Inappropriate antibiotic prescribing is a major patient safety concern. In any given year in the United States, one-half of patients in ambulatory care receive an antibiotic prescription for respiratory symptoms, and one-third of these prescriptions are not necessary.¹ Adverse effects from antibiotics, such as rashes or gastrointestinal upset, are common reasons that patients present to emergency departments, and most antibiotics can increase the risk of Clostridioides difficile infections.^2,3 Antibiotic-resistant organisms are a national and global health threat and result in almost 3 million infections and 35,000 deaths per year.⁴

Prescribing antibiotics only when they are needed and using a narrow-spectrum agent for the briefest duration are the core principles of antibiotic stewardship. Family physicians should take a judicious approach to the use of antibiotics, particularly in patients with upper respiratory tract infections.⁵

The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use was an antibiotic steward-ship intervention implemented in 389 primary and urgent care practices across the United States in 2020.⁶ The program focused on three domains that are essential to facilitating change in antibiotic-prescribing practices in ambulatory care: developing a team to lead and implement antibiotic stewardship efforts; applying strategies to improve communication about antibiotics among clinicians and clinic staff and between clinicians, clinic staff, and patients; and learning best practices for management of common infections in outpatients. Participating practