Introducing antimicrobial stewardship to the outpatient clinics of a suburban academic health system

Abstract

Objective: To establish an antimicrobial stewardship program in the outpatient setting.

Design: Prescribers of antimicrobials were asked to complete a survey regarding antimicrobial stewardship. We also monitored their compliance with appropriate prescribing practices, which were shared in monthly quality improvement reports.

Setting: The study was performed at Loyola University Health System, an academic teaching healthcare system in a metropolitan suburban environment.

Participants: Prescribers of antimicrobials across 19 primary care and 3 immediate- and urgent-care clinics.

Methods: The voluntary survey was developed using SurveyMonkeyand was distributed via e-mail. Data were collected anonymously. Rates of compliance with appropriate prescribing practices were abstracted from electronic health records and assessed by 3 metrics: (1) avoidance of antibiotics in adult acute bronchitis and appropriate antibiotic treatment in (2) patients tested for pharyngitis and (3) children with upper respiratory tract infections.

Results: Prescribers were highly knowledgeable about what constitutes appropriate prescribing; verified compliance rates were highly concordant with self-reported rates. Nearly all prescribers were concerned about resistance, but fewer than half believed antibiotics were overprescribed in their office. Among respondents, 74% reported intense pressure from patients to prescribe antimicrobials inappropriately. Immediate- and urgent-care prescribers had higher rates of compliance than primary-care prescribers, and the latter group responded well to monthly reports and online educational resources.

Conclusions: Intense pressure from patients to prescribe antimicrobials when they are not indicated leads to overprescribing, an effect compounded by the importance of patient satisfaction scores. Compliance reporting improved the number of appropriate antibiotics prescribed in the primary care setting.

Fig. 1.

Survey data for prescriber knowledge and perception of antimicrobial stewardship and resistance.

Fig. 2.

Survey data for provider antibiotic prescribing habits.

Fig. 3.

Survey data for factors influencing the decision to prescribe an antibiotic.

Fig. 4.

Delayed Prescribing Practices. (A) Survey data for frequency of using delayed prescribing strategies. (B) Survey data for type of delayed prescribing strategies used.

Fig. 5.

Survey data for type of antibiotic educational resources that prescribers would like (A) to provide to patients and (B) to obtain for themselves.

Fig. 6.

Antibiotics prescriptions per month. The number of prescriptions remained relatively stable across 2019, dropped during 2020, and stabilized again in 2021, particularly when considering (A) the total number of prescriptions and (B) antibiotic treatment for adults with acute bronchitis. This trend also applied to the number of prescriptions for (C) antibiotic treatment for children with URI and (D) antibiotic treatment for patients tested for pharyngitis.

Fig. 7.

Prescriber compliance rates. (A) Compliance rates for immediate- or urgent-care prescribers were above the target threshold for all 3 metrics assessed. For monthly reporting before and after the intervention, P = .3071 for appropriate treatment for children with URI, P = .0007 for avoidance of antibiotic treatment in adults with acute bronchitis, and P = .0805 for appropriate antibiotic treatment in patients tested for pharyngitis. (B) Primary care prescribers responded well to compliance reports and education. For monthly reporting before and after the intervention, P = .0021 for appropriate treatment for children with URI, P = .0001 for avoidance of antibiotic treatment in adults with acute bronchitis, and P = .0001 for appropriate antibiotic treatment in patients tested for pharyngitis. For electronic education material before and after initiating monthly reporting, P = .0010 for appropriate treatment for children with URI, P = .0001 for avoidance of antibiotic treatment in adults with acute bronchitis, and P = .0002 for appropriate antibiotic treatment in patients tested for pharyngitis.