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Antimicrobial Stewardship for Outpatients: Progress, But a Long Way to Go

ASPs have been developed for hospitals and long-term care facilities, with none developed specifically for dialysis centers. By far the biggest challenge for an ASP in the dialysis setting is education. “Dialysis units are so busy that introducing a new program is hard. Education for the neurologist is crucial, since they just don’t get any,” said Dr. D’agata.

"The lack of training could change," according to Dr. D'agata, "because dialysis in the United States is done by three companies." Discussion with company leaders has revealed enthusiasm to make things better. It is in the companies’ best bottom-line interest to do so.

Adult outpatients represent another ASP challenge. “It’s always stunning to me about the lack of focus on outpatients; they represent 35 million hospitalizations, 135 million emergency department visits and antibiotics are prescribed for 12% of them,” said Jeffrey Linder, MD, MPH, Brigham & Women’s Hospital/Harvard Medical School, Boston, Massachusetts, in his talk.

Antibiotics are the go-to treatment. For ambulatory care visits, there are 506 antibiotic prescriptions for every 1000 Americans. Of these, 30% are unnecessary with the rate rising to 50% for those with acute respiratory infections. A contrast is provided by the country of Sweden, where the antibiotic prescription rate for ambulatory care visits is 388 per 1000 people, with a national campaign underway to lower the rate to 250 per 1000. 

In seeking to change the treatment culture in the US, it is helpful to remember that much of any change that will happen will be driven by behavior. An ‘educate and remind’ approach has really not worked for physicians, who are by-and-large already aware of the problem of antimicrobial resistance and the need to take action.

“Our radical notion is that doctors are people. Just like everybody else, they make decisions fast and often automatically, not knowing why they made them, and are influenced by emotion and social factors. So we can take advantage of cognitive bias and appeal to clinician self-image,” said Dr. Linder in his talk.

Antibiotic prescription can be driven by a number of factors: the belief that the patient wants them, that it is easier and quicker to just prescribe an antibiotic, habitual behavior, or a desire to err on the side of safety. Dr. Linder and colleagues undertook a randomized controlled trial using what they termed a “nudging guideline” in which doctors received an email either praising their antibiotic stewardship or reprimanding them for inadequate performance. The blow-to-the-ego approach was effective in significantly reducing inappropriate prescriptions compared to those who did not receive the emails.

Issuing a prescription, but instructing the patient to take a ‘wait and see’ approach before obtaining the drug, is another option. However, Dr. Linder opined that this puts too much of the decision making on the patient. Rather, he argues, the physician should drive the decision. “It can send a mixed and confusing message to a patient that they need a drug but should not get the drug,” he said.

In that vein, communication between physician and patient is paramount. For this to be effective, the physician needs to understand and buy-in to the need to actively participate in antimicrobial stewardship.
Michael Pulia: Advisory boards, Thermo Fisher and Cempra
Erica D’agta: None
Jeffrey Linder:  Stockholder in Amgen, Biogen, and Eli Lilly; Former grant funding from Astellas Pharma Inc., and Clintrex/Astra Zeneca; Honoraria from SHEA (supported by Merck)
  • Photos and tape of IDSA presentation
  • US Department of Health and Human Services Report #90 2016
  • Fuller BM et al. J Emerg Med 2013 44:910-918
  • Spiro DM et al. 2006 JAMA 13:1235-1241
  • Meeker D et al. 2014 JAMA Intern Med 174:425-431
Approaching Antimicrobial Stewardship in Outpatient Settings
  • View From the Emergency Department; Michael Putia, MD, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
  • Strategy Implementation in Hemodialysis; Erica D’agata, MD, MPH, Brown University, Providence, Rhode Island
  • View From the Outside: Adult Outpatients; Jeffrey Linder, MD, MPH, Brigham & Women’s Hospital/Harvard Medical School, Boston, Massachusetts

​Brian Hoyle, PhD, is a medical and science writer and editor from Halifax, Nova Scotia, Canada. He has been a full-time freelance writer/editor for over 15 years. Prior to that, he was a research microbiologist and lab manager of a provincial government water testing lab. He can be reached at
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