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Journal of the American Pharmacists Association 56 (2016) 608e609
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association
journal homepage: www.japha.org
EDITORIAL
Takin’ it to the streets: Antimicrobial stewardship in the
outpatient setting
Antibiotic resistance has emerged internationally as a
major public health crisis. The National Action Plan for
Combating Antibiotic-Resistant Bacteria outlines a plan to
reduce the development and spread of antibiotic-resistant
organisms by 2020.1 The National Action Plan’s goals include
reducing the incidence of Clostridium difficile by 50%, which
the Centers for Disease Control and Prevention (CDC) esti-
mates led to nearly half a million incident infections in 2011.
This issue of the Journal coincides with CDC’s 2016 “Get
Smart About Antibiotics Week” campaign2 designed to raise
awareness about the problem of antibiotic resistance and to
promote appropriate antibiotic prescribing. The majority of
antibiotics are prescribed in the outpatient setting, and
antibiotic-resistant infections primarily occur in the general
community.3,4 The National Action Plan set a goal of reducing
inappropriate outpatient antibiotic prescribing by 50% and
strengthening antibiotic stewardship in both health care and
community settings. Included in this issue of the Journal,
Suda et al. provide interesting findings concerning outpatient
populationelevel antibiotic usage data by provider type.5
Although physicians still account for the majority of outpatient
antibiotic prescribing, their prescribing rates are decreasing,
whereas prescribing by physician extenders, including nurse
practitioners and physician assistants, has increased. Further-
more, trends of increases in broad-spectrum prescribing
were noted among the physician extenders, including macro-
lide, cephalosporin, and quinolone agents.
Given the high estimates of inappropriate outpatient oral
antibiotic use rates (nearly 70% by some estimates4), there
are many opportunities for outpatient stewardship interven-
tions. This is particularly true for upper respiratory tract indi-
cations, with an estimated 50% of prescribing for these being
inappropriate.4 Specific drug targets include quinolones,
which are often associated with C. difficile infection6 and
received a recent Food and Drug Administration Drug Safety
Communication regarding restriction of their use for uncom-
plicated infections, such as sinusitis and acute bronchitis,
owing to joint/tendone and central nervous systemerelated
effects.7 As noted by Suda et al., targeting other health care
professionals, such as dentists, in stewardship efforts should
be considered.5 In a study of community-associated C. difficile
DOI of original article: http://dx.doi.org/10.1016/j.japh.2016.08.015.
Disclosure: The authors have no known conflicts to disclose.
http://dx.doi.org/10.1016/j.japh.2016.10.006
1544-3191/© 2016 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
infection, dental offices were visited by nearly 30% of C. difficile
cases in the 12 weeks before a C. difficileepositive specimen.8
Dentists’ higher proportion of clindamycin prescribing,4 in
particular, could serve as an antibiotic stewardship target.
Probably the most well known stewardship guidelines are
the Core Elements for antimicrobial stewardship programs
published by CDC, which are available for both the inpatient
setting9 and long-term care facilities.10 Beginning January 1,
2017, The Joint Commission (TJC) accreditation standards for
hospitals and nursing centers will include a new standard
requiring the establishment of antimicrobial stewardship pro-
grams.11 The Centers for Medicare and Medicaid Services
(CMS) also initiated efforts to promote antimicrobial steward-
ship by proposing language requiring that stewardship pro-
grams be added to the CMS Conditions of Participation for
hospitals.12 Forthcoming guidance from CDC will help to
address the lack of recommendations on antimicrobial stew-
ardship efforts in the outpatient setting.
Pharmacists play an important role in promoting the
appropriate use of antimicrobials.13,14 This is particularly
evident in the inpatient setting. The CDC Core Elements specif-
ically mention the appointment of “a single pharmacist leader
responsible for working to improve antibiotic use.”9 TJC’s new
accreditation standard mirrors this language.11 The American
Society of Health-System Pharmacists has developed a policy
statement related to pharmacists and stewardship.15
This is not to say that pharmacists in community or outpa-
tient settings have no role in antimicrobial stewardship. Given
that most antibiotics are prescribed in the community setting,3
pharmacists outside of hospitals are in a position to influence
antibiotic use in positive ways. Pharmacists in ambulatory care
clinics or physician offices can work directly with prescribers
to promote appropriate antibiotic prescribing. Community
pharmacists may be the first health professionals that patients
interact with when feeling sick and can play an important role
in educating patients about when antibiotics are actually
appropriate. Community and ambulatory care pharmacists
can also counsel patients on appropriate adherence to courses
of antibiotic therapy. Even when patients are otherwise
healthy, pharmacists in outpatient settings can promote vacci-
nations and help to determine whether reported allergies to
antibiotics are true allergies. A range of materials that can
be used with patients to help promote the appropriate use of
antibiotics can be found on CDC’s Get Smart: Know When An-
tibiotics Work website at https://www.cdc.gov/getsmart/
community/materials-references/index.html.

