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Management Brief No. 79

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Management eBriefs
Issue 79March 2014

A Systematic Review: Antimicrobial Stewardship Programs in Outpatient Settings

The majority of antimicrobials prescribed to humans originate in outpatient settings. In making prescribing decisions, primary care providers are faced with patient expectations, and with patient and provider lack of awareness of antimicrobial resistance and lack of understanding of the seriousness of the antimicrobial resistance problem. An antimicrobial stewardship program (ASP) is a focused effort by a healthcare system or a portion of a system (e.g., a primary care clinic, a hospital) to optimize the use of antimicrobial agents in order to improve patient outcomes, reduce adverse effects (e.g., rash, drug fever, hepatitis, renal dysfunction), reduce antimicrobial resistance, and deliver cost-effective therapy.

Investigators with the VA Evidence-based Synthesis Program in Minneapolis conducted a synthesis of the evidence about the effectiveness of ASPs implemented in outpatient settings. The topic was nominated on behalf of the VA Antimicrobial Stewardship Task Force, in order to help guide clinical practice and policy in regard to inpatient ASPs within the VA healthcare system. Investigators reviewed over 6,000 titles and abstracts published between 2000 and November 2013, and identified 50 articles that were used in this review.

Summary of review results
Overall findings from this review show:

  • There are limited data on the effectiveness of ASPs in outpatient settings other than primary care clinics; most studies are of patients with respiratory infections. There are limited data on sustainability and scalability of interventions.
  • There is medium strength of evidence for the association of communication skills training and laboratory testing with a reduction in the use of antimicrobials.
  • There is low strength of evidence that other ASP interventions are associated with changes in prescribing.
  • Where reported, patient outcomes were not adversely affected. However, studies were generally underpowered to detect patient outcomes or harms, and therefore, the body of evidence is inadequate to answer questions about these endpoints.
  • Few studies reported cost outcomes, and no studies reported microbial outcomes.

Please see more detailed findings in regard to the following five key questions.

Key Question #1
What is the effectiveness of antimicrobial stewardship programs in outpatient settings on the following:

Primary Outcome: Antimicrobial prescribing (decision to prescribe, selection of antimicrobial, duration of treatment, and guideline concordant use); and Secondary Outcomes: 1) Patient-centered outcomes (return clinic visits, hospital admission, adverse events, late antimicrobial prescription, patient satisfaction with care); 2) Microbial outcomes (resistance in study population); and 3) Costs (program costs, drug costs)?

  • Provider and/or patient education interventions were associated with improved prescribing rate or use, with mixed results for antimicrobial selection and no effect on patient outcomes. Interventions were directed at providers in 13 of 16 studies.
  • Communication skills training to enhance patient and provider communication, address patient expectations for antimicrobial treatment, and foster a more "patient-centered" approach to care. Limited evidence suggested that there was little impact on patient or cost outcomes.
  • Limited data demonstrated that guidelines generally improved antimicrobial outcomes, with no difference in patient satisfaction and mixed results on antimicrobial costs.
  • Limited data suggested that delayed prescribing strategies may reduce antimicrobial use and return clinic visits, with no major adverse events. No data on costs or other outcomes were reported.
  • Clinical decision-support linked to the existing electronic health record generally improved prescribing outcomes, with no change in patient outcomes. No data were provided on microbial or cost outcomes.
  • Individualized provider feedback on prescribing resulted in mixed findings for prescribing outcomes, and possibly improved costs.
  • Restriction policies resulted in little impact on prescribing, patient, or cost outcomes.
  • A single CBA study reported that financial incentives improved the volume of prescribing and adherence to recommended use for 2 of 7 antimicrobials studied, though changes were not maintained at one year.
  • Testing (procalcitonin, viral PCR, and C-reactive protein) generally improved prescribing outcomes, with no difference in patient outcomes, and may be cost effective with regard to antimicrobial use.

Key Question #2
What are the key intervention components associated with effective outpatient antimicrobial stewardship (e.g., type of intervention, personnel mix, level of support)?

  • Limited evidence is available on key intervention components. However, speculation by authors and/or information from focus group interviews suggests that leadership and the use of a team approach, patient education materials, provider reminders, user friendly interfaces, and evidence-based materials may be important to the effectiveness of outpatient ASPs.

Key Question #3
Does effectiveness vary by clinic type or setting (e.g., primary care clinic vs. emergency department or urgent care, or VA vs. non-VA), or by suspected patient condition (e.g., respiratory tract infections, urinary tract infections, soft-tissue infections)?

  • Most studies included in the review were conducted in primary care clinics and included enrolled patients with respiratory tract infections. With limited information from other settings or other suspected patient conditions, it is not possible to reach conclusions about whether effectiveness varies by clinic type or patient condition.
  • Two studies were conducted at VA medical centers. Provider and patient education was found to decrease the percentage of patients presenting to emergency departments prescribed antimicrobials for respiratory tract infections without affecting patient outcomes, and a computerized clinical decision support system was found to reduce the proportion of unwarranted prescriptions.

Key Question #4
What are the harms of antimicrobial stewardship programs in outpatient settings?

  • None of the recent eligible studies reported possible harms of outpatient ASP implementation. There was limited reporting on return clinic visits, hospitalizations, and adverse events (including mortality). Studies that did report, generally found no significant differences between intervention and control groups.

Key Question #5
What are the barriers to implementation, sustainability, and scalability of antimicrobial stewardship programs in outpatient settings?

  • Limited data suggest that scalability and sustainability outside of the studied settings may be difficult. Implementation facilitators include convenience of interventions and access to training sessions, as well as efforts to include patients in self-care.

Future Research
This review highlights reduced prescribing associated with stewardship interventions. Future research might look at ways to enhance outpatient antimicrobial stewardship by involving infectious disease specialists and clinical pharmacists in the prescribing decision at the point-of-service via electronic interface – or by using automated surveillance techniques to monitor patient progress. Future studies also should focus on differences in clinically-meaningful endpoints, such as return clinic visits, emergency department visits, adverse drug events, and duration of illness. Large healthcare systems might introduce new stewardship programs in a staggered manner, randomizing facilities to different roll-out times and collecting data as the roll-out proceeds, allowing for a block-randomized trial while instituting a stewardship program. To achieve large sample sizes needed to adequately assess patient outcomes, review investigators recommend a collaborative approach with large healthcare institutions working together.

A Cyberseminar session on this ESP Report will be held at 12:00pm (ET) on May 12, 2014. To register, go to the HSR&D Cyberseminar web page.

This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers — and to disseminate these reports throughout VA.


Drekonja D, Filice G, Greer N, Olson A, MacDonald R, Rutks I, Wilt T. Antimicrobial Stewardship Programs in Outpatient Settings: A Systematic Review. VA-ESP Project #09-009;2014.

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This Management eBrief is a product of the HSR&D Evidence Synthesis Program (ESP). ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers - and to disseminate these reports throughout VA.

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