The Centers for Disease Control and Prevention (CDC) late last week released new guidelines for antibiotic prescribing in outpatient settings that involve four stewardship pillars such as tracking and reporting.
The CDC's Core Elements of Outpatient Antibiotic Stewardship, published in Morbidity and Mortality Weekly Report (MMWR), calls on all facilities involved in outpatient care—including primary care clinics, emergency departments, specialty clinics, community pharmacies, and retail health and urgent care clinics—to implement strategies to improve antibiotic prescribing and reduce unnecessary antibiotic use. The document suggests outpatient practitioners use the following four pillars to guide these efforts:
- Commitment: Demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety
- Action for policy and practice: Implement at least one policy or practice to improve antibiotic prescribing, assess whether it's working, and modify as needed
- Tracking and reporting: Monitor antibiotic prescribing practices and offer regular feedback to clinicians, or have clinicians assess their own antibiotic prescribing practices themselves
- Education and expertise: Provide educational resources to clinicians and patients on antibiotic prescribing, and ensure access to needed expertise on optimizing antibiotic prescribing
The CDC says reducing inappropriate antibiotic use, which it argues is the most important modifiable factor contributing to antibiotic resistance, can help reduce the spread of drug-resistant infections, improve patient safety, and ultimately lower healthcare costs.
"Establishing effective antibiotic stewardship interventions can protect patients and improve clinical outcomes in outpatient health care settings," the authors write.
The extent of unnecessary prescribing
The guidelines come on the heels of two reports that were joint efforts of the Pew Charitable Trusts and the CDC and documented the scope of inappropriate antibiotic prescribing in outpatient settings.
The first report, issued in May, found that at least 30% of antibiotics prescribed in outpatient settings are unnecessary, resulting in 47 million excess prescriptions. Most of those antibiotics, the report concluded, are being prescribed for viral illnesses that don't respond to antibiotic therapy.
The second report, which came out in October, found that only half of the patients treated for three common bacterial infections—sinus infections, middle ear infections, and pharyngitis—are being treated with the right antibiotic. Instead of being treated with narrow-spectrum drugs like penicillin and amoxicillin, they are being treated with broad-spectrum antibiotics that can fuel greater resistance to those drugs.
While not prescriptive, the new CDC guidelines aim to rectify this by providing a framework for different types of clinical settings to reduce inappropriate use.
"The idea was to highlight the critical pieces of outpatient antibiotic stewardship that providers or clinicians can use in small practices, but also in larger organizations," corresponding author Katherine Fleming-Dutra, MD, of the CDC's Division of Healthcare Quality Promotion, told CIDRAP News.
"Those reports really inform us that there is a lot of room to improve", Fleming-Dutra said, and a lot of what she and her colleagues identified is "low hanging fruit," such as eliminating antibiotics for the common cold.
Under each of the elements, the CDC includes a menu of options that providers can choose from to help fulfill that element. The effort should start with a commitment from all healthcare team members to prescribe antibiotics correctly and publicly display their commitment to antibiotic stewardship, the document says. That could come in the form of a letter stating a physician's commitment to appropriate prescribing being posted in an examination room, or a clinic hiring a single leader to direct stewardship activities. "Commitment is the foundational piece," Fleming-Dutra said.
But that has to be followed by action, such as following evidence-based diagnostic criteria and treatment recommendations, or implementing delayed prescribing for patients who have conditions that usually resolve without treatment. "Action is necessary to transform policy and practice into measurable outcomes," Fleming-Dutra and her colleagues write.
Tracking and reporting can also guide changes in prescribing patterns. The preferred approach, the CDC says, is to track antibiotic prescribing at the individual clinician level and then provide feedback by comparing his or her performance with peers' performance. "Individualized feedback provided to clinicians on antibiotic prescribing is an effective way to promote adherence to evidence-based guidelines," the authors write.
Finally, outpatient facilities need to spend time educating physicians and patients about the value of appropriate prescribing. That means doctors should take the time to explain to their patients why antibiotics are not necessary for viral illnesses, or what potential harms might arise from antibiotic treatment. It also means that healthcare systems should offer continuing education on antibiotic prescribing to clinicians, and provide access to professionals who have antibiotic expertise, such as infectious disease pharmacists.
Guidelines provide flexibility
The value of these types of guidelines, says David Hyun, MD, senior officer with Pew's antibiotic resistance project, is that they offer a general set of evidence-based principles to guide outpatient providers. But they also provide flexibility, which Hyun says is important given the wide range of clinical settings in the outpatient space.
"Outpatient encompasses anywhere from doctor's offices to emergency departments to urgent care clinics and retail clinics, and comes in a very different variety and spectrum of clinical settings," Hyun said. "By keeping things at a higher level, it's providing a common framework that encompasses all these clinical settings but allows for the flexibility for each of those settings to adapt."
But Debbie Goff, PharmD, an infectious disease specialist at The Ohio State University Medical Center, says that while the core elements will help start a conversation about antibiotics in outpatient settings, she's not sure they adequately address the issue of patient expectation and how it affects providers.
"In a physician's office, time is money," Goff said. "If they need to spend 10 to 15 minutes educating patients about antibiotics in place of seeing more patients, I'm not sure that will happen."
Fleming-Dutra says the CDC recognizes that patient expectation is an obstacle to appropriate prescribing, and she believes that some of the options offered in the document—such as providing clinicians with communication skills training—can help physicians navigate the issue.
Hyun, who was among the experts who provided feedback on the guidelines, believes that part of their value is that they don't put the onus on individual doctors. Public health agencies and professional societies, he says, can also use the document to educate and promote antibiotic stewardship.
"It's not just going to be about what the individual clinicians can do, but also about what all these other stakeholders who are part of the healthcare system can do to promote outpatient stewardship," Hyun said.
The document, released in conjunction with the CDC's Get Smart About Antibiotics Week this week, augments existing guidelines for other clinical settings. In 2014 and 2015, respectively, the agency released the Core Elements of Hospital Antibiotic Stewardship Programs and the Core Elements of Antibiotic Stewardship for Nursing Homes.
See also:
Nov 11 MMWR report
May 3 Pew report
May 4 CIDRAP News story "Study: 30% of outpatient antibiotic prescriptions unnecessary"
Oct 24 Pew report
Oct 24 CIDRAP News story "Study finds wrong antibiotics often given for common infections"
