Improving Prescribing and Antibiotic Stewardship
The goal of antibiotic stewardship is to maximize the benefit of antibiotic therapy while minimizing harms to both the individual person and the community. Modest reductions in antibiotic prescribing can make a substantial impact. One study predicted that a 10% decrease in outpatient antibiotic prescribing rates would lead to a 16% decrease in C. difficile infection incidence in the community. Likewise, reducing exposure of hospitalized patients to broad-spectrum antibiotics by 30% can result in an estimated 26% reduction in inpatient C. difficile infections.
To reduce inappropriate prescribing, recent guidelines for common outpatient infections emphasize stringent case definitions and clinical observation for mild cases. For example, children aged ≥24 months with unilateral acute otitis media and mild symptoms are less likely to benefit from antibiotics, and are good candidates for close observation with shared decision-making that involves clinicians and caregivers. A mechanism for follow-up in 48–72 hours in such cases is recommended.
Several interventions have been shown to improve antibiotic prescribing. Audit and feedback involves tracking individual provider prescribing behaviors and giving feedback on their performance relative to peers or established benchmarks. Academic detailing is a method that adapts some strategies developed by pharmaceutical companies to influence prescribing behaviors that involves active, tailored, and personalized education to promote desired behaviors. Clinical decision support can be integrated with electronic health records to promote appropriate prescribing practices for common infections. Effective ambulatory care interventions have been summarized previously and may be adapted to different settings. Although no single intervention can improve all prescribing behaviors in a given outpatient setting, multifaceted interventions involving active provider education appear to have the greatest benefit. Evidence increasingly supports the reduction of unnecessary antibiotic use through delayed prescribing strategies, where patients are given an antibiotic prescription to be filled within a specified timeframe if symptoms do not improve.
Measures promoting appropriate antibiotic prescribing in inpatient settings are primarily implemented through antimicrobial stewardship programs, which CDC recommends for all hospitals in the United States (https://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html). In a recent review of hospital interventions to improve antibiotic prescribing, both restrictive interventions (e.g., required approval from an infectious disease specialist to order certain antibiotics) and persuasive interventions (e.g., audit and feedback on prescribing behaviors or provider education) appeared to be equally effective after approximately 6 months. Interventions intended to reduce excess antibiotic prescribing have also been associated with reductions in C. difficile infection, and a meta-analysis of clinical outcomes found no significant increases in mortality caused by reductions in antibiotic prescribing when intervention groups were compared with controls (risk for mortality 0.92; 95% confidence interval = 0.81–1.06).
Educational campaigns aim to decrease inappropriate antibiotic prescribing by promoting judicious prescribing among providers and by increasing general public and provider knowledge about antibiotic resistance. Strategies to further employ appropriate antibiotic use messages include distribution of public health messages via pharmacies, child daycare centers, and workplaces. The CDC "Get Smart: Know When Antibiotics Work" and "Get Smart for Healthcare" campaigns (https://www.cdc.gov/getsmart) inform consumers and providers about antibiotic use and resistance, promote adherence to clinical practice guidelines, and support state- and local-level appropriate antibiotic use programs.
Morbidity and Mortality Weekly Report. 2015;64(32):871-873. © 2015 Centers for Disease Control and Prevention (CDC)