Improving Antimicrobial Use in Adult Outpatient Clinics: the New Frontier for Antimicrobial Stewardship Programs

Abstract

Antimicrobial stewardship (AS) programs are expanding efforts across the entire healthcare continuum. Antimicrobials are commonly overused in outpatient care locations, which have not received the same intensity of AS intervention as inpatient settings. Guidance for AS programs is needed on how to implement interventions and monitor for improvement. Antimicrobials prescribed in the outpatient setting are inappropriate in 23–76% of cases. Factors associated with inappropriate prescribing include older adult patients, advanced practice practitioner prescribers, and urgent care clinics. Indications such as upper respiratory infections and asymptomatic bacteriuria are common conditions in which antibiotics should not be used yet they are major contributors to inappropriate antibiotic use. Promising interventions include peer comparison and clinical decision support, but gaps remain. There is little evidence for how to limit the use of fluoroquinolones and newly approved antibiotics. Improving antibiotic use is needed in the outpatient setting and poses unique challenges for AS programs. Defining problems unique to designated outpatient centers and implementing proposed interventions targeting these problems is an effective strategy. Collaboration with State Health Departments, health insurers, and healthcare systems will be essential.