Novel approaches to decrease inappropriate ambulatory antibiotic use.

Introduction: Inappropriate antibiotic use and antibiotic resistance are major public health threats. In the United States, most antibiotic use occurs in ambulatory care and 30% to 50% may be inappropriate. The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotics by 50% by 2020. Areas covered: This review summarizes the epidemiology of antibiotic use in ambulatory care and explores evidence-based, novel approaches for improving ambulatory antibiotic use. Expert opinion: We leveraged insights from behavioral science and social psychology to implement novel peer comparison - a form of audit-and-feedback - and accountable justification alert interventions that reduced inappropriate antibiotic prescribing to 5% or less. We and others have been successful in reducing inappropriate antibiotic prescribing with precommitment posters, communication training, combined patient/clinician education, and clinical decision support. Other commonly employed, but unsound approaches to reducing inappropriate antibiotic prescribing include point-of-care testing and delayed antibiotic prescriptions. These approaches are not durable (e.g. CRP testing), have not been proven in primary care (e.g. procalcitonin), or are conceptually flawed, such as using testing for non-antibiotic-appropriate diagnoses or using delayed antibiotic prescriptions. To decrease inappropriate ambulatory antibiotic use, clinicians, pharmacists, practices, and health systems need to collect antibiotic prescribing data, select concrete improvement targets, and implement evidence-based interventions such as peer comparison, accountable justification, precommitment, and communication training.