An Outpatient Antimicrobial Stewardship Needs Assessment

Background

Over 20% of pediatric outpatient visits result in an antibiotic prescription, most commonly for acute respiratory tract infections (ARTIs). Approximately 30% of prescriptions for ARTIs may be unnecessary or inappropriate. These prescriptions contribute to resistance and other adverse outcomes. Thus, outpatient antimicrobial stewardship (OAS) is a priority of the American Academy of Pediatrics and primary care physicians play a critical role in promoting optimal antibiotic use.

A variety of antimicrobial stewardship interventions have been successfully implemented in outpatient settings, including education for providers and families, audit of prescribing with feedback, and electronic medical record (EMR) modifications. We sought to obtain provider input on OAS prioritization and strategies to inform our efforts in establishing an outpatient antimicrobial stewardship program (ASP) at a large academic medical center located in an urban setting.

Methods

We distributed a survey to all outpatient care providers at our institution to evaluate current antibiotic prescribing practices and gather feedback on strategies for enhancing antimicrobial stewardship in their practice.

Results

Sixty-four providers completed our survey. Respondents included residents, attending physicians, and advanced practice providers in a range of adult and pediatric specialties. Eighty-three percent agreed that antibiotic overuse is an issue in primary care and 75% believed that an outpatient ASP would be helpful to their practice. The most popular interventions were related to EMR modification, with 75% of respondents expressing interest in at least one. Only 41% of providers reported currently using EMR-based tools in their antibiotic decision-making, however, so EMR interventions need to honed further to be successful. Forty-seven percent of providers identified streamlining penicillin allergy de-labeling (referrals, resources, etc.) in the outpatient setting as a desired priority for an ASP. Finally, 69% of surveyed providers take patient/family expectations and/or social situation into account when deciding whether to prescribe antibiotics. This provides justification for community-engaged initiatives to hold a central role in our implementation strategy.

Conclusions

In the literature, EMR modifications have been successfully implemented and shown to reduce inappropriate antibiotic prescriptions regarding choice of antibiotic, dose, or duration of treatment. Based on our survey results, providers at our institution believe that such modifications will be useful to their practice as well. These results will inform our next steps in building an effective outpatient ASP at our institution and may also be translatable to other large academic institutions.