What are the CDC's guidelines for antibiotic stewardship in outpatient vs inpatient (hospital) settings?

CDC Guidance for Antibiotic Stewardship in Outpatient versus Inpatient Settings

The CDC recommends establishing antimicrobial stewardship programs (ASPs) in all acute care hospitals by 2020, while also expanding stewardship activities to outpatient settings, with each requiring distinct approaches tailored to their unique challenges and opportunities. 1

Core Differences Between Settings

Inpatient (Hospital) Setting

• Program Structure Requirements:

  • Requires physician and pharmacist leadership with infectious diseases expertise 1
  • Formal ASP structure with dedicated committees and regular monitoring 1
  • Preauthorization and/or prospective audit and feedback are core components 1

• Key Intervention Strategies:

  • Preauthorization requirements for restricted antibiotics to control use of broad-spectrum agents 1
  • Prospective audit and feedback after antibiotics are prescribed 1
  • Focus on de-escalation of broad-spectrum antibiotics once culture results are available 1
  • Emphasis on appropriate collection of cultures before starting antibiotics 1

• Unique Considerations:

  • Antibiotics initiated in emergency departments are often continued in inpatient settings, creating a critical connection point 1
  • Hospital ASPs must address the continuum from emergency department to inpatient units 1
  • Focus on reducing length of antibiotic treatment courses 2

Outpatient Setting

• Program Structure Approach:

  • Less formal structure than hospital settings 1
  • CDC recommends four core elements for outpatient stewardship 1:
    1. Commitment to optimizing antibiotic prescribing and patient safety
    2. Implementation of specific stewardship policies or practices
    3. Tracking and reporting of antibiotic prescribing practices
    4. Education and expertise resources for clinicians 1

• Key Intervention Strategies:

  • Patient-based interventions, particularly delayed prescriptions for non-urgent conditions 3
  • Multi-faceted educational interventions targeting physicians, patients, and the public 3
  • Interactive educational meetings rather than didactic lectures 3
  • Physician reminders and decision support tools 3

• Unique Challenges:

  • Higher percentage of unnecessary prescribing (up to 50-75% of outpatient antibiotic prescriptions may be inappropriate) 4, 5
  • Patient expectations and time constraints often drive inappropriate prescribing 4
  • Non-face-to-face encounters prompt many antibiotic prescriptions 4

Implementation Considerations

Effectiveness of Interventions

• Inpatient Setting:

  • Restrictive interventions (preauthorization) show immediate impact but may create delays in treatment 1
  • Enabling interventions that include feedback show greater sustained impact 2
  • Combination of enabling and restrictive approaches yields best results 2
  • ASPs can reduce antibiotic use without adversely affecting mortality 2

• Outpatient Setting:

  • Multi-faceted interventions combining physician, patient, and public education are most successful 3
  • Printed educational materials or audit and feedback alone produce minimal changes 3
  • Sustained benefits require ongoing interventions rather than one-time education 5

Common Pitfalls and How to Avoid Them

• Inpatient Setting:

  • Pitfall: Restrictive interventions may lead to delays in treatment and negative professional culture 2
  • Solution: Combine restrictive approaches with enabling interventions and maintain clear communication between infectious disease specialists and clinical teams 2

• Pitfall: Restricting one class of antibiotics may lead to overuse of alternatives 1

  • Solution: Monitor changes in usage patterns across all antibiotic classes 1

• Outpatient Setting:

  • Pitfall: Diagnosis codes often don't match the condition for which antibiotics are prescribed 4
  • Solution: Implement specific documentation requirements for antibiotic prescriptions 4

• Pitfall: Clinician perception that patients expect antibiotics 3

  • Solution: Provide communication tools and patient education materials 3, 5

Emergency Department: A Critical Bridge Between Settings

• Serves as both a rapid diagnostic center and primary source for hospital admissions 1
• Actions taken by emergency providers have significant implications for both inpatient and outpatient antibiotic use 1
• Specific stewardship focus areas include:
  • Rapid and accurate diagnosis using appropriate biomarkers and diagnostic tests 1
  • Collection of cultures before starting antibiotics 1
  • Appropriate empirical therapy selection 1
  • Clear documentation and communication with inpatient teams 1

Measuring Success

• Inpatient Metrics:

  • Compliance with institutional antibiotic policies 2
  • Duration of antibiotic therapy 2
  • Hospital length of stay 2
  • Rates of Clostridioides difficile infection 2
  • Patterns of antimicrobial resistance 2

• Outpatient Metrics:

  • Overall antibiotic prescribing rates 5
  • Unnecessary antibiotic prescribing rates 5
  • Guideline-concordant selection of antibiotics 5
  • Guideline-concordant duration of therapy 5

Future Directions

• CDC guidance emphasizes the need to expand stewardship activities beyond hospitals to all healthcare settings 1
• Guidelines should better incorporate local resistance patterns in making recommendations 6
• More research is needed on the unintended consequences of restrictive interventions 2
• Innovative approaches like telemedicine consultation may help extend stewardship to settings without on-site infectious disease expertise 1