Table 1.

Strategies and methods of outpatient antimicrobial stewardship programmes.

Category	Methods of implementation	Strengths	Challenges
Prospective audit and feedback	Dedicate a physician/pharmacist to review prescriptions Provide rapid feedback to ordering provider on individual prescriptions Consider starting with a single antibiotic class or disease state	Individualized interventions with relatively immediate feedback	Time consuming Dedicated personnel necessary Requires frequent review and often manual chart review
Personalized prescription feedback	Summary of antibiotic prescription data for individual prescribers May be presented in comparison to similar peers or clinics Can be conducted over review periods	Does not require daily review Can compare to other providers	May require some manual chart review to determine appropriateness of antibiotics
Patient education	Educational printouts Posters in healthcare facilities One-on-one discussion with a member of healthcare team	Can be personalized to the patient group/disease state	Varying education levels of patients
Provider education	Training on how to maintain patient satisfaction without prescribing antimicrobials Education provided at already scheduled and recurring meetings covering the inappropriate and appropriate use of antimicrobials and the associated risks and benefits Education can be provided by an infectious diseases/antimicrobial stewardship practitioner either directly to prescribers or to unit leaders who will disseminate information Ideal option for multidisciplinary antimicrobial stewardship teams that can appeal to their peers	Can be incorporated into already scheduled/recurring meetings Does not require one person to lead all training	Frequent updates may be necessary
Institutional guidelines	Individualized guidance for a specific infectious syndrome with recommended drug, dose and duration Development of outpatient antibiograms to guide antibiotic selection Use literature-backed guideline recommendations in combination with local resistance patterns May disseminate on paper, via email and/or posted on healthcare intranet sites	Accessible for referencing by providers Specific to one’s institution, infectious syndrome Evidence-based recommendations	Requires work up front and may require leadership buy-in to implement Updates required as national guidelines change
Computerized order-entry sets	Provide selections for drug, dose and duration for individual infections based on guidelines Include lab-ordering recommendations	Real-time recommendation implementation Does not require any action outside of usual practice by practitioners	Requires information technology support
Clinical decision-support algorithms	May be integrated into the electronic health record Uses symptoms and diagnoses to guide providers to treatment recommendations based on guidelines and local susceptibility profiles	Does not require any action outside of usual practice by practitioners Real-time recommendation implementation	Requires information technology support
Educational pop-ups/warnings in the electronic health record	Electronic alerts to provide clinical pearls to an ordering provider May include suggestions regarding need for antibiotics, selection, dose or duration of therapy	Real-time recommendation implementation	Requires information technology support
Note templates with treatment options	Templates for use by ordering providers to guide decision-making Can include discussion/educational points to address with the patient Serves as both an educational and workflow-streamlining tool	Real-time recommendation implementation	Requires information technology support
Delayed antibiotic prescribing	Watchful waiting for infections where antibiotics may not be necessary Encourage discussion with patients regarding risks and benefits of antibiotics Can avoid writing prescription and request follow up if necessary, or can write prescription and instruct patient not to fill unless necessary	May avoid unnecessary antibiotics	Requires close follow up for patients for whom delayed antibiotic prescribing has been provided
Point of care testing	Rapidly available results can guide need for antibiotics and selection Viral point of care testing can be helpful in ruling out bacterial infections and the need for antibiotics Point of care allergy testing may be beneficial to determine true allergies and need for less-optimal, alternative (non-first line) antibiotics	May be able to avoid antibiotics or less-optimal antibiotics	Requires additional training and resources to perform