Antimicrobial Stewardship for Outpatients: Progress, But a Long Way to Go

Establishing and maintaining an antimicrobial stewardship program (ASP) in the controlled confines of hospital wards is challenging enough, but in the chaos of the emergency department (ED) and outside the hospital grounds, the challenge is magnified. A trio of speakers addressed some of the outpatient challenges at the annual meeting of the Infectious Diseases Society of America in New Orleans, Louisiana.

Antimicrobial stewardship in the ED ripples outward into the rest of the hospital. “The ED is the nexus of the [United States] healthcare system. 20% of the US population goes to an ED each year. ED visits trigger about 75% of all hospital admissions and about 30% of acute care visits. Antibiotics are administered in about 25% of the nearly 35 million ED visits annually in the United States, making them the second most common category of drug used in the US health care system,” said Michael Pulia, MD, MS from the University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, in his session.

Antibiotics started in the ED can be continued following admission, at least for awhile, so if the antibiotics used in the ED are inappropriate, the misuse will spill over to subsequent patient care.

“There is a paucity of ED stewardship research. In a systematic review we have done, encompassing 1979 to 2016, only about 40 interventional studies were identified. There was a wide range of strategies making it difficult to compare and our overall rating of methodologic quality was only fair,” said Dr. Putia.

Challenges to antimicrobial stewardship in the ED setting include a lack of perception of antibiotic misuse by some emergency physicians, time pressure to do something for patients despite the knowledge of ramifications later on in terms of antibiotic resistance, variable levels of training for ED staff, variations in regional practices, and compensation for ED physicians that is often linked to the numbers of patients who actually receive treatment.

The ASP challenges for those receiving dialysis are even greater, since dialysis is done in private clinics. However, the fact that dialysis in the US is delivered by just a few companies could make progress easier.

“The risk of [methicillin-resistant Staphylococcus aureus] infection is 100-fold higher among chronic hemodialysis patients compared to the general population and hemodialysis has been associated with a 13-fold higher risk of [extended spectrum beta-lactamase] producing Klebsiella pneumonia infections. Chronic hemodialysis patients contribute to the spread of multidrug-resistant organisms in the hospital and community settings,” said Erica D’agata, MD, MPH, Brown University, Providence, Rhode Island, in her session.

ASPs have been developed for hospitals and long-term care facilities, with none developed specifically for dialysis centers. By far the biggest challenge for an ASP in the dialysis setting is education. “Dialysis units are so busy that introducing a new program is hard. Education for the neurologist is crucial, since they just don’t get any,” said Dr. D’agata.

"The lack of training could change," according to Dr. D'agata, "because dialysis in the United States is done by three companies." Discussion with company leaders has revealed enthusiasm to make things better. It is in the companies’ best bottom-line interest to do so.

Adult outpatients represent another ASP challenge. “It’s always stunning to me about the lack of focus on outpatients; they represent 35 million hospitalizations, 135 million emergency department visits and antibiotics are prescribed for 12% of them,” said Jeffrey Linder, MD, MPH, Brigham & Women’s Hospital/Harvard Medical School, Boston, Massachusetts, in his talk.

Antibiotics are the go-to treatment. For ambulatory care visits, there are 506 antibiotic prescriptions for every 1000 Americans. Of these, 30% are unnecessary with the rate rising to 50% for those with acute respiratory infections. A contrast is provided by the country of Sweden, where the antibiotic prescription rate for ambulatory care visits is 388 per 1000 people, with a national campaign underway to lower the rate to 250 per 1000.

In seeking to change the treatment culture in the US, it is helpful to remember that much of any change that will happen will be driven by behavior. An ‘educate and remind’ approach has really not worked for physicians, who are by-and-large already aware of the problem of antimicrobial resistance and the need to take action.

“Our radical notion is that doctors are people. Just like everybody else, they make decisions fast and often automatically, not knowing why they made them, and are influenced by emotion and social factors. So we can take advantage of cognitive bias and appeal to clinician self-image,” said Dr. Linder in his talk.

Antibiotic prescription can be driven by a number of factors: the belief that the patient wants them, that it is easier and quicker to just prescribe an antibiotic, habitual behavior, or a desire to err on the side of safety. Dr. Linder and colleagues undertook a randomized controlled trial using what they termed a “nudging guideline” in which doctors received an email either praising their antibiotic stewardship or reprimanding them for inadequate performance. The blow-to-the-ego approach was effective in significantly reducing inappropriate prescriptions compared to those who did not receive the emails.

Issuing a prescription, but instructing the patient to take a ‘wait and see’ approach before obtaining the drug, is another option. However, Dr. Linder opined that this puts too much of the decision making on the patient. Rather, he argues, the physician should drive the decision. “It can send a mixed and confusing message to a patient that they need a drug but should not get the drug,” he said.

In that vein, communication between physician and patient is paramount. For this to be effective, the physician needs to understand and buy-in to the need to actively participate in antimicrobial stewardship.

DISCLOSURES

Michael Pulia: Advisory boards, Thermo Fisher and Cempra

Erica D’agta: None

Jeffrey Linder: Stockholder in Amgen, Biogen, and Eli Lilly; Former grant funding from Astellas Pharma Inc., and Clintrex/Astra Zeneca; Honoraria from SHEA (supported by Merck)

SOURCES

• Photos and tape of IDSA presentation
• US Department of Health and Human Services Report #90 2016
• Fuller BM et al. J Emerg Med 2013 44:910-918
• Spiro DM et al. 2006 JAMA 13:1235-1241
• Meeker D et al. 2014 JAMA Intern Med 174:425-431

PRESENTATIONS

Approaching Antimicrobial Stewardship in Outpatient Settings

• View From the Emergency Department; Michael Putia, MD, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
• Strategy Implementation in Hemodialysis; Erica D’agata, MD, MPH, Brown University, Providence, Rhode Island
• View From the Outside: Adult Outpatients; Jeffrey Linder, MD, MPH, Brigham & Women’s Hospital/Harvard Medical School, Boston, Massachusetts

​Brian Hoyle, PhD, is a medical and science writer and editor from Halifax, Nova Scotia, Canada. He has been a full-time freelance writer/editor for over 15 years. Prior to that, he was a research microbiologist and lab manager of a provincial government water testing lab. He can be reached at hoyle@square-rainbow.com.