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Outpatient antibiotic stewardship programs can combat resistance :

December 21, 2016

Antimicrobial agents encompass compounds that act against many types of microorganisms, including bacteria, viruses, fungi and protozoa. Antibacterial agents are active against bacteria. The advent of many antibiotics revolutionized the success with which infectious diseases were treated in individual patients and in control of potential disease outbreaks.

However, almost every intervention in medicine has associated risks. Easily identifiable risks associated with antibiotics range from common side effects such as diarrhea and rashes to less common adverse events such as severe allergic reactions. The more insidious adverse effects of antibiotics are not immediately recognized and have the potential to affect much larger populations.

Since the time of Alexander Fleming and the advent of penicillin, bacteria have engineered ways to protect themselves from antibiotics and have produced multiple resistance mechanisms. Antimicrobial resistance emerged quickly with each new antimicrobial agent developed and reduced clinical usefulness. Exposed bacteria may no longer respond to first-line treatment, and practitioners must resort to second- or third-line therapies that are broad-spectrum, expensive, often more toxic and tend to have a larger adverse event profile. In general, broad-spectrum antibiotics are responsible for selecting these resistances but sometimes are the only effective available therapy. Colistin tends to be a last resort antibiotic for multidrug-resistant gram-negative infections. Unfortunately, clinicians already are seeing infections from colistin-resistant Enterobacteriaceae, Pseudomonas spp. and Acinetobacter spp.

Kirby-Bauer plate testing for antibiotic resistance in a pyoverdine-producing Pseudomonas aeruginosa. Photo courtesy of Robert C. Jerris, Ph.D, D(ABMM)Kirby-Bauer plate testing for antibiotic resistance in a pyoverdine-producing Pseudomonas aeruginosa. Photo courtesy of Robert C. Jerris, Ph.D, D(ABMM)


The Centers for Disease Control and Prevention (CDC) has declared antibiotic resistance one of the greatest current public health threats. Antibiotic resistance has led to an estimated 2 million infections with drug-resistant bacteria and 23,000 deaths annually in the U.S. These drug-resistant pathogens complicate patient care while increasing morbidity and mortality. These complications lead to an estimated $20 billion in health care expenses and $35 billion in expenses to society annually.

To combat these drug-resistant bacteria, antibiotic prescribing in all health care settings must improve. Of the 269 million antibiotic prescriptions dispensed in 2013, at least 30% were unnecessary, and half may have been inappropriate in terms of antibiotic selection, dose or duration.

As a result of inappropriate antibiotic use, health care providers inadvertently pushed bacteria to develop genetic mutations, which led to multiple mechanisms of resistance. Antibiotic resistance causes difficulty in outpatient treatment of infections. A prime example is the treatment of Escherichia coli and other gram-negative urinary tract infections due to extended-spectrum beta-lactamase resistance. In addition, Neisseria gonorrhoeae continues to develop resistance to the currently recommended outpatient antibiotics. The only way clinicians can win this battle is through judicious and appropriate use of antibiotics.

The CDC hopes to encourage appropriate antibiotic use by promoting antibiotic stewardship, which is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. The CDC recently published “Core Elements of Outpatient Antibiotic Stewardship,” which provides a framework for antibiotic stewardship for outpatient clinicians and facilities that routinely provide antibiotic treatment. The goal is “to maximize the benefit of antibiotic treatment while minimizing harm to individual people and to communities.”

The four core elements include:

  • commitment;
  • action for policy and practice;
  • tracking and reporting; and
  • education and expertise.

The first, and potentially most important, of the core elements is commitment. All health care team members must commit to antibiotic stewardship if there is to be accountability and optimization of antibiotic use and patient safety. When discussing antibiotics with patients and family members, it is important to have effective communication among all staff members. In addition, it is essential to communicate that an acute illness may not require an antibiotic prescription.

Parents often want something from their pediatrician that will help their child feel better. It is easy to provide a prescription for antibiotics if families are persistent, but it is important not to give in if it is not in the child’s best interests. If the child has an illness that will not benefit from antibiotics, it may be sufficient to prescribe another medication or give advice on a remedy for the patient’s symptoms such as a nasal decongestant, probiotic, throat spray or other low-risk intervention.

Action for policy and practice, the second core element, encourages adoption of at least one policy or practice to improve antibiotic prescribing. The first example from the CDC is using evidence-based diagnostic criteria and treatment recommendations, which includes using local pathogen susceptibility patterns (antibiogram) (see figure) along with local or national clinical practice guidelines published by professional societies. Clinicians also may adopt delayed prescription practices or watchful waiting when appropriate, especially for conditions that usually resolve spontaneously (e.g., acute uncomplicated sinusitis or bronchitis). 

By tracking and reporting antibiotic prescribing, also referred to as audit and feedback, clinicians can compare individual prescribing habits with those of coworkers or their practice. A study that directly informed individual clinicians that they prescribed more antibiotics than 80% of their peers showed a dramatic reduction in overall antibiotic prescribing. Tracking also allows for assessment of antibiotic use.

The last core element focuses on education on appropriate antibiotic use and access to expertise. Education on when antibiotics are or are not indicated occurs at patient and clinician levels. Partnering with local hospitals, microbiologists and laboratories will help clinicians know which bacteria are circulating in the community and their antibiotic susceptibility patterns. 

By using these core elements, it is possible to build a framework for outpatient antibiotic stewardship. Effective implementation of the elements will require a dedicated and consistent effort. Change will not be easy, and many barriers will need to be addressed. By making a commitment to improve antibiotic use and adopting these strategies, clinicians can help halt the spread of antibiotic-resistant organisms.

Which of the following choices can you or your practice adopt to improve antibiotic stewardship?

A. Make a commitment to optimize antibiotic prescribing and be accountable.

B. Apply at least one policy or practice to improve antibiotic prescribing.

C. Monitor how antibiotics are prescribed and provide that information to clinicians.

D. Provide educational material to clinicians and patients about antibiotic prescribing.

E. All of the above

 Answer: E is correct.


Dr. Prestel is a post-graduate training fellow in pediatric infectious diseases at Emory University School of Medicine. Dr. Jerris is director of clinical microbiology, Children’s Healthcare of Atlanta, and clinical associate professor, Department of Pathology and Laboratory Medicine, Emory University School of Medicine. Dr. Pickering was editor of the AAP Red Book from 2000-’12. He is adjunct professor of pediatrics in the Department of Pediatrics at Emory University School of Medicine. 

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