Table 3.

Summary of outpatient antibiotic stewardship interventions and considerations

Intervention	Considerations
Patient Education	Effectiveness of smaller-scale interventions uncertain Mass-media campaigns may be effective
Clinician Education	Active, in-person education more effective than passive education Factors influencing prescribing go beyond knowledge gaps, so should be provided in combination with other interventions
Communication Skills Training	Effective with sustained benefits over time May improve patient satisfaction Effective elements of communication in conditions where antibiotics are not needed include: Using both a negative and positive treatment recommendation Providing a contingency plan
Diagnostics and Point of Care Testing	Can be useful in diagnosing bacterial etiologies Accurate diagnosis decreases inappropriate antibiotic use for viral infections Diagnostic stewardship is needed in any intervention where diagnostics or point of care testing are used
Active Monitoring/Delayed Prescribing	Can reduce antibiotic use for conditions where antibiotics are sometimes indicated Guideline recommended for some conditions (acute otitis media in children and acute sinusitis) Should never be used in conditions where antibiotics are not indicated or are immediately indicated
Clinical Decision Support	Evidence on effectiveness is mixed Can range from low-tech (such as printed clinical pathways) to high-tech (integrated into EHR) Low uptake can be a barrier to effectiveness More effective if integrated into existing systems and easy to use
Audit and Feedback + Peer Comparison	Peer comparison rooted in behavioral science Effective in reducing inappropriate prescribing Should provide an appropriate prescribing target (not mean) to prevent regression to the mean effect
Accountable Justification	Based in behavioral science Effective in reducing inappropriate prescribing Must be integrated into EHR
Public Commitment Posters	Based in behavioral science Low-cost, effective intervention Intended effect is for clinician rather than patient Should be placed in exam room (not waiting room) Templates available from CDC and some state health departments

A full discussion of these interventions and supporting evidence is available in the “Interventions to improve outpatient antibiotic prescribing” section of the text.