Posted on March 15, 2018 in: Patient Safety
By Pui Shan (Debby) Chu, Pharm.D., PGY1 pharmacy resident, Beaumont Hospital, Royal Oak and Jennifer Chou, Pharm.D., PGY1 infectious diseases pharmacy resident, Beaumont Hospital, Royal Oak
To combat multi-drug resistant bacteria, most hospitals have implemented comprehensive inpatient antimicrobial stewardship programs. While it is imperative to halt overuse of inpatient antibiotics, the need for antimicrobial stewardship in outpatient settings should not be overlooked. In 2009, $10.7 billion was spent in the United States on antibiotics, 62 percent of which occurred in the outpatient setting.1 According to the Centers for Disease Control and Prevention (CDC), at least 30 percent of outpatient antibiotic prescriptions are unnecessary.1 The Executive Order: Combating Antibiotic-Resistant Bacteria issued by the White House in 2014 highlighted the importance of appropriate antibiotic use in all healthcare facilities across the continuum of care.2 In response to areas for opportunity in outpatient antimicrobial stewardship, the National Action Plan for Combating Antibiotic-Resistant Bacteria has set a goal to reduce inappropriate antibiotic use by half in the outpatient setting.2,3 The CDC has also released the Core Elements of Outpatient Antibiotic Stewardship, which include: commitment, action for policy and practice, tracking and reporting and education and expertise.4
Showing commitment to antimicrobial stewardship is the essential first step in initiating a new program; therefore, a champion should be identified to lead its development.3 Not only should physicians be included in the team, but nurses, pharmacists and other clinical staff members should be involved as well. This ensures that a consistent vision is conveyed across all disciplines. To promote patient awareness of the program, educational information can be provided in the form of a poster or pamphlet.4 The program should then assess its own antibiotic prescribing trends for different disease states as well as patterns at a prescriber level so as to identify specific areas for improvement.3,5 For instance, viral respiratory tract infections and acute bronchitis are common disease states that are treated unnecessarily with antibiotics.5 It is important to understand and address the particular reasons that lead to deviation from standard practice of prescribing. Clinic leaders can implement guidelines and protocols to improve antibiotic prescribing practices. These guidelines should take site prescribing trends, local antibiotic resistance and cost into account.3,5
A number of strategies can be implemented by pharmacists to promote outpatient antimicrobial stewardship. These include providing telephone support to patients where delayed prescribing or watchful waiting is used, promoting and administering vaccinations and educating patients about healthy lifestyles. Furthermore, educating patients on both the benefits and harm of antibiotic use will be helpful for the those who expect to receive antibiotics.3,5 In order to assess the impact of the program, an antimicrobial tracking and reporting system should be implemented.4 Real-time antibiotic use metrics and antibiotic prescribing summaries should be provided in order for the stewardship team to track changes in prescribing patterns.5 They can also be used as a tool for quality improvement.5 Clinicians who closely adhere to the prescribing guidelines can be identified and provided with positive reinforcement. The Michigan Society of Health-System Pharmacists Antimicrobial Stewardship Committee is currently developing a program to assist outpatient facilities quantify and assess the appropriateness of outpatient antibiotic use.
Undoubtedly pharmacists play a crucial role on the antimicrobial stewardship team. As a medication expert, pharmacists provide evidence-based recommendations on treatment dose and duration when prescriptions are written. They can also offer continuing education to other healthcare providers regarding optimal antibiotic use. Pharmacists can reduce unnecessary antibiotic use by providing point-of-care testing services in the outpatient setting which can be implemented by creating a physician-pharmacist collaborative practice agreement.4,5 Some rapid point-of-care tests that are already being widely used in Michigan include those for influenza and Group A streptococcus.3,5
The emergence of antibiotic-resistant bacteria has become a worldwide problem. Guidelines and strategies for implementing outpatient antimicrobial stewardship programs have begun to solidify and highlight numerous areas for pharmacist involvement. Curbing inappropriate antibiotic use in the outpatient setting will not be easy. However, pharmacists can tap into their decades of experience in providing inpatient antimicrobial stewardship and lead the efforts that are now beginning to take shape in the community. Pharmacists are the most accessible healthcare providers and our availability, knowledge and relationships with patients will be needed to combat this problem.
1. Centers for Disease Control and Prevention. Facts about Antibiotic Resistance. CDC.gov. https://www.cdc.gov/antibiotic-use/community/about/fast-facts.html. Accessed Jan. 14, 2018.
2. The White House. National Action Plan for Combating Antibiotic-Resistant Bacteria. CDC.gov. https://www.cdc.gov/drugresistance/pdf/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf. Accessed Jan., 14, 2018
3. Klepser ME, Dobson EL, Pogue JM, et al. A call to action for outpatient antibiotic stewardship. J Am Pharm Assoc. 2003;57(4):457-463.
4. Centers for Disease Control and Prevention: The Core Elements of Outpatient Antibiotic Stewardship. CDC.gov. https://www.cdc.gov/antibiotic-use/community/pdfs/16_268900-A_CoreElementsOutpatient_508.pdf. Accessed Jan. 14, 2018
5. Dobson EL, Klepser ME, Pogue JM, et al. Outpatient antibiotic stewardship: Interventions and opportunities. J Am Pharm Assoc. 2003;57(4):464-473.