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Download PDF: Complete Report, Executive Summary, Report, Appendices, Supplementary Materials
Substantial growth in the size of the evidence base for outpatient antimicrobial stewardship has occurred since 2013. Published studies most commonly evaluated audit and feedback, multicomponent antimicrobial stewardship programs, and patient/clinician education. Audit and feedback, clinical decision support systems (CDSS), or a combination of both did not consistently reduce overall antimicrobial use or inappropriate prescribing; however, there was substantial variation in characteristics of strategies and multicomponent programs. There remains an urgent need for effective strategies or multicomponent programs that can be implemented and sustained in the outpatient setting.
Outpatient health care settings are complex environments serving a variety of patient needs. Antimicrobial stewardship programs seek to improve antimicrobial prescribing practices and optimize patient outcomes. More than 80% of antimicrobial usage occurs in the outpatient setting, and diverse outpatient settings present an array of challenges for antimicrobial stewardship. Understanding the effects of programs and individual strategies will be critical for optimizing and implementing future stewardship efforts.
We identified 285 primary studies and 37 systematic reviews that evaluated the effects and implementation efforts of various stewardship programs and strategies in outpatient settings. Most primary studies implemented audit and feedback (in combination with clinician/patient education), and most were conducted in emergency room (ER) and/or primary care settings. In a further systematic review of 45 prioritized primary studies conducted in primary care and/or ER settings, we found that audit and feedback, CDSS, and multicomponent programs did not consistently reduce overall or inappropriate antimicrobial prescribing. In addition to prescribing outcomes, there were also generally no differences in patients' treatment outcomes and health care utilization. Few studies addressed implementation cost or barriers, reach, or sustainability. Most studies evaluated audit and feedback (k=25), while 6 implemented CDSS, and 14 examined multicomponent programs (that primarily combined audit and feedback with CDSS).
Antimicrobial Stewardship Strategies and Programs in the Outpatient Setting (Management Brief)
