Novel approaches to decrease inappropriate ambulatory antibiotic use

ABSTRACT

Introduction: Inappropriate antibiotic use and antibiotic resistance are major public health threats. In the United States, most antibiotic use occurs in ambulatory care and 30% to 50% may be inappropriate. The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotics by 50% by 2020.

Areas covered: This review summarizes the epidemiology of antibiotic use in ambulatory care and explores evidence-based, novel approaches for improving ambulatory antibiotic use.

Expert opinion: We leveraged insights from behavioral science and social psychology to implement novel peer comparison – a form of audit-and-feedback – and accountable justification alert interventions that reduced inappropriate antibiotic prescribing to 5% or less. We and others have been successful in reducing inappropriate antibiotic prescribing with precommitment posters, communication training, combined patient/clinician education, and clinical decision support. Other commonly employed, but unsound approaches to reducing inappropriate antibiotic prescribing include point-of-care testing and delayed antibiotic prescriptions. These approaches are not durable (e.g. CRP testing), have not been proven in primary care (e.g. procalcitonin), or are conceptually flawed, such as using testing for non-antibiotic-appropriate diagnoses or using delayed antibiotic prescriptions. To decrease inappropriate ambulatory antibiotic use, clinicians, pharmacists, practices, and health systems need to collect antibiotic prescribing data, select concrete improvement targets, and implement evidence-based interventions such as peer comparison, accountable justification, precommitment, and communication training.

KEYWORDS:

• Ambulatory care
• anti-bacterial agents
• antimicrobial stewardship
• clinical decision making
• drug resistance
• bacterial
• economics
• behavioral

Article highlights

• Antibiotics are commonly prescribed in ambulatory care. Thirty percent to 50% may be inappropriate.

• Reducing inappropriate antibiotic use is critical to curb the emergence of antibiotic resistant bacteria.

• Novel antibiotic stewardship interventions such as peer comparison and accountable justification informed by behavioral science and social psychology are effective in reducing inappropriate antibiotic prescribing.

• Other effective interventions include precommitment, communication training, patient and clinician education, and clinical decision support.

• Practices and health systems need to collect antibiotic prescribing data, select concrete targets, and implement evidence-based interventions to decrease inappropriate antibiotic use.

Declaration of interest

J Linder is supported by grants from the National Institute on Aging (R21AG057400, R21AG057396, R21AG057383), National Institute on Drug Abuse (R21AG057395), Agency for Healthcare Research and Quality (R01HS024930, R01HS026506), The Gordon and Betty More Foundation, The Peterson Center on Healthcare, and a contract from the Agency for Healthcare Research and Quality (HHSP2332015000201). T Rowe is supported by grants from the National Institute on Aging (R21AG057383) and a contract from the Agency for Healthcare Research and Quality (HHSP2332015000201). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.