Improving Diagnosis in Health Care: A Focus on Outpatient Antibiotic Stewardship

The crucial aspect of enhancing patient care lies in the accuracy of diagnosis and the subsequent appropriateness of treatment. In outpatient settings, a significant area for improvement is antibiotic stewardship. This involves ensuring antibiotics are prescribed only when necessary and are the most effective choice for the diagnosed condition. This article delves into the core elements of outpatient antibiotic stewardship, drawing from established guidelines and best practices, and highlights its integral role in improving diagnosis in health care.

Core Elements of Outpatient Antibiotic Stewardship

Effective outpatient antibiotic stewardship programs are built upon four fundamental pillars. These are summarized in checklists designed for both clinicians and facilities, acting as practical tools to guide implementation and monitor progress in optimizing antibiotic use and patient safety.

Commitment: A demonstrable dedication from all members of the healthcare team is paramount. This commitment encompasses accountability for optimizing antibiotic prescribing practices and prioritizing patient safety above all else.
Action for Policy and Practice: Moving beyond commitment, concrete action is required. This involves implementing at least one policy or practice aimed at improving antibiotic prescribing habits. Crucially, this action must be followed by assessment to determine its effectiveness and a willingness to modify the approach as needed based on the data gathered.
Tracking and Reporting: To gauge the impact of stewardship efforts, consistent monitoring of antibiotic prescribing practices is essential. Regular feedback should be provided to clinicians, or systems should be in place for clinicians to self-assess their prescribing habits. This data-driven approach allows for informed adjustments and continuous improvement.
Education and Expertise: Providing readily accessible educational resources for both clinicians and patients is vital. These resources should focus on appropriate antibiotic prescribing. Furthermore, ensuring access to expert guidance on optimizing antibiotic use is a key component of a robust stewardship program.

Demonstrating Commitment to Antibiotic Stewardship

A strong commitment to antibiotic stewardship must permeate all levels of an outpatient facility. Every healthcare professional, regardless of their direct patient interaction, plays a role in promoting responsible antibiotic use. Clinicians, in particular, have the power to act as antibiotic stewards in every patient encounter.

Clinicians can actively demonstrate their commitment through actions such as:

Publicly Stating Support for Stewardship: Making a visible commitment can be a powerful tool. For instance, displaying posters in examination rooms that feature a letter from the clinician to their patients, explicitly stating their dedication to appropriate antibiotic prescribing, has been shown to reduce inappropriate prescriptions for acute respiratory infections (18). This open communication can also facilitate constructive conversations with patients about antibiotic use.

Outpatient clinic and healthcare system leaders hold a crucial position in fostering a culture of antibiotic stewardship. They can demonstrate their commitment by:

Appointing a Stewardship Leader: Designating a specific individual to lead and direct antibiotic stewardship activities within the facility is highly recommended. This single point of accountability, reporting directly to senior leadership, mirrors successful models in hospital stewardship programs (21,22) and is likely to be equally effective in outpatient settings.
Integrating Stewardship into Job Roles: Formalizing antibiotic stewardship responsibilities by including them in position descriptions and job evaluation criteria for roles such as medical directors, nursing leaders, and practice managers ensures that stewardship is not seen as an add-on but as an integral part of healthcare delivery. This integration also helps allocate sufficient time and resources for staff to dedicate to stewardship activities. While outpatient-specific evidence is still developing, hospital programs have demonstrated the importance of this type of leadership support (29).
Setting Clear Patient Expectations: Proactive communication with patients is key. It’s important to manage expectations by conveying that visits for acute illnesses may or may not result in an antibiotic prescription. Consistent messaging from all clinic staff, including administrative personnel, medical assistants, nurses, and physicians, about the appropriate use of antibiotics is crucial.

Actionable Policies and Practices for Improvement

To translate commitment into tangible improvements, outpatient clinicians and clinic leaders must implement concrete policies and interventions that actively promote appropriate antibiotic prescribing practices. A phased approach, starting with achievable goals, can make policy and practice changes more manageable and less overwhelming for clinicians and staff. As with any quality improvement initiative, regular assessment and adaptation of implemented policies are critical to ensuring ongoing progress. Prioritization should be given to interventions based on their feasibility, acceptability to staff and patients, resource requirements, and potential barriers to successful implementation. Action is the bridge between policy and measurable positive outcomes.

