Outpatient Clinics

In the outpatient clinic setting, patients present to healthcare workers with a range of symptoms. Any of a number of symptoms or signs may suggest a bacterial infection treatable with antibiotics—fever, shaking chills, cough, sore throat, abdominal pain, burning on urination, a wound with drainage. The healthcare provider will have a short window of time to evaluate the patient’s presenting complaint, obtain a history and complete a physical exam, order diagnostic tests, and propose a treatment plan. This treatment may or may not include prescribing an antibiotic. In some resource-limited setting, healthcare workers use clinical algorithms to evaluate, say, a child presenting with fever. To narrow down the possible diagnosis, a rapid diagnostic test might be used, and a positive finding might suggest to the healthcare worker to treat for malaria. The respiratory rate—if too high—might suggest a pneumonia, treatable with oral antibiotics. If more severe, the referral decision might be made to send the patient to a hospital to be further evaluated and admitted for antibiotics that can only be administered intravenously. The approach taken will depend on the local prevalence of bacterial disease, lab infrastructure and training of healthcare workers.

The patient may be a child, brought by a parent who may have taken off work to come to the clinic. The patient or the parents bringing in a child may expect the healthcare provider to offer a prescription, even if the infection is likely viral and not treatable with an antibiotic. Patients may have traveled significant distances to be seen at the clinic. Knowing that the patient might not easily return if the condition worsens, the provider might offer an antibiotic prescription in order to avoid missing a bacterial infection in case the symptoms are not self-limited and worsen. Clinic arrangements may limit the time the provider has with each patient and whether diagnostic tests are available. Financial incentives and drug company promotion can also influence whether healthcare providers prescribe or not.

Challenges include:

  • Non-financial incentives, such as patient expectations of antibiotic treatment
  • Financial incentives
  • Availability (or not) of appropriate, rapid diagnostic tests
  • Local pharmacy availability (or stockout) of needed antibiotic
  • Opportunity for referral for hospital evaluation
  • Feasibility of watchful waiting and delayed prescription
  • Institutional constraints, such as short visit time

Background Literature

Making available antibiotic guidance in the practice setting, by signposting to online references and in printed materials. Auditing prescribing activity at the practice level can also help guide steps as to where to position information or training to improve antibiotic stewardship. [Owens R, Jones LF, Moore M, Pilat D, McNulty C. Self-Assessment of Antimicrobial Stewardship in Primary Care: Self-Reported Practice Using the TARGET Primary Care Self-Assessment Tool. Antibiotics (Basel) 2017; 6(3). Available at: https://www.ncbi.nlm.nih.gov/pubmed/28813003 ]

The “Treat Antibiotics Responsibly, Guidance, Education, Tools” (TARGET) toolkit—grounded in the evidence of earlier, successful interventions—engaged prescribers in reflecting on their own practices through a self-assessment questionnaire and local prescribing data, educational resources for both provider and patient (including waiting room materials) audit toolkits and national antibiotic management guidance among other components. [McNulty C, Hawking M, Lecky D, Jones L, Owens R, Charlett A, et al. Effects of primary care antimicrobial stewardship outreach on antibiotic use by general practice staff: pragmatic randomized controlled trial of the TARGET antibiotics workshop. J Antimicrob Chemother 2018; 73(5): 1423-1432. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5909634/pdf/dky004.pdf

Current Efforts

Behavioral economic approaches might also usefully shape prescriber behavior. In Australia, the Chief Medical Officer sent letters to high prescribers among general practitioners. The letters that provided comparisons to their peers had more effect than the education-only message. [Australian Department of Health and Department of the Prime Minister and Cabinet. Nudge vs Superbugs: A behavioural economics trial to reduce the overprescribing of antibiotics, June 2018. Available at: http://www.health.gov.au/internet/main/publishing.nsf/content/Nudge-vs-Superbugsbehavioural-economics-trial-to-reduce-overprescribing-antibiotics-June-2018]

Delayed prescribing for specific conditions, like acute respiratory tract infections, can be implemented in several different ways. Systematic review of randomized controlled trials using delayed prescribing suggest that the lowered antibiotic use did not make a difference in the clinical outcomes. [Sargent, L., McCullough, A., Del Mar, C., & Lowe, J. (2016). Is Australia ready to implement delayed prescribing in primary care? A review of the evidence. Aust Fam Physician, 45(9), 688-690. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27606375]

Alternatives to antibiotic prescribing—an herbal remedy for palliating the symptoms of a viral infection not requiring an antibiotic—have been developed as part of Thailand’s Antibiotic Smart Use project. [Sumpradit N, Chongtrakul P, Anuwong K, Pumtong S, Kongsomboon K, Butdeemee P, Khonglormyati J, Chomyong S, Tongyoung P, Losiriwat S, Seesuk P. Antibiotics Smart Use: a workable model for promoting the rational use of medicines in Thailand. Bulletin of the World Health Organization 2012; 90: 905-913. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3524958/]

Opportunities for Innovation

—How can targeting specific conditions—which seldom require antibiotics—be assessed effectively and incentives given to providers not to overprescribe antibiotics in such cases?

—Are there any diagnostic approaches—when combined with present symptoms and signs in the patient—that could improve rational use and decrease inappropriate use of antibiotics?

—What new approach—perhaps building on previous efforts from behavioral economics to audit-and-feedback—might motivate prescribers in outpatient settings to reduce overprescribing of antibiotics?

—What other practices—such as substituting antibiotics with an herbal alternative for palliating viral symptoms—might change the sociology of practice and address patient expectations of treatment, but not result in overuse of antibiotics?

—How can delayed prescribing be implemented in resource-limited settings? Might mobile phones help implement such an approach?