Supervision of antibiotics in outpatient care

Antibiotic-resistant pathogens require multiple strategies to reduce morbidity and mortality. According to the Centers for Disease Control and Prevention (CDC), antibiotic-resistant pathogens are implicated in at least 35,000 deaths and more than 2.8 million infections each year in the United States (US)1. In 2019, 250 million prescriptions were written of oral antibiotics on an outpatient basis, equivalent to 8 antibiotic prescriptions per 10 people. However, according to a Pew Charitable Trust study, 1 in 3 prescriptions written in these settings are considered unnecessary.1-4

As part of a multidisciplinary healthcare team, infectious disease pharmacists are considered experts in drugs and pharmacotherapy and are now a vital part of the core clinical team, playing a key role in patient care and in the selection of prescription drugs.

Incorrect antibiotic prescribing and overuse have led to a loss of efficacy for currently used antibiotics. Often, antibiotics prescribed for common acute infections are prescribed for 10 or more days of treatment, which is generally longer than necessary and puts patients at greater risk of adverse events such as Clostridioides with intractable diarrhea and drug toxicity and increases the chances of resistant strains to emerge.

In 129 Veterans Affairs medical centers, 40% of pneumonia infections were prescribed antibiotics for 8 days or more, and in one center study, 42% of uncomplicated skin infections were prescribed antibiotics for 10 days or longer.5 Depending on the type of infection, about 20-50% of antibiotic prescriptions for bacterial infections do not meet current guidelines or fail to take into account local resistance patterns.4, 6, 7, 8

Antibiotic stewardship programs are designed to assess antibiotic use and introduce measures that improve the way antibiotics are prescribed by clinicians, as well as educate patients to use antibiotics for what they have been prescribed and take the entire course. Not stopping when they feel better and keeping the rest of the pills. So, if antibiotics are so widely abused, why aren’t these programs being developed and implemented in all outpatient settings?

Although hospital antibiotic stewardship programs have demonstrated remarkable value and healthcare benefits, community service providers face many challenges and barriers to implementation. For example, descriptors come from diverse disciplines, geographic locations, and types of practices.

Also, for changes in antibiotic use to be successful, outpatient providers need the resources and time to address inappropriate antibiotic prescribing. The CDC has adapted recommendations for inpatient supervision to outpatients, noting that clinicians should do the following:9

• Demonstrate commitment to improving antibiotic prescribing and patient safety

• Take a single policy or practice action to improve antibiotic prescribing

• Tracking Prescribing Practices

• Provide regular feedback to doctors

• Providing educational resources and expertise on improving antibiotic prescribing

However, despite recent efforts by the Academy of Urgent Care Medicine, which has developed an education program for antibiotic stewardship, very few sites have completed training to obtain accreditation in antimicrobial stewardship.

According to the Pew Trust report, only about 50% of physicians surveyed are concerned about the problem of antibiotic resistance and inappropriate prescribing in their own practices, and feel they prescribe antibiotics more appropriately than their peers.10 About 84% of physicians also reported moderate pressure to prescribe antibiotics from their patients or caregivers. Some providers even practice defensive antibiotic prescribing out of concern about missed bacterial infections, potential medical-legal implications, patient satisfaction, and financial ramifications.

Although updated Clinical Practice Guidelines have been released for two of the most common outpatient bacterial infections, community-acquired pneumonia (CAP) and skin and soft tissue infection (SSTI), many prescribers are unaware of these updates, time to read them, or have not received Ongoing education on updates from previous guidelines. There are many opportunities to make smart and informed choices when prescribing antibiotics, given the number of CAP infections that occur annually (up to 5.6 million.11) and SSTI (about 14.2 million12) in the United States.

Antibiotic efficacy, safety, local resistance rates, and total cost, as well as patient-specific factors and disease presentation should aid community antibiotic management, or smart prescriptions. A multidisciplinary group of experts met in 2021 to discuss the topic of antimicrobial stewardship programs related to Gram-positive community-acquired infections. This group agreed that prescribers could help increase the effectiveness of antibiotic stewardship by taking into account the “4 D’s” (1) prescribing an antibiotic only for an infectious bacterial disease, (2) selecting an appropriate drug, (3) considering dosage, and ( 4) Avoid excessive antibiotic duration.13

The following recommendations for the most common pathogens and patient groups in CAP and SSTI are for the ‘standard’ patient with one of these bacterial infections; A good general rule of thumb is that for 80% of cases treatment should line these lines.

