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Antimicrobial Stewardship in Outpatient Settings: A Systematic Review

Published online by Cambridge University Press:  22 December 2014

Dimitri M. Drekonja
Affiliation:
Department of Medicine, University of Minnesota School of Medicine, Minneapolis, Minnesota Infectious Disease Service, Minneapolis VA Health Care System, Minneapolis, Minnesota
Gregory A. Filice
Affiliation:
Department of Medicine, University of Minnesota School of Medicine, Minneapolis, Minnesota Infectious Disease Service, Minneapolis VA Health Care System, Minneapolis, Minnesota
Nancy Greer*
Affiliation:
Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
Andrew Olson
Affiliation:
Department of Medicine, University of Minnesota School of Medicine, Minneapolis, Minnesota Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minnesota
Roderick MacDonald
Affiliation:
Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
Indulis Rutks
Affiliation:
Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
Timothy J. Wilt
Affiliation:
Department of Medicine, University of Minnesota School of Medicine, Minneapolis, Minnesota Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
*
Address correspondence to Nancy Greer, PhD, Minneapolis VA Health Care System, One Veterans Drive, Mail Code 111-O, Minneapolis, MN 55417 (nancy.greer@va.gov).

Abstract

Objective

Evaluate the effect of outpatient antimicrobial stewardship programs on prescribing, patient, microbial outcomes, and costs.

Design

Systematic review

Methods

Search of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (eg, infectious conditions, prescription services) evaluating stewardship programs in outpatient settings and reporting outcomes of interest. Data regarding study characteristics and outcomes were extracted and organized by intervention type.

Results

We identified 50 studies eligible for inclusion, with most (29 of 50; 58%) reporting on respiratory tract infections, followed by multiple/unspecified infections (17 of 50; 34%). We found medium-strength evidence that stewardship programs incorporating communication skills training and laboratory testing are associated with reductions in antimicrobial use, and low-strength evidence that other stewardship interventions are associated with improved prescribing. Patient-centered outcomes, which were infrequently reported, were not adversely affected. Medication costs were generally lower with stewardship interventions, but overall program costs were rarely reported. No studies reported microbial outcomes, and data regarding outpatient settings other than primary care clinics are limited.

Conclusions

Low- to moderate-strength evidence suggests that antimicrobial stewardship programs in outpatient settings improve antimicrobial prescribing without adversely effecting patient outcomes. Effectiveness depends on program type. Most studies were not designed to measure patient or resistance outcomes. Data regarding sustainability and scalability of interventions are limited.

Infect Control Hosp Epidemiol 2014;00(0):1–11

Type
Original Articles
Copyright
© 2014 by The Society for Healthcare Epidemiology of America. All rights reserved 

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