It's about the patients: Practical antibiotic stewardship in outpatient settings in the United States

Abstract

Antibiotic-resistant pathogens cause over 35,000 preventable deaths in the United States every year, and multiple strategies could decrease morbidity and mortality. As antibiotic stewardship requirements are being deployed for the outpatient setting, community providers are facing systematic challenges in implementing stewardship programs. Given that the vast majority of antibiotics are prescribed in the outpatient setting, there are endless opportunities to make a smart and informed choice when prescribing and to move the needle on antibiotic stewardship. Antibiotic stewardship in the community, or "smart prescribing" as we suggest, should factor in antibiotic efficacy, safety, local resistance rates, and overall cost, in addition to patient-specific factors and disease presentation, to arrive at an appropriate therapy. Here, we discuss some of the challenges, such as patient/parent pressure to prescribe, lack of data or resources for implementation, and a disconnect between guidelines and real-world practice, among others. We have assembled an easy-to-use best practice guide for providers in the outpatient setting who lack the time or resources to develop a plan or consult lengthy guidelines. We provide specific suggestions for antibiotic prescribing that align real-world clinical practice with best practices for antibiotic stewardship for two of the most common bacterial infections seen in the outpatient setting: community-acquired pneumonia and skin and soft-tissue infection. In addition, we discuss many ways that community providers, payors, and regulatory bodies can make antibiotic stewardship easier to implement and more streamlined in the outpatient setting.

Keywords: antibiotic stewardship; antimicrobial stewardship; inappropriate prescribing; infectious skin diseases; microbial drug resistance; overprescribing; pneumonia; therapeutic antibacterial agents.

FIGURE 1

Regional distribution of antibiotic prescribing patterns and antibiotic resistance within the United States (US). (A) Outpatient antibiotic prescription rates from the Centers for Disease Control and Prevention, 2018 (3). (B) Erythromycin-resistant Streptococcus pneumoniae phenotype rates, 2019 (98). (C) Methicillin-resistant Staphylococcus aureus (MRSA) rates, as a percentage of all S. aureus isolates, 1997–2017 (51). Resistance rates were derived from isolates collected at US hospitals in the SENTRY surveillance program.

FIGURE 2

Susceptibility rates of Streptococcus pneumoniae to common antibiotics in North America (2010, 2014) using CLSI breakpoints (20). Amoxicillin–clavulanate rates were determined using non-meningitis breakpoints. CLSI, Clinical and Laboratory Standards Institute; TMP/SMX, trimethoprim–sulfamethoxazole.

FIGURE 3

Susceptibility of > 191,000 S. aureus isolates to older antibiotics, from a global surveillance program (51). MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-susceptible S. aureus; TMP-SMX, trimethoprim–sulfamethoxazole.