Clinicians can take immediate action by implementing practices such as:

Adhering to Evidence-Based Guidelines: The foundation of appropriate antibiotic prescribing lies in utilizing evidence-based diagnostic criteria and treatment recommendations. These should ideally be grounded in national or local clinical practice guidelines, informed by local pathogen susceptibility data. Resources such as guidelines from the American Academy of Pediatrics and the Infectious Diseases Society of America (30–35) provide valuable frameworks for managing common infections.
Employing Delayed Prescribing and Watchful Waiting: For certain conditions that often resolve without antibiotics, but may require them if symptoms persist or worsen (e.g., acute uncomplicated sinusitis, mild acute otitis media), delayed prescribing or watchful waiting are effective strategies. Delayed prescribing involves providing a postdated prescription with instructions to fill it only if symptoms do not improve after a set period, or advising the patient to contact the clinic if needed (36–40). Watchful waiting focuses on symptomatic relief and a clear plan for follow-up if symptoms worsen or fail to improve. Both approaches are evidence-backed and can safely reduce antibiotic use when applied according to clinical guidelines (41–44).

Clinic and healthcare system leaders can further support these efforts by implementing system-level actions:

Communication Skills Training: Equipping clinicians with enhanced communication skills is vital. Training can focus on strategies for addressing patient concerns regarding prognosis, the benefits and risks of antibiotic treatment, managing self-limiting conditions, and navigating patient expectations for antibiotics during consultations (45,46). Effective communication can significantly reduce unnecessary antibiotic requests and prescriptions.
Justification for Non-Recommended Prescribing: Requiring clinicians to provide explicit written justification in the patient’s medical record when prescribing antibiotics against recommendations can promote accountability and reduce inappropriate prescribing (19). This encourages thoughtful decision-making and documentation.
Clinical Decision Support Systems: Integrating clinical decision support tools into the clinical workflow, whether electronic or in print, can provide clinicians with readily accessible, specific information at the point of care. This support can facilitate accurate diagnoses and appropriate management, discouraging, for example, antibiotic use for acute bronchitis in healthy adults (47–52).
Utilizing Triage Systems: Implementing call centers, nurse hotlines, or pharmacist consultations as triage systems can effectively prevent unnecessary clinic visits. These resources can help manage conditions that do not require in-person appointments, such as the common cold, thereby reducing potential opportunities for inappropriate antibiotic prescriptions (53).

Tracking and Reporting for Continuous Improvement

Monitoring and reporting on clinician antibiotic prescribing practices, often termed “audit and feedback,” are indispensable for guiding practice changes and assessing the effectiveness of stewardship initiatives. When establishing tracking systems, key decisions need to be made regarding the level of tracking (individual clinician vs. facility), the specific outcomes to be measured, and the data collection methods. Data sources can range from automated electronic health record extraction to manual chart reviews or existing quality measure data (e.g., Healthcare Effectiveness Data and Information Set [HEDIS] measures). Analysis can be performed at both the individual clinician and facility levels. Ideally, tracking should be conducted at the individual clinician level, as personalized feedback has proven to be a powerful tool for promoting adherence to evidence-based guidelines (20,54–56). Effective feedback mechanisms often involve comparing a clinician’s performance to that of their peers (20), particularly highlighting top performers (19). Conversely, feedback from clinicians regarding stewardship interventions is crucial for refining strategies and maximizing their impact and acceptability (57). Furthermore, simply informing clinicians that their antibiotic prescribing rates are higher than the majority of their peers has been shown to reduce overall prescribing (58).

Tracking and reporting can be focused on specific high-priority conditions to assess the appropriateness of antibiotic use for those diagnoses. This includes evaluating if an antibiotic was justified for the assigned diagnosis, if diagnostic criteria were met prior to prescribing, if the chosen antibiotic was the recommended agent, and if the dosage and duration were correct. Outpatient clinicians and leaders can select outcomes for tracking based on identified areas for improvement within their specific practice or clinic. Conditions like acute bronchitis, for which antibiotics are not recommended yet are frequently prescribed (59,60), are prime candidates for targeted tracking. Providing feedback on the percentage of acute bronchitis visits resulting in antibiotic prescriptions, compared to peer performance, can be highly effective. This focused approach has been shown to reduce inappropriate prescribing and improve antibiotic selection (19,20).

Systems can also track the overall percentage of visits for which each clinician prescribes antibiotics. Comparing these individual percentages against peer averages has been shown to reduce antibiotic prescribing (58) and can mitigate the influence of variations in diagnostic coding practices. “Diagnosis shifting,” where a clinician might alter a diagnosis code to justify antibiotic use (e.g., coding pneumonia instead of acute bronchitis), can be missed when tracking only specific conditions. However, monitoring the percentage of all visits leading to antibiotic prescriptions is less susceptible to this issue. It’s important to consider patient population differences when comparing these metrics, as clinicians may serve patient groups with varying needs for antibiotics (e.g., a clinician with a higher proportion of immunocompromised patients).

Advanced healthcare systems may also be able to track and report complications associated with antibiotic use (e.g., C. difficile infections, drug interactions, adverse drug events) and antibiotic resistance patterns in common outpatient pathogens (24). At smaller clinic levels, these measures may be less statistically reliable due to smaller sample sizes. However, investigating C. difficile infections to identify potential links to recent ambulatory care visits and antibiotic prescriptions can serve as a marker for possible adverse drug events.

Both clinicians and clinic leaders have roles to play in tracking and reporting. Clinicians can engage in:

Self-Evaluation: Clinicians can proactively evaluate their own antibiotic prescribing practices against current evidence-based recommendations and clinical guidelines.
Continuing Education and Quality Improvement: Participation in relevant continuing medical education and quality improvement activities provides opportunities to track and refine prescribing habits. These activities can be tailored to specific specialties and may also fulfill licensure and other professional requirements.

Clinic and healthcare system leaders can implement:

Antibiotic Prescribing Tracking Systems: Establishing at least one system to track and report antibiotic prescribing is crucial. Tracked outcomes can include high-priority conditions, overall antibiotic prescribing rates, and, for larger systems, antibiotic-related complications and resistance trends. Reporting can be at the individual clinician level (preferred) or facility level.
Performance Assessment Against Quality Measures: Assessing and sharing performance data against established quality measures and reduction goals from healthcare plans and payers is important. National initiatives, such as the National Strategy for Combating Antibiotic-Resistant Bacteria, aim to significantly reduce inappropriate outpatient antibiotic use (61). Existing HEDIS measures include quality metrics for appropriate testing for pharyngitis in children, appropriate treatment of upper respiratory infections in children (avoiding antibiotics), and avoiding antibiotics for acute bronchitis in adults (62).

Education and Expertise: Empowering Clinicians and Patients

Education is a cornerstone of effective antibiotic stewardship, targeting both patients and clinicians. Patient education enhances health literacy and supports efforts to improve antibiotic use. Clinician education reinforces appropriate prescribing practices and elevates the quality of care (56,63,64). It’s important to recognize that clinician knowledge gaps are often not the sole driver of inappropriate prescribing in outpatient settings. Effective clinician education often involves reviewing prescribing guidelines while also addressing the psychosocial factors that influence prescribing decisions, such as concerns about patient satisfaction. Access to expert colleagues and consultants (e.g., pharmacists, specialists) is also an invaluable resource.

Clinicians can educate patients and families by:

Effective Communication: Employing clear communication strategies to educate patients about when antibiotics are and are not necessary is paramount. Patients should understand that antibiotics are ineffective against viral infections and should not be used for them. They should also be informed that some bacterial infections (e.g., mild ear and sinus infections) may resolve on their own without antibiotics. Combining explanations of when antibiotics are not needed with recommendations for symptom management has been linked to higher patient satisfaction (65). Providing clear guidance on when to seek further medical attention if symptoms worsen or do not improve (a contingency plan) also enhances satisfaction among patients who expected but did not receive antibiotics (66).
Educating About Potential Harms: Patients need to be informed about the potential downsides of antibiotic treatment, including common and sometimes serious side effects like nausea, abdominal pain, diarrhea, C. difficile infection, allergic reactions, and other adverse events. Parents of young children are particularly interested in understanding potential antibiotic-related adverse events (67). Emerging evidence also suggests links between early antibiotic exposure in infancy and childhood and an increased risk of allergic, infectious, and autoimmune diseases, possibly due to disruptions of the body’s microbiome (68).
Providing Educational Materials: Offering readily accessible patient education materials, including information on appropriate antibiotic use, potential adverse drug events, and resources for symptom management, reinforces key messages. The CDC website (http://www.cdc.gov/getsmart) offers a wealth of resources on managing common infections.

Clinic and healthcare system leaders can support clinician education and access to expertise by:

Face-to-Face Educational Training (Academic Detailing): Providing direct educational training, often termed “academic detailing,” delivered by peers, colleagues, or opinion leaders (including pharmacists and other clinicians), can be highly effective. This approach utilizes reinforcement techniques and peer comparison to promote changes in prescribing practices (69–71).
Continuing Education Activities: Offering relevant continuing education activities for clinicians, focusing on appropriate antibiotic prescribing, adverse drug events, and communication strategies to improve patient satisfaction, is essential. Communication training that equips clinicians to assess patient expectations, discuss risks and benefits, provide contingency plans, and confirm patient understanding has been shown to lead to sustained reductions in inappropriate antibiotic prescribing (46,72).
Ensuring Access to Expertise: Facilitating timely access to expert consultation, such as from pharmacists or medical and surgical specialists, is crucial. These experts can assist clinicians in optimizing antibiotic prescribing, particularly for complex cases or conditions requiring specialized care. In hospital settings, infectious disease-trained pharmacists have been invaluable members of stewardship programs, contributing to improved patient outcomes and cost savings (73). The specific expertise needed in outpatient settings may vary and should be determined based on the facility’s needs and patient population.

By focusing on these core elements – commitment, action, tracking, and education – and prioritizing improving diagnosis in health care, outpatient facilities can significantly enhance antibiotic stewardship, leading to better patient outcomes and combating the growing threat of antibiotic resistance.