Introduction to Antibiotic Stewardship in the Outpatient Setting

By Juan M. Vidal, RN, BSN

Since the discovery of Penicillin in 1929, antibiotics have saved countless lives by treating infections that were once considered deadly. The use of antibiotics to treat infections revolutionized the field of medicine around the world, and has become one of the greatest public health achievements of our time. Antibiotics are life-saving medications used to treat millions of individuals including those receiving chemotherapy for cancer treatment, and those undergoing surgical procedures.

Bacteria have been on our planet much longer than humans have; they have perfected the technique of evolution. Bacteria have been living inside our bodies since the inception of mankind; however, some have the power to be pathogenic, meaning they can cause serious disease. These specific pathogenic bacteria are evolving and becoming resistant to antibiotics. In the United States, 23,000 deaths and 2 million illnesses occur every year due to resistant-bacterial infections that cannot be treated with antibiotics.

Throughout the years, health practitioners have been prescribing antibiotics carelessly leading to multiple side effects from overuse, and far worse, resistance. The power of antibiotics is diminishing each time health practitioners overprescribe these medications. Overprescribing is not the only reason for increased resistance to antibiotics; prescribing the wrong medication for specific bacteria can also increase resistance.1

Our country’s leadership is taking significant steps in tackling this problem. When President Barack Obama signed the executive order to combat antibiotic-resistant bacteria in 2014, this started a domino effect throughout the country’s health infrastructure. This executive order helped raise awareness, not only in the US but also throughout the world, regarding the need to develop awareness campaigns to collaborate on addressing this issue. Strong antibiotic stewardship programs (ASP) are critical for healthcare organizations to lead the fight against antibiotic resistance. ASP were more commonly known to the inpatient hospital setting in the past. Recently, the move has turned to the outpatient setting where most of the antibiotics are prescribed. Studies show that outpatient prescription reduction of antibiotics can lead to a decreased prevalence in resistant bacteria throughout the community.2-3

Antibiotic stewardship programs are the efforts to measure antibiotics prescribing, improve antibiotic prescribing methods, and minimize misdiagnosis leading to underuse of the drugs. These programs also strive to ensure that the right doses of the medications are used, the correct drug and duration are selected, and ONLY when needed. ASP in the outpatient setting focuses on the CDC four core elements that institutions must have in place to address and solve this challenging issue.

Commitment from leadership is needed to ensure the support from multidisciplinary groups. Successful ASPs have gathered the support from key leaders in their organizations. When the chief medical officer and/or chief nursing officer are committed, not only does it move the project forward, but also helps to facilitate communication between experts in different areas of the healthcare arena. Members in ASP task forces should include a pharmacist with some type of training in infection control, an infectious disease physician, working in collaboration with an infection control nurse. A laboratory expert in microbiology is useful in determining bacterial lab tests. Some facilities receive the support from their information technology (IT) departments and specialized nurses to help sort through electronic data. Initially, meetings should be held at least once a month to ensure the program is moving in the right direction and meeting its target timelines.

Policies that change infection control practices should be implemented and approved by the members of the ASP Task Force. An example would be the implementation of a policy for delayed prescribing. This initiative could be used for patients with conditions that may resolve on their own without the need for antibiotics. Patients must be reassured that that they can return to the clinic if the symptoms do not resolve on their own. Posters in waiting rooms with personal physician pictures can also provide a reassuring factor to manage the patient’s expectation during their visit.1

Data is a big component of ASPs providing a snapshot of current practices in antibiotics prescribing. Measuring prescribing practices can help tailor practitioners in individual specialties to self-evaluate and seek evidence-based recommendations and guidelines. Outcomes of the data can be shared with other providers to help improve their prescribing practices. Antibiograms from lab specimens in the community can help guide proper antibiotic use to what’s sensitive in the population. A challenge posed is acquiring data from a third-party organization that could breech HIPPA regulations regarding sensitive information being shared.4

Engaging nurses and physicians can play a significant role in creating awareness to relay accurate information to patients. Misconceptions regarding the proper use of antibiotics are rampant throughout the community; and healthcare providers have a role in debunking these myths. Experts in this field can conduct seminars training sessions to educate the staff on the most effective methods of tackling this issue. Public health professionals are essential in delivering and guiding the community in such practices.1,4

Antibiotics are considered a miracle drug and have advanced modern medicine into a new era of infection disease management. The creation and development of new antibiotics are slow, and not many have been introduced into the market in recent decades. Developing medications that will become resistant and not be effective in a few years does not represent a good profitable business model. Incentives for pharmaceutical development companies are outlined in President’s Obama executive order, and will be crucial to stimulate production of new and more effective types of antibiotics. If we want to stay ahead of the curve, stewardship programs are an essential component to solve this crisis.5

Juan M. Vidal, RN, BSN, is an infection control practitioner and adjunct faculty at University of Miami - School of Nursing and Health Studies.

1. Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016;65(No. RR-6):1–12. DOI:
2. The Antibiotic Resistance National Action Plan. Medscape. Mar 27, 2015.
3. Dantes, R., Mu, Y., Hicks, L. A., Cohen, J., Bamberg, W., Beldavs, Z. G., … Lessa, F. C. (2015). Association Between Outpatient Antibiotic Prescribing Practices and Community-Associated Clostridium difficile Infection. Open Forum Infectious Diseases, 2(3), ofv113.
4. Society for Healthcare Epidemiology of America. Jan. 30, 2018. Inappropriate antibiotic prescribing differs by patient age, insurance, race: To reduce inappropriate prescribing, tailored education is needed for older physicians, nurse practitioners and physician assistants. ScienceDaily. Accessed at:
5. Prabhavathi F and Martens E. Antibiotics in late clinical development. Biochemical Pharmacology. Vol. 133, Pages 152-163. 2017. (

University of Miami Miller School of Medicine Takes Action to Manage Antibiotic Use in Outpatient Settings

By Richard Westlund

Through an innovative outpatient antimicrobial stewardship program, the University of Miami Miller School of Medicine is taking action to manage antibiotics appropriately.

“At least 30 percent of outpatient antibiotic prescriptions are unnecessary,” says Jose G. Castro, MD, medical director of the University of Miami Medical Group Infection Control Department. “Physicians and patients need to understand the importance of using antibiotics judiciously.”

To improve antibiotic stewardship in the community, the Miller School is collaborating with Health Services Advisory Group (HSAG), the Medicare Quality Innovation Network-Quality Improvement Organization for Florida.

“Antibiotic resistance has been identified by the Centers for Disease Control and Prevention (CDC) as a fundamental aspect of global health concern,” says HSAG president and CEO Mary Ellen Dalton, PhD, MBA, RN.

“Through this collaboration, we will work to implement CDC-recommended protocols and best practices to combat antibiotic resistance,” she adds. “Together, we will strengthen our pledge to establish antibiotic stewardship activities that are effective and sustainable and continue our commitment to patient safety.”

Several years ago, the Centers for Medicare & Medicaid Services (CMS) and partners such as HSAG began focusing on managing antibiotic use in hospital settings. Last year, that objective was expanded to include physician offices, health clinics, emergency departments, urgent care facilities, pharmacies and other outpatient settings.

“We began working with HSAG on this collaborative initiative in March,” says Juan M. Vidal, RN, an infection preventionist and antimicrobial stewardship program staff champion for UHealth – the University of Miami Health System. “Since then, we’ve taken several steps, including sharing patient videos in English and Spanish, tracking antibiotic use, and providing evidence-based feedback to prescribers.”

For example, Vidal is helping to develop an antibiogram that will provide real-time information to clinicians on the resistance and suitability of antibiotics for various types of bacterial or other microbial infections.

“This will be a big step forward in providing appropriate prescriptions in an outpatient setting,” he says. “We want to ensure that the right drug, dose, and duration are selected when an antibiotic is needed.”

To date, the Miller School stewardship program has received positive feedback from clinical leaders, says Castro. “Many divisions and departments have asked us to get in the trenches with their clinicians and to cover this topic in grand rounds so physicians in training are aware of this worldwide patient safety issue.”