CAP Smart Prescription Recommendations:

diagnose
• In addition to the main clinical notes, try to use diagnostic tests to reduce uncertainty

duration of treatment
• The initial duration of antibiotic treatment should be 5 to 7 days, and efficacy has been demonstrated for this shorter period
• Short cycle associated with less adverse reactions and development of resistance. Clostridium difficile It often occurs after certain types of antibiotics

medicine selection
• Selection of antibiotics based on local resistance patterns, and known/suspected pathogens. NMRs are a suitable alternative

• If rates of local macrolide resistance are not known, choose another first-line monotherapy
• If local rates are known to be less than 25%, consider a macrolide
• Informed by the previous microbiological culture if available

• Common treatments to consider: beta-lactams + macrolides, tetracyclines and fluoroquinolones

SSTI Smart Prescription Recommendation:
diagnose
• Collect key history to help ascertain potential risk factors because culture results will not affect initial management
• It is important to exclude MRSA or appropriately describe it if you are not sure

duration of treatment

• Evidence of SSTI
• The initial duration of antibiotic treatment should be 7 to 10 days
• Short course associated with fewer adverse reactions, such as Clostridium difficile associated with diarrhea, and development of resistance

Choice of treatment
• Incision and drainage are encouraged when clinically indicated, followed by culture
May be sufficient to treat superficial infections

• Selection of antibiotics based on known/suspected pathogen local resistance patterns, national resistance rates and a suitable alternative
• Common treatments to consider: Cephalosporins (unless they are methicillin-resistant aureus bacteria suspected), trimethoprim/sulfonamides, glycopeptides, oxazolidinone, tetracycline

For further reading, please see the manuscript, supported by Roundtable Experts, “It Pertains to Patients: Practical Oversight of Antibiotics in Outpatient Clinics in the United States,” by Amin et al. 13, published in Frontiers in Medicine (https://www. frontiersin.org/articles/10.3389/fmed.2022.901980/full).

references

  1. Centers for Disease Control and Prevention. Outpatient Antibiotic Prescribing – United States, 2019 (2019). Available from: (Accessed 14 September 2021).
  2. Blue Cross Blue Shield. Low antibiotic prescription filling rates in the United States (2017). Available online at: (Accessed 14 September 2021).
  3. Fisher MA, Mahesri M, Lee J, Linder JA. Non-visit-based, infection-related antibiotic use in the United States: a cohort study of privately insured patients during 2016–2018. Open the forum dis infect. (2021) 8: ofab412.
  4. Pew Charitable Trusts. Use of antibiotics in outpatient settings. (2016). Available from: (Accessed 14 December 2021).
  5. Lowery JLI, Alexander B, Nair R, Heintz BH, Livorsi DJ. Assessment of antibiotic prescribing in emergency departments and urgent care centers across the Veterans Health Administration. Infect Hospital Control Epidemiol. (2021) 42: 694-701.
  6. Hurley HJ, Knepper BC, Price CS, Mehler PS, Burman WJ, Jenkins TC. Avoidable antibiotic exposure to uncomplicated skin and soft tissue infections in the ambulatory care setting. I J Med. (2013) 126: 1099-106.
  7. Shivley NR, Buehrle DJ, Clancy CJ, Decker BK. Prevalence of inappropriate antibiotic prescribing in primary care clinics within the veterans health care system. Chemother antimicrobial agents. (2018) 62:e00337–18.
  8. Jenkins TC, Knepper BC, Moore SJ, O’Leary ST, Caldwell B, Savelli CC, et al. Antibiotic prescribing practices in a multicenter group of patients hospitalized with acute bacterial dermatitis and skin structure infection. Infect Hospital Control Epidemiol. (2014) 35: 1241-50.
  9. Sanchez JV, Fleming Dutra KE, Roberts RM, Hicks Los Angeles. Essential elements of antibiotic supervision in the outpatient setting. MMWR Morb Mort Wkly Rep. (2016) 65: 1-12.
  10. Pew Charitable Trusts. Physicians’ survey reveals challenges and strategies to reduce inappropriate use of antibiotics. 2020. Available from: (accessed September 14, 2021).
  11. Magill SS, Edwards Jr, Beldaves Zdj et al. Emerging Health Care-Associated Infections Program and Antimicrobial Prevalence Survey Team. Prevalence of antimicrobial use in US acute care hospitals, May-September 2011. Gamma. 2014; 312 (14): 1438–1446.
  12. Hersh AL, Chambers HF, Maselli JH, Gonzales R. National trends in ambulatory visits and antibiotic prescribing for skin and soft tissue infections. Bow Apprentice Med 2008; 168: 1585-1591.
  13. Amin AN, Dellinger EP, Harnett G, Kraft BD, LaPlante KL, LoVecchio F, McKinnell JA, Tillotson G, Valentine S. It concerns patients: Practical supervision of antibiotics in a US outpatient setting. front med. 2022; 9: 901980.