Antimicrobial stewardship is defined as a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms. Stewardship initiatives in the hospital are paving the way for the rest of healthcare through education campaigns, monitoring, and restrictions. Outpatient practice is beginning to catch up as the stories of resistance grow and the lines between nosocomial and community-acquired infections blur.

We all have a role to play in stewardship, and with education and careful communication, we can make a difference. Urgent cares can do a better job in this regard. As you have heard me say before, we practice in a unique setting with increased risks and challenges. Our lack of continuity relationships makes it difficult to build trust and ensure patients are progressing as expected.

All the while, we have a primary obligation to remain vigilant for serious bacterial illness and concerning complications.

In the end, I believe this issue is all about balance. Balancing risk, trust, and time is uniquely difficult in urgent care. Here are a few thoughts for you to consider as you build your own approach to this tricky subject:

 

  • You can’t win every battle, but you can make a dent in the armor.
    • Sometimes a back-up prescription is a useful tool to build trust so you can begin to chip away at some of the myths of antibiotics and their efficacy. E-prescription programs are even creating special “wait and see” prescriptions that are only filled upon patient request.
    • Referring those with recurrent URIs like “sinusitis” and “bronchitis” to a specialist for a better evaluation and treatment plan can be helpful for breaking the cycle of misuse. Demonstrate genuine concern for the patient and they will show appreciation.
  • You’d be surprised what a little sensitivity can do.
    • If you don’t make people feel silly for coming in and if you don’t downplay the severity of their symptoms, they are more likely to follow your guidance and appreciate your care.
    • I often will remind patients that many viral illnesses are far worse than bacterial infections. The degree of illness does not determine need for or responsiveness to antibiotics.
    • Show empathy, and never say, “It’s just a virus!”
  • When antibiotics are indicated, use the narrowest-spectrum choice for the treatment of the infection. Follow IDSA guidelines if in doubt.
  • Use your best judgement and don’t ignore atypical courses of disease.
    • If a patient is getting worse after a period of getting better, strongly consider a bacterial superinfection like pneumonia.
    • Remember that early in an illness like pneumonia, infiltrates will not always be seen. If you think a patient clinically has pneumonia, then do not hesitate to treat it as such.
    • Those with cardiopulmonary disease; immunosuppression and other immunologic disease; cancer; and other comorbidities should be managed more aggressively. These are not the patients to stand on a stewardship soapbox for.
  • For pharyngitis, only treat with antibiotics when testing is positive for strep (rapid test or culture).
  • Children with a diagnosis of URI, bronchitis or serous otitis media should not receive antibiotics.
    • Most parents understand the need to avoid antibiotics for viral illness.
    • Most parents do not realize that bronchitis is a viral illness, but are happy to learn.

 

As noted in a separate column by Jasmeet Bhogal, MD and Laurel Stoimenoff, PT, CHC, on page X of this issue, the Urgent Care Association, in collaboration with the College of Urgent Care Medicine, the Centers for Disease Control and Prevention, and the Antibiotic Resistance Action Center is actively engaged in a campaign to improve antibiotic stewardship in the urgent care setting. In my next column, I will discuss some of the methods developed by this collaborative for tracking and reporting quality measures related to antibiotic stewardship, as well as tools available to you for provider and patient education. With a collective effort, we can demonstrate our industry’s commitment to this important issue and reduce unnecessary antibiotic use.

Urgent Care and Antibiotics: Advancing Care and Stewardship
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