Ambulatory ASPs are worth the trip

By on April 8, 2021 0

The quest for outpatient antimicrobial stewardship in the outpatient setting can begin with understanding 2 key documents: the CDC’s “Basics of Ambulatory Antimicrobial Stewardship” and the CDC’s “Antimicrobial Stewardship in Ambulatory Care” Standard. TJC.1 Both focus on 4 basic elements of stewardship: leadership commitment; action in policy and practice; education; and data analysis and reporting.1.3

Leadership commitment. The success of any ASP can be linked to the level of commitment of an institution’s management, prescribers within the institution and the ASP team. Without the commitment of institutional leadership to the practice, effort and enthusiasm are unlikely to gain ground. Leadership commitment can be demonstrated in several ways. One of the most critical is the designation of health system and / or local officials for outpatient ASP.2.4 This should ideally be accompanied by dedicated practice time and the incorporation of clear expectations and specific responsibilities into job descriptions. Consider writing and publicly displaying a commitment to antimicrobial stewardship practices to demonstrate the facility’s commitment to patients receiving care.

Action in policy and practice. The first step towards designing and implementing interventions as an outpatient ASP is to set an annual goal. Outpatient antimicrobial use occurs in a wide variety of sites and specialties, including emergency departments, doctor’s offices, retail clinics, and emergency care settings. It is important that programs focus on specific objectives to allow appropriate follow-up of association measures. Urgent care visits have some of the highest rates of antimicrobial prescription per patient encounter and should not be overlooked when designing ASP plans.5 A recent review of prescribing antimicrobials in a network of emergency care clinics found that respiratory encounters accounted for 41.8% of all visits.6 In addition, 21.3% of visits for respiratory infections unlikely to benefit from antimicrobial treatment still resulted in a prescription for antibiotics. When considering ambulatory ASP targets at the consultation level, genitourinary, respiratory and skin and soft tissue infections probably represent the 3 most logical areas of intervention, with respiratory infections being the most commonly studied target. in the litterature.5-11

The next step is to implement the best practices that favorably affect the prescribing of antimicrobials in relation to the established goal. One opportunity is to formalize prescribing times and vigilant waiting processes, which have resulted in a 60% or more reduction in antibiotic use compared to patients receiving immediate prescription.12.13 Another option is to implement evidence-based guidelines or practice protocols for the appropriate prescribing of antimicrobials.3 Improving clinical decision support in the electronic medical record and requiring the indication of antimicrobial prescriptions can also facilitate appropriate prescribing. However, there are barriers, including limitations in information handling (IT) and resistance to change in the workflow of prescribers.

Education. Educational efforts that target both clinicians and patients are essential.1 It is essential that prescribers are made aware of the annual goal and that they provide tools to support it. The emerging literature has identified that many factors, beyond knowledge gaps, contribute to inappropriate prescribing by clinicians.9 These can be emotional, financial or social, including the belief that some patients may be impossible to meet without giving them an antibiotic prescription, the perceived correlation between the prescription and the value of antibiotics, and the potential negative implications resulting from failure to prescribe antibiotics.9 Provider training should include a review of clinical content as well as communication tools and support to overcome psychosocial pressures associated with unnecessary prescription of antibiotics.1

Significant gaps in patient knowledge about the appropriate use of antimicrobials also represent a substantial opportunity.14 Give patients a clear rationale when antibiotics are not indicated, including potential unintended consequences of antimicrobial use, such as adverse events, increased costs, complications from infection and development resistance.3 In addition to doctor-patient interaction, use educational materials, such as posters, brochures, and videos, to ensure patients receive a consistent message. To address the perceived value when antibiotics are not indicated, provide patients with written instructions for symptomatic treatment and an emergency plan for follow-up if symptoms worsen.3

Data analysis and reporting. Monitoring antimicrobial prescribing practices and providing regular feedback to clinicians is essential both for progressing towards established goals and for sustainable culture change.3 Unfortunately, this element can run into a multitude of hurdles, such as a lack of IT support and limitations around data mining. Additionally, a large portion of antimicrobial prescribing has been shown to occur due to unvisited care, resulting in ambulatory PSA efforts failing to target around half of prescribing. antibiotics.15

