Table 2.
Ambulatory Care Antibiotic Stewardship Interventions and Potential Applications for Older Adult Populations
| Ambulatory Care Stewardship Interventions | Application for Older Adults |
|---|---|
| Clinical Decision Support | |
| Best Practice Alerts (electronic health record) | Target high risk conditions specific to older adults (e.g., asymptomatic bacteriuria) |
| Care Pathways | Incorporate evidence-based diagnostic criteria into care pathways for common infections in older adults (e.g., pneumonia, cellulitis, urinary tract infection) |
| Pharmacist Medication Review | Particular attention to dosing adjustments, drug-drug interactions and known adverse effects of antibiotics in older adults (e.g., neuro- and cardiac toxicities) |
| Behavior Modification | |
| Audit and Feedback/Academic Detailing | Focus on high impact clinical scenarios (e.g., bronchitis, asymptomatic bacteriuria) |
| Justifying Prescriptions | Mandate that all antibiotic prescriptions, including those given “just in case”, include a syndrome-specific indication (e.g., cystitis, pneumonia) |
| Clinician Education | Include topics specific to older adults (e.g., atypical presentations, stepwise workup for delirium, when to obtain cultures) |
| Communication Skills Training | Ensure training incorporates scenarios related to older adults (e.g. diagnostic uncertainty around presence of pneumonia or cellulitis) and emphasizes contingency planning |
| Patient Education | Provide educational materials specific to common conditions (e.g., upper respiratory tract infections) that suggest supportive care measures and detail the potential adverse consequences of antibiotics (e.g., drug-drug interactions, Clostridiodes difficile colitis) Public Commitment to Stewardship Posters |
| Public Commitment to Stewardship Posters | Specifically mention stewardship commitment for conditions common among older adults (e.g., asymptomatic bacteriuria) and ensure font size on posters is legible to individuals with visual impairments |
| Diagnostic Tools | |
| Pharmacist Culture Review | Modifying therapy to narrow-spectrum agents and shortest duration possible based on culture results |
| Biomarkers | Ensure availability of real-time C-reactive protein or procalcitonin to help guide antibiotic prescribing for respiratory tract infections |
| Rapid Diagnostic Tests | Ensure availability and provide education about low value of antibiotics for stable patients with negative rapid strep tests or confirmed influenza, consider using respiratory antigen panels to identify serious respiratory illnesses caused by viral infections other than influenza (e.g., respiratory syncytial virus, human metapneumovirus, parainfluenza) |