Exploring CDC's New Outpatient Antibiotic Stewardship Program

In mid-November, the CDC released the “Core Elements of Outpatient Antibiotic Stewardship.”

Hailing antibiotics as miracle medicines with life-saving benefits, the Centers for Disease Control and Prevention (CDC) hosted a webinar informing health professionals about the significance of prescribing them judiciously in outpatient settings. The CDC held the online presentation on November 15, as part of the Get Smart About Antibiotics Week initiative.

In mid-November, the CDC released the “Core Elements of Outpatient Antibiotic Stewardship.” The webinar—which is available on the agency’s website, Tune in to Safe Healthcare: A CDC Webinar Series—provides a framework for prescribing improvements by outpatient clinicians and within facilities that routinely provide outpatient antibiotic treatment. They followed the release of antibiotic stewardship for hospitals and nursing homes in 2014 and 2015, respectively.

“We need to improve antibiotic use across the spectrum of healthcare, and we can’t leave the outpatient setting out of those efforts,” said Katherine Fleming-Dutra, MD, medical officer in the Office of Antibiotic Stewardship within the Division of Healthcare Quality Promotion at the CDC, who led the webinar.

Thanks to antibiotics, “infectious bacterial diseases that were once deadly are now treatable, substantially reducing deaths compared to the pre-antibiotic era,” Dr. Fleming-Dutra noted.

As adjuncts to modern medical advances, antibiotics help make transplants and chemotherapy possible by preventing and treating bacterial infections. “We need them, and we need them to keep working,” said Dr. Fleming-Dutra. “That’s why antibiotic resistance is one of the most pressing public health threats of our time.”

Antibiotic resistant infections account for two million illnesses and 23,000 deaths each year in the United States, accounting for an estimated $20 billion in excess direct healthcare costs annually, according to the CDC.

Emphasizing the importance of resorting to antibiotics only when necessary, Dr. Fleming-Dutra said that while antibiotic stewardship programs exist traditionally in the inpatient setting, the volume of antibiotic use is much higher in outpatient practice. Based on data from other developed countries, the CDC estimated that 80% to 90% of use occurs in the outpatient setting, illustrating why antibiotic stewardship is also critical to combatting antibiotic resistance.

So, what is antibiotic stewardship? Dr. Fleming-Dutra, who trained as a pediatric-emergency medicine physician, defined it as an “effort to measure antibiotic prescribing, to improve antibiotic prescribing so that antibiotics are only prescribed and used when needed, to minimize misdiagnoses or delayed diagnoses leading to the underuse of antibiotics, to ensure that the right drug, dose and duration are selected when an antibiotic is needed. And antibiotic stewardship is fundamentally about patient safety and delivering high quality healthcare.”

The new guidelines are aimed at outpatient clinicians, clinics, and health systems with an interest in improving antibiotic prescribing and use—from primary and specialty care to emergency departments and urgent care, retail health and dentistry.

At least 30% of antibiotic prescriptions written in the outpatient setting are unnecessary, the CDC estimated. Even among the remaining 70%, inappropriate antibiotic prescribing is still prevalent. Total inappropriate antibiotic prescribing, including unnecessary antibiotic prescribing plus inappropriate selection, dosing and duration is likely much higher, Dr. Fleming-Dutra suspected.

“The primary modifiable driver of antibiotic resistance is antibiotic use,” she said. Even as newer options appear, “resistance is never far behind.” That’s because “bacteria will inevitably find ways of resisting antibiotics developed by humans, which is why aggressive action is needed now to keep new resistance from developing and to prevent the resistance that already exists from spreading.”

Antibiotics can also precipitate minor to severe adverse events and other unintended consequences that compromise patient safety. They can cause side effects, such as rashes and antibiotic-associated diarrhea, as well as severe allergic reactions, including a life-threatening condition known as anaphylaxis.

One in a thousand antibiotic prescriptions leads to an emergency department visit for an adverse event—totaling 142,000 ER visits per year for antibiotic-associated adverse events. Among children, antibiotics are the most common cause of drug-related ER visits.

Emerging evidence points to long-term consequences of antibiotic use, associating them with chronic conditions, such as allergic and autoimmune diseases by disrupting the community of microbes living in and on our bodies and the collective genes and their products.

Another serious unintended consequence of antibiotic use is Clostridium difficile infections. C. difficile is a bacterium that can cause potentially life-threatening diarrheal illness. In 2013, the CDC estimated that C. difficile was responsible for at least 250,000 infections and 14,000 deaths in the United States, leading to approximately $1 billion in medical costs. More recent projections were even higher, citing 453,000 infections and 15,000 deaths annually.

The initial steps to implementing outpatient antibiotic stewardship are identifying opportunities for improvement by pinpointing the high-priority conditions for intervention, in which clinicians are commonly deviating from best practices for prescribing antibiotics. For instance, antibiotics are often overprescribed for acute bronchitis.

It’s also important to identify barriers that lead to deviation from best practices, such as clinician knowledge gaps, perception of patients’ expectations for antibiotics, perceived pressure for practitioners to see them quickly, and concerns about decreased satisfaction with visits when antibiotics are not prescribed.

Setting standards for antibiotic prescribing is essential as well. They can be based on national clinical practice guidelines by professional organizations, such as the American Academy of Pediatrics, the American College of Physicians, or the Infectious Diseases Society of America, to name a few.

“Establishing standards is really the foundation of deciding what is and what is not appropriate antibiotic prescribing,” Dr. Fleming-Dutra said. “Clinicians need to know what they are supposed to be prescribing to be able to make improvements.”

She highlighted four core elements of outpatient antibiotic prescribing: commitment to demonstrating dedication to and accountability for optimizing prescribing and patient safety; action to implement at least one policy or practice to improve prescribing and assess whether it’s working and modify as needed; tracking and reporting prescribing practices and offering regular feedback to clinicians or having them assess their own antibiotic use; and education and expertise to provide educational resources to clinicians and patients.

Even clinicians who are pressed for time can inform patients about appropriate antibiotic use and potential harms, including both common and serious side effects, C. difficile infection, and antibiotic resistance. Clinicians can provide materials that contain information about potential adverse drug events and symptomatic relief for common infections, Dr. Fleming-Dutra said.

“Patients really want communication whether or not they get an antibiotic,” she added. Many experts would contend that “part of good patient care, regardless of the treatment plan that you’re providing, is “to give those messages in short and succinct ways that don’t add much time to the visit but also help maintain satisfaction.”

Susan Kreimer, MS, is a medical journalist who has written articles about infectious diseases and many other health topics. For two decades, her coverage has informed consumers, physicians, nurses and health system executives. Raised in the Chicago area, she holds a master’s degree in journalism from Columbia University and lives in New York City.