vs 64.8%; P = .641). The median duration of therapy in both groups was 10 days (P = .88). Patients completing virtual visits were more likely to revisit for sinusitis within 24 hours (8% vs 1.7%; P = .006) and within 30 days (14.9% vs 7.4%; P = .027). Conclusions In adult patients presenting with sinusitis, care at a virtual visit was associated with an increase in guideline-concordant diagnosis and a decrease in antibiotic prescribing compared with in-office primary care visits. Virtual visit platforms may be a valuable tool for antimicrobial stewardship programs in the outpatient setting.

Practitioners in primary care settings play an important role in preventing suicide

2009 ◽  
Author(s):  
C. J. Bryan ◽  
K. A. Corso ◽  
T. A. Neal-Walden ◽  
M. D. Rudd
Keyword(s):  
Primary Care ◽  
Primary Care Settings
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