Editorial / Journal of the American Pharmacists Association 56 (2016) 608e609
As antimicrobial stewardship guidance continues to
evolve in both inpatient and outpatient settings, developing
regulatory efforts will support antimicrobial stewardship
through reimbursement and accreditation mechanisms.
Given the importance of antimicrobial resistance for both pa-
tient care and public health, pharmacists across all settings
must work together with patients and other health care pro-
fessionals to promote the judicious use of antimicrobial
agents.
References
1. National Action Plan for Combating Antibiotic-Resistant Bacteria.
Available at: https://www.whitehouse.gov/sites/default/files/docs/
national_action_plan_for_combating_antibotic-resistant_bacteria.pdf.
Accessed September 26, 2016.
2. Centers for Disease Control and Prevention. Get Smart: Know When
Antibiotics Work. Available at: http://www.cdc.gov/getsmart. Accessed
September 26, 2016.
3. Centers for Disease Control and Prevention. Antibiotic Resistance Threats
in the United States, 2013. Atlanta: Centers for Disease Control and
Prevention, US Dept of Health and Human Services; 2014. Available
at: http://www.cdc.gov/drugresistance/threat-report-2013/. Accessed
September 26, 2016.
4. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate
antibiotic prescriptions among US ambulatory care visits, 2010-2011.
JAMA. 2016;315(17):1864e1873.
5. Suda KJ, Roberts RM, Hunkler RJ, Taylor TH. Antibiotic prescriptions in
the community by type of provider in the United States, 2005-2010.
Am Pharm Assoc (2003). 2016;56(6):621e626.
6. Brown KA, Khanafer N, Daneman N, Fisman DN. Meta-analysis of antibi-
otics and the risk of community-associated Clostridium difficile infection.
Antimicrob Agents Chemother. 2013;57(5):2326e2332.
7. FDA Drug Safety Communication: FDA updates warnings for oral and
injectable fluoroquinolone antibiotics due to disabling side effects. Pub-
lished July 26, 2016. Updated September 8, 2016. Available at: http://
www.fda.gov/Drugs/DrugSafety/ucm500143.htm. Accessed September
26, 2016.
DEPARTMENTS
8. Chitnis AS, Holzbauer SM, Belflower RM, et al. Epidemiology of
community-associated Clostridium difficile infection, 2009 through
2011. JAMA Intern Med. 2013;173(14):1359e1367.
9. Centers for Disease Control and Prevention. The Core Elements of Hos-
pital Antibiotic Stewardship. Atlanta: Centers for Disease Control and
Prevention, US Department of Health and Human Services; 2014.
Available at: http://www.cdc.gov/getsmart/healthcare/implementation/
core-elements.html. Accessed September 26, 2016.
10. Centers for Disease Control and Prevention. The Core Elements of Anti-
biotic Stewardship for Nursing Homes. Atlanta: Centers for Disease Con-
trol and Prevention, US Dept of Health and Human Services; 2015.
Available at: http://www.cdc.gov/longtermcare/prevention/antibiotic-
stewardship.html. Accessed September 26, 2016.
11. Approved. new antimicrobial stewardship standard. Jt Comm Perspect.
2016;36(7):1,3e4,8.
12. Medicare and Medicaid programs; hospital and critical access hospital
(CAH) changes to promote innovation, flexibility, and improvement in
patient care. Fed Regist. 2016;81(116):39448e39480.
13. Erikson AK. Pharmacists critical to managing antimicrobials, developing
infection control procedures. Pharm Today. 2014;20(12):6e7.
14. International Federation of Pharmacy. Fighting Antimicrobial Resis-
tance: The Contribution of Pharmacists. The Hague: International Feder-
ation of Pharmacy; 2015. Available at: https://www.fip.org/files/fip/
publications/2015-11-Fighting-antimicrobial-resistance.pdf. Accessed
September 26, 2016.
15. ASHP statement on the pharmacist’s role in antimicrobial stewardship
and infection prevention and control. Am J Health Syst Pharm.
2010;67(7):575e577.
Amy L. Pakyz, PharmD, MS, PhD, Associate Professor,
Virginia Commonwealth University School of Pharmacy,
PO Box 908533, Richmond, VA 23298
E-mail address: apakyz@vcu.edu
Spencer E. Harpe, PharmD, PhD, MPH, Associate Professor,
Midwestern University Chicago College of Pharmacy,
Downers Grove, IL
609