Apply the selected parameters to the established objectives, including the analysis of the types of encounters, the percentage of visits resulting in an antimicrobial prescription, and the prescription rate by antimicrobial class.3 In addition to the primary parameters, formalize a plan of counterbalancing measures to monitor unanticipated complications that may result from a decrease in antimicrobial use.3 While the ability to thoroughly assess outpatient data is required, it is also imperative that this data is communicated regularly to providers. Interventions at the prescriber level, such as dashboards and personalized letters, can promote individual behavior change through peer comparison.9.16

While the CDC building blocks provide a roadmap for the successful implementation of outpatient ASP, there can be detours. PHAs in the early stages of outpatient implementation should perform a comparison of current performance with desired performance, through which gaps in practice can be identified. Start improvements with high impact, low effort interventions. For items that require more effort, develop an action plan with a realistic timeline. While the road to a successful deployment may seem similar to the pursuit of the Holy Grail, the growth and advancement that a program encounters along the way will make the journey worthwhile.


1. CDC. Basic elements of antibiotic management programs in hospitals. Updated November 16, 2020. Accessed February 8, 2021.

2. Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Essential elements of antibiotic management on an outpatient basis. Recommended Representative MMWR. 2016; 65 (6): 1-12. doi: 10.15585 / mmwr.rr6506a1

3. The Joint Commission. R3 Report Number 23: Antimicrobial Management in Ambulatory Health Care. Accessed February 8, 2021.

4. Quality improvement organizations. A field guide on the management of antibiotics on an outpatient basis. July 2018. Accessed February 8, 2021.

5. Palms DL, Hicks LA, Bartoces M, et al. Comparison of Prescribing Antibiotics in Retail Clinics, Emergency Care Centers, Emergency Departments, and Traditional Ambulatory Care Facilities in the United States. JAMA Med Intern. 2018; 178 (9): 1267-1269. doi: 10.1001 / jamainternmed.2018.1632

6. Stenehjem E, Wallin A, Fleming-Dutra KE, et al. Variability in the prescription of antibiotics in a large emergency care network: a new target for outpatient stewardship. Clin Infect Dis. 2020; 70 (8): 1781-1787. doi: 10.1093 / cid / ciz910

7. Fleming-Dutra KE, Hersh AL, Shapiro DJ et al. Prevalence of inappropriate antibiotic prescriptions among outpatient visits in the United States, 2010-2011. JAMA. 2016; 315 (17): 1864-1873. doi: 10.1001 / jama.2016.4151

8. White AT, Clark CM, Sellick JA, Mergenhagen KA. Outpatient antibiotic management objectives. Am J Infect Control. 2019; 47 (8): 858-863. doi: 10.1016 / j.ajic.2019.01.027

9. Kohut MR, Keller SC, Linder JA et al. The unconvincing patient: how clinicians perceive the demand for outpatient antibiotics. Fam Pract. 2020; 37 (2): 276-282. doi: 10.1093 / fampra / cmz066

10. Wattengel BA, DiTursi S, Schroeck JL, Sellick JA, Mergenhagen KA. Ambulatory antimicrobial management: targets for urinary tract infections. Am J Infect Control. 2020; 48 (9): 1009-1012. doi: 10.1016 / j / ajic.2019.12.018

11. CDC. The basic elements of the annex on the management of antibiotics on an outpatient basis. Accessed February 8, 2021.

12. Little P, Moore M, Kelly J et al. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: a pragmatic and factorial randomized controlled trial. BMJ. 2014; 348: g1606. doi: 10.1136 / bmj.g1606

13. McCormick DP, Chonmaitree T, Pittman C, et al. Acute non-severe otitis media: a clinical trial comparing the results of watchful waiting with immediate antibiotic treatment. Pediatrics. 2005; 115 (6): 1455-1465. doi: 10.1542 / peds.2004-1665

14. Seipel MBA, Prohaska ES, Ruisinger JF, Melton BL. Knowledge and experiences of patients regarding the use of antibiotics and delayed outpatient prescription of antibiotics. J Pharm Pract. Published online: December 13, 2019. doi: 10.1177 / 0897190019889427

15. Fischer MA, Mahesri M, Lii J, Linder JA. Prescribing antibiotics unrelated to infection and without consultation is common in Medicaid patients. Health Aff (Millwood). 2020; 39 (2): 280-288. doi: 10.1377 / hlthaff.2019.00545

16. Hallsworth M, Chadborn T, Sallis A, et al. Providing normal social feedback to high prescribers of general medicine antibiotics: a pragmatic national randomized controlled trial. Lancet. 2016; 387 (10029): 1743-1752. doi: 10.1016 / S0140-6736 (16) 00215-4

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