Antibiotic Stewardship Toolkit

OverviewAntibiotic resistance is a pressing public health issue. Overuse/misuse of antibiotics is a major cause of increasing antibiotic resistance. According to the Centers for Disease Control and Prevention (CDC), 30% of outpatient antibiotic use is unnecessary, especially when prescribed for viral upper respiratory infections. This number may approach 50% for all outpatient antibiotic use. One out of every five emergency room visits for adverse drug events is due to antibiotics.

Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing involves implementing effective strategies to modify prescribing habits to align with evidence-based recommendations for diagnosis and management. The CDC’s Core Elements of Outpatient Antibiotic Stewardship provides a framework for antibiotic stewardship for outpatient clinicians and facilities that routinely provide antibiotic treatment.

With this toolkit, we are providing some tools and resources to help you implement the Core Elements in your facility.

CDC’s Core Elements of Outpatient Antibiotic Stewardship Core Elements Checklist

About HQI

As the Quality Innovation Network - Quality Improvement Organization for Maryland and Virginia, HQI convenes patients, families, providers and partners to rapidly improve health quality. For more information about our antibiotic stewardship initiative, please contact:

Maryland - Katie Richards, MPH Virginia – Deb Smith, MLT (ASCP), BSN, CIC, CPHQ HQI Improvement Consultant HQI Improvement Consultant krichards@hqi.solutions dsmith@hqi.solutions

Core Element #1: Commitment

• Write and display public commitments in support of antibiotic stewardship.• Identify a single leader to direct antibiotic stewardship activities within a facility.• Include antibiotic stewardship-related duties in position descriptions or job evaluation

criteria.• Communicate with all clinic staff to set patient expectations.

Tools for Implementation:

• Safe Use of Antibiotics Poster:o Marylando Virginia

• Safe Use of Antibiotics Flyer:o Marylando Virginia

Core Element #2: Action

• Use evidence-based diagnostic criteria and treatment recommendations.• Use delayed prescribing practices or watchful waiting, when appropriate.• Provide communications skills training for clinicians.• Require explicit written justification in the medical record for non-recommended

antibiotic prescribing.• Provide support for clinical decisions.• Use call centers, nurse hotlines, or pharmacist consultants as triage systems to prevent

unnecessary visits.

Tools for Implementation

• Antibiotic Treatment Guidelines for Adults• Infectious Diseases Society of America Infections by Organism• Infectious Diseases Society of America Infections by Antimicrobial Agent Use• University of California, San Francisco Guideline for Empiric Therapy: Adult

Outpatients• Delayed Prescribing• Watchful Waiting• How to Prescribe Fewer Unnecessary Antibiotics: Talking Points that Work with

Patients and Their Families• Educating Patients About Antibiotic Use (Video)• CDC Commentary: Don’t Give in and Give Those Antibiotics!• Outpatient Acute Bronchitis Treatment Algorithm for Adults• Outpatient Acute Pharyngitis for Adults and Pediatric Patients Treatment Algorithm• Outpatient Acute Sinusitis for Adults and Pediatric Patients Treatment Algorithm

Core Element #3: Tracking and Reporting

• Self-evaluate antibiotic prescribing practices.• Participate in continuing medical education and quality improvement activities to track

and improve antibiotic prescribing.• Track and report antibiotic prescribing for one or more high priority conditions.• Track and report the percentage of all visits leading to antibiotic prescriptions.• Track and report, at the level of a health care system, complications of antibiotic use and

antibiotic resistance trends among common outpatient bacterial pathogens.• Assess and share performance on quality measures and established reduction goals

addressing appropriate antibiotic prescribing from health care plans and payers.

Tools for Implementation

• HQI’s Quarterly Antibiotic Prescribing Reports (provided to participating facilities)• Peer Comparison May Yield Lasting Boost in Antibiotic Stewardship• CDC’s Antibiotic Resistance Patient Safety Atlas• Measuring Outpatient Prescribing• Maryland Acute Care Hospital Healthcare-Associated Clostridium difficile and MRSA

Data• Audit Worksheet for Viral Upper Respiratory Infections: Four Steps to Track Antibiotic

Prescribing

Core Element #4: Education

• Patient Educationo Use effective communications strategies to educate patients about when

antibiotics are and are not needed.o Educate patients about the potential harms of antibiotic treatment.o Provide patient education materials.

• Provider Educationo Provide face-to-face educational training (academic detailing) to clinicianso Provide continuing education activities for clinicians.o Ensure clinicians have timely access to persons with expertise.

Tools for Implementation

• Patient Educationo Antibiotics in Our Time: A Global Health Challenge (Video)o Viruses or Bacteria – What’s Got You Sick?o ABCs of Antibioticso Antibiotics, When You Need Them - and When You Don’to Antibiotics: Will They Help You or Hurt Youo Taking Your Antibiotics Appropriatelyo Symptomatic Relief for Viral Illnesses (prescription pad)o Preventing and Treating Bronchitis

• Provider Educationo Stanford CME Course - To Prescribe or Not to Prescribe? Antibiotics and

Outpatient Infectionso Is it Really a Penicillin Allergyo Setting Goals for Antibiotic Prescribing in U.S. Outpatient Settings (Video)o Pharmacist Antibiotic Resistance Continuing Educationo Antibiotic Stewardship Basics for Multi-Disciplinary Health Care Professionalso CDC Training on Antibiotic Stewardship

Other Antibiotic Stewardship Resources

• Be Antibiotics Aware (New CDC Website)• National Event – Antibiotic Stewardship, Understanding Physician to Patient

Communication Strategies• Antibiotic Prescribing and Use in Doctor’s Offices Print Materials• Pew Charitable Trusts Antibiotic Use in Outpatient Settings• Choosing Wisely• Public Health Foundation Toolkit• Society for Healthcare Epidemiology of America Toolkit• Joint Commission Toolkit• Agency for Healthcare Research and Quality Clostridium difficile Infections Toolkit• American Hospital Association Toolkit• National Quality Forum Playbook• Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe

Care• MMWR April 2018 Vital Signs: Containment of Novel Multidrug-Resistant Organisms

and Resistance Mechanisms• Antimicrobial Stewardship Toolkit for ED and Urgent Care• A Field Guide to Antibiotic Stewardship in Outpatient Settings