Antimicrobial Stewardship in Outpatient and Long-Term Care Settings

Reviewed by: Jesse Sutton, PharmD, VA Salt Lake City Health Care System; James “Brad” Cutrell, MD, FIDSA, University of Texas Southwestern Medical Center

The recent rules and regulations from the Centers for Medicare & Medicaid Services and standards from the Joint Commission underscore the importance of antimicrobial stewardship in both the ambulatory care and long-term care settings. Two recent articles describe multifaceted stewardship interventions in the ambulatory care and long-term care settings, which were associated with lower rates of antibiotic prescriptions and extended spectrum beta-lactamase (ESBL) bacterial colonization. 

Peñalva and colleagues performed a quasi-experimental antimicrobial stewardship intervention in 214 primary health centers in Andalusia, Spain from 2012-2017. The intervention was multi-faceted, with the primary activity consisting of individual educational interviews between prescribers and local intervention champions. Additional intervention components included recurring didactic modules, local treatment pathways, and quarterly progress reports for feedback and benchmarking. The authors performed an interrupted time-series analysis to evaluate changes in antibiotic prescription rates, antibiotic prescription appropriateness in a subset of prescriptions, and incident density of ESBL-E. coli isolated from urine cultures. Antibiotic use was measured in defined daily doses per 1000 inhabitants in the study population per day.  The study population was comprised of 1.9 million adult and pediatric individuals seen by 1,387 prescribers. Twenty-four thousand educational interviews were performed from 2014-2017. There were no changes in the overall trend of antibiotic prescriptions. There was a decrease in rates of fluoroquinolone and cephalosporin use, and an increase in amoxicillin and fosfomycin use. The authors reported a downward trend of 3.2% per year in the rate of inappropriate prescriptions. The incidence density of ESBL E. coli in urine cultures was lower in the post-intervention period by -0.028 cases per 1000 inhabitants (95% confidence interval -0.024 to -0.021), which was a significant downward trend in the post-intervention period. The intervention overall received positive feedback from participants. 

Sloane and colleagues performed a multi-faceted quality-improvement intervention to reduce antibiotic use in 27 community nursing homes in North Carolina from 2015 – 2017. The intervention components included training modules for nurses and providers, disease-state based educational posters, pocket-card treatment algorithms, communication guidelines for nurses, quarterly progress briefs, and annual reports targeted to providers and nursing staff. Informational brochures were provided to residents and families. Compared to the baseline prescription rate of 12.4 prescriptions / 1000 resident days, antibiotic prescriptions were lower at one year with 10.4 prescriptions / 1000 resident days (incident rate ratio [IRR] 0.82, 95% CI 0.69-0.98) and two years with 9.9 prescriptions / 1000 patient days (IRR 0.77, 95% CI 0.65-0.90). The lower rate of antibiotic prescribing was primarily from less treatment of suspected UTI. After 2 years, the rate of urine culture orders was lower compared to baseline (4.2 vs. 3.1 per 1000 resident days, p-value = 0.03). There were no differences in any other outcomes after 1-2 years compared to baseline. In multivariable analysis, the only factor associated with lower antimicrobial prescription rate was having the facility medical director as the resident’s primary physician. The estimated intervention cost ranged from $354-$3653 depending on degree of staff participation in training modules.

These two studies highlight the positive impact of multi-faceted stewardship interventions in outpatient and long-term care settings. However, there remain barriers to effective implementation outside acute-care settings. 


  1. Peñalva G, Fernández-Urrusuno R, Turmo JM, et al. Long-term impact of an educational antimicrobial stewardship programme in primary care on infections caused by extended-spectrum β-lactamase-producing Escherichia coli in the community: an interrupted time-series analysis. Lancet Infect Dis 2019 Nov 22. pii: S1473-3099(19)30573-0. doi: 10.1016/S1473-3099(19)30573-0. [Epub ahead of print] 
  2. Sloan PD, Zimmerman S, Ward K, et al. A 2-year pragmatic trial of antibiotic stewardship in 27 community nursing homes. J Am Geriatr Soc 2020;68(1):46-54. 
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