Inappropriate Antibiotic Prescribing in Outpatient Settings

A Need for Antibiotic Stewardship in Outpatient Settings

Antimicrobial stewardship has historically been considered a hospital initiative, despite the majority of antibiotic prescribing occurring in the outpatient setting. While this suggests that antimicrobial stewardship efforts should expand to include outpatients, it may be difficult to know where to begin due to the heterogeneity of outpatient settings.

A recent retrospective descriptive study by Shively and colleagues^[1] evaluated antibiotic prescribing by primary care providers at seven Veterans Affairs clinics in Pittsburgh, Pennsylvania. The analysis included a total of 3880 prescriptions written by 74 providers between September 2015 and August 2016, resulting in a median of 84 prescriptions per 1000 patients per year.

The antibiotics prescribed most frequently overall were azithromycin (25.8%), amoxicillin/clavulanate (13.3%), doxycycline (12.4%), amoxicillin (11%), fluoroquinolones (11%), and trimethoprim-sulfamethoxazole (10.6%). Furthermore, the investigators evaluated a subset of prescriptions (5% per provider or 300 prescriptions from 59 distinct providers) to determine compliance with national guidelines.

In total, 76% of prescriptions reviewed were deemed inappropriate for the following reasons:

No antibiotic was indicated (49.7% of cases);
The wrong antibiotic was selected (12.3% of cases); and
The wrong duration of therapy was ordered (14% of cases).

The antibiotics that were most often inappropriately prescribed were azithromycin and ciprofloxacin. The most common indications for antibiotics were respiratory tract infection (28.3%) and urinary tract infection (23%). No indication was provided in 5.7% of cases. In 34% of cases, the antibiotic was ordered without a face-to-face visit with the patient. Antibiotic prescribing by provider was also analyzed, finding significant variability among providers.

In another study, Palms and colleagues^[2] analyzed data from the 2014 Truven Health MarketScan Commercial Claims and Encounters Database to evaluate antibiotic prescribing in patients under 65 years of age with commercial healthcare insurance in the outpatient setting. All visits were included with the exception of those with missing diagnoses or for patients with recent hospital admissions or recent antibiotic prescriptions. Antibiotic prescribing was most frequent in urgent care settings, accounting for 39.0% of 2.7 million visits, followed by 36.4% in retail clinics, 13.8% in emergency department (ED) visits, and 7.1% in office visits.

The investigators also analyzed antibiotic prescribing in conjunction with visits for antibiotic-inappropriate respiratory diagnoses for which antibiotics are considered unnecessary according to clinical guidelines. These conditions include viral upper respiratory infection, bronchitis/bronchiolitis, asthma/allergy, influenza, nonsuppurative otitis media, and viral pneumonia, which, combined, accounted for 5%-17% of all outpatient visits. Among visits for inappropriate respiratory conditions, antibiotic prescribing was highest in urgent care settings (45.7%), followed by the ED (24.6%), office visits (17.0%), and retail clinics (14.4%).

Viewpoint

These two studies support the need for antibiotic stewardship in outpatient settings, particularly in urgent care. Several important areas for potential intervention were identified, including increasing guideline-based prescribing and decreasing the number of antibiotics prescribed outside of a face-to-face encounter. These studies may provide a framework for initiating outpatient antimicrobial stewardship initiatives.

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