Antibiotic Awareness in the Outpatient Setting – Insight from Dr. Michael Klepser

Briefly describe your work involving antimicrobial stewardship and antibiotic awareness.

My colleagues and I have been promoting antimicrobial stewardship in the outpatient setting for approximately 10 years.  We developed disease management programs in community pharmacies that utilize clinical laboratory improvement amendments (CLIA)-waived point-of-care (POC) tests, resulting in reductions in inappropriate antibiotic use of >60% for acute pharyngitis and influenza.  We also developed methods to quantify and assess the appropriateness of antibiotic prescriptions using a EMR-based method.  This technique looks at indication-specific prescribing and compares antimicrobial regimens with published guidelines.  These methods are the basis for the development of an outpatient antibiotic usage registry with the Michigan Department of Health and Human Services.  Using these methods, we discovered non-guideline-based dosing of antibiotics is even more common than use of non-recommended agents, further emphasizing the importance of pharmacist involvement. These initiatives are important because stewardship starts with an understanding of current usage patterns and knowledge of how the impact of initiatives will be measured.  

What stewardship initiative or antibiotic awareness effort are you most proud of that you have participated in or lead?

I am most proud of our development of disease management programs in community pharmacies.  Develop of programs that allow pharmacists to assess symptomatic patients, run CLIA-waived POC tests, and dispense appropriate therapies has a tremendous potential to decrease inappropriate antibiotic use and decrease healthcare costs.  They also serve as a means to improve vaccination rates and patient understanding of when antibiotics should be used.  We also developed a pharmacist training program to empower pharmacists with the skills needed to implement and run these services.  To date, more than 4,500 pharmacists have received training through this program.  Our models have been replicated nation/world-wide.

Have you measured the impact of this initiative; if so, what has the impact been?

We have noted that with acute pharyngitis, we achieved a reduction in inappropriate prescribing of >60% in adults compared with historical data and 100% reduction in inappropriate antibiotic use among individuals with influenza-like-illness.

What actions do pharmacists take at your institution to optimize antibiotic use?

We promote immunizations and examine the appropriateness of antimicrobial regimens for common outpatient conditions including acute pharyngitis, urinary tract infections, and upper respiratory tract infections.

What is your primary goal for the next year to continue to improve antibiotic use?

We hope to implement a report card intervention for our clinic prescribers utilizing data generated from their own prescribing practices.  The report card will summarize individual prescribing practices and provide a visual peer comparison. They will also look at the percentage of regimens that are adherent to published guidelines (selection of agent, use of diagnostic tests, and dosing regimens).  We will use our tracking methodology to track performance over time.

What is one pearl you have for non-ID trained pharmacists to help them be antibiotic stewards?

In the outpatient setting you do not have the luxury of being reactive.  Once the patient receives an antibiotic, they are gone.  We need to think about infections as a cycle that begin and end with baseline health and move through various phases that patient and clinicians are involved with.  We need to recognize the multiple places where we can intervene in this cycle to improve antibiotic utilization.  We need to think globally and not just in our clinics.  Involving community pharmacists can have a dramatic impact on improving antibiotic use.  Also, inpatient practitioners need to consider the outpatient setting as an extension of their practice.

Michael E. Klepser, PharmD, FCCP, FIDP

Professor, Pharmacy Practice

Ferris State University College of Pharmacy