title: Antimicrobial stewardship in outpatient settings: a systematic review.
abstract: OBJECTIVE
  Evaluate the effect of outpatient antimicrobial stewardship programs on prescribing, patient, microbial outcomes, and costs.
  
  
  METHODS
  Systematic review
  
  
  METHODS
  Search of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (eg, infectious conditions, prescription services) evaluating stewardship programs in outpatient settings and reporting outcomes of interest. Data regarding study characteristics and outcomes were extracted and organized by intervention type.
  
  
  RESULTS
  We identified 50 studies eligible for inclusion, with most (29 of 50; 58%) reporting on respiratory tract infections, followed by multiple/unspecified infections (17 of 50; 34%). We found medium-strength evidence that stewardship programs incorporating communication skills training and laboratory testing are associated with reductions in antimicrobial use, and low-strength evidence that other stewardship interventions are associated with improved prescribing. Patient-centered outcomes, which were infrequently reported, were not adversely affected. Medication costs were generally lower with stewardship interventions, but overall program costs were rarely reported. No studies reported microbial outcomes, and data regarding outpatient settings other than primary care clinics are limited.
  
  
  CONCLUSIONS
  Low- to moderate-strength evidence suggests that antimicrobial stewardship programs in outpatient settings improve antimicrobial prescribing without adversely effecting patient outcomes. Effectiveness depends on program type. Most studies were not designed to measure patient or resistance outcomes. Data regarding sustainability and scalability of interventions are limited.
authors: 1Department of Medicine,University of Minnesota School of Medicine,Minneapolis,Minnesota.
authors: Dimitri M
authors: DM
authors: Drekonja
authors: 1Department of Medicine,University of Minnesota School of Medicine,Minneapolis,Minnesota.
authors: Gregory A
authors: GA
authors: Filice
authors: 3Center for Chronic Disease Outcomes Research,Minneapolis VA Health Care System,Minneapolis,Minnesota.
authors: Nancy
authors: N
authors: Greer
authors: 1Department of Medicine,University of Minnesota School of Medicine,Minneapolis,Minnesota.
authors: Andrew
authors: A
authors: Olson
authors: 3Center for Chronic Disease Outcomes Research,Minneapolis VA Health Care System,Minneapolis,Minnesota.
authors: Roderick
authors: R
authors: MacDonald
authors: 3Center for Chronic Disease Outcomes Research,Minneapolis VA Health Care System,Minneapolis,Minnesota.
authors: Indulis
authors: I
authors: Rutks
authors: 1Department of Medicine,University of Minnesota School of Medicine,Minneapolis,Minnesota.
authors: Timothy J
authors: TJ
authors: Wilt
mesh_terms: D000554:Ambulatory Care Facilities; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D003658:Decision Making, Computer-Assisted; D016527:Drug Costs; D004352:Drug Resistance, Microbial; D004502:Education, Medical, Continuing; D005246:Feedback; D006801:Humans; D016134:Organizational Policy; D010353:Patient Education as Topic; D010817:Physician-Patient Relations; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'
chemical_list: D000900:Anti-Bacterial Agents