To the Editor—Antibiotic overuse is a persistent public health problem that has contributed to an alarming increase in the prevalence of antibiotic resistance.¹ In the United States, >70% of antibiotic courses are prescribed in ambulatory settings.Reference Suda, Hicks, Roberts, Hunkler, Matusiak and Schumock² To encourage the appropriate use of antibiotics in outpatient practices, the Centers for Disease Control and Prevention (CDC) released the Core Elements of Outpatient Antibiotic Stewardship (hereafter Core Elements).Reference Sanchez, Fleming-Dutra, Roberts and Hicks³ However, detailed evaluations of how practices implement and sustain the Core Elements are lacking.

From January through June 2019, an antimicrobial stewardship quality improvement initiative was conducted by the American Academy of Pediatrics Chapter Quality Network (AAP-CQN), Colorado Department of Public Health and Environment, and the CDC. In this project, 8 outpatient pediatric practices in Colorado were enrolled: 3 practices that were part of larger systems and 5 independent practices. All practices but 1 were urban or suburban. The initiative utilized the Core Elements and Model for Improvement frameworks.Reference Sanchez, Fleming-Dutra, Roberts and Hicks³ Practices implemented interventions to improve prescribing for pharyngitis and acute otitis media. The AAP-CQN provided webinars, learning sessions, monthly tracking and reporting, and Maintenance of Certification (MOC) credit. The ability of the practices to continue antibiotic stewardship following the conclusion of the initiative was assessed.

Using surveys and telephone-based semistructured interviews with physician champions, we assessed the ability of practices to sustain the Core Elements of commitment, tracking and reporting, and education and expertise. Because the initial intervention focused on evaluation of the Core Element “action for policy and practice,” our interviews targeted the other Core Elements. The project was determined exempt by the AAP Institutional Review Board.

Most practices identified a leader for antibiotic stewardship (7 of 8) and intended to display commitment posters (5 of 7).Reference Meeker, Knight and Friedberg⁴ Most had access to antibiotic expertise (6 of 8) and planned to provide ongoing education regarding antibiotic use (6 of 8). Few practices had established systems for ongoing antibiotic stewardship-related duties (4 of 8), tracking (5 of 8), or reporting (3 of 7).

Interviews identified 6 barriers to sustaining the 3 Core Elements (Table 1). Lack of control and competing priorities complicated practices’ capacity to display commitment. Of the 5 practices reporting implementation of a commitment poster on the survey, only 2 affirmed the finding during interviews. Barriers to displaying posters included modifying the CDC template, inserting provider photos, and printing logistics. For practices that were part of a larger healthcare system, the need to obtain administrative approval (for information technology (IT) support or to hang commitment posters) was a key limitation.

Table 1. Qualitative Survey Results Assessing Sustainability of Antibiotic Stewardship Efforts From 8 Colorado Practices Participating in an Intensive American Academy of Pediatrics Chapter Quality Network (AAP CQN) and Centers for Disease Control and Prevention (CDC) Antibiotic Stewardship Intervention, July 2019

^a Action for policy and practice were implemented as part of the AAP CQN collaborative work and were not included in the sustainability assessment of the Core Elements.

Barriers to tracking and reporting included time constraints and lack of information technology (IT) support. Only 2 practices had IT support. Practices reported that manual or electronic abstraction took substantial time (range, 4–20 hours by a physician or clinic manager). Consequently, 5 practices did not plan to continue tracking and reporting, and 3 practices planned abbreviated and less frequent (every 3–6 months) tracking and reporting. Practices were most likely to sustain tracking and reporting if a nonphysician was responsible for data.

Barriers to sustaining education/expertise included scheduling and lack of resources (eg, regional experts). In the absence of MOC and outside support, the structures of most practices did not support scheduled education on antibiotic stewardship.

To sustain antibiotic stewardship, practices would benefit from increased availability of practical strategies and tools. Strategies to support the commitment to the Core Elements might include a centralized online system for practices to design and order custom commitment posters. For our initiative, AAP-Colorado created and supplied posters, which were well received. Because tracking and reporting (with individualized provider feedback) is the most effective way to reduce antibiotic use,Reference Gerber, Prasad and Fiks^{5,Reference Meeker, Linder and Fox6} practices need support to efficiently use metrics for electronic data tracking. Strategies to improve tracking and reporting might include reducing the frequency of tracking and reporting, using a point-prevalence survey,Reference Frost, Knepper, Shihadeh and Jenkins⁷ creating tip sheets for electronic health records, and promoting an online forum focused on efficiently pulling data. In this initiative, practices benefitted from sharing tips on how to pull data. To facilitate ongoing stewardship-focused education and expertise, practices could incorporate brief opportunities for stewardship-based education into their routine schedule. Alternative approaches might include virtual learning communities or use of MOC. Practices in our initiative found success in routinely setting aside 5–10 minutes at provider meetings to discuss antibiotic use or asking medical students or residents to present relevant topics.

This study has several strengths including coordinated national expertise in antimicrobial stewardship that included the involvement of the AAP, state health department, CDC, and highly engaged practices. The study was limited by a small sample, which may have reduced generalizability of the results. However, the challenges identified here likely reflect those at other community-based outpatient clinics. Future steps will include evaluating antibiotic stewardship practices 6 months after the initiative.

In conclusion, although the Core Elements provide a framework for outpatient antibiotic use, further work is needed to develop practical strategies and tools that are simple, evidence based, high impact, and sustainable. In this project, implementing even seemingly simple interventions, such as adding photos to a commitment poster, posed logistical challenges that became barriers. Although several publicationsReference Sanchez, Fleming-Dutra, Roberts and Hicks^3,8 offer various suggestions to improve outpatient stewardship efforts, ambulatory practices would benefit from additional clear, step-by-step guidance and enhanced sustainability tool kits, analogous to the playbook for antibiotic stewardship produced for hospitals.⁹ We consider a few potential approaches to sustaining outpatient stewardship here, but a broader discussion among antibiotic stewards, patient care organizations, public health, and other stakeholders will be important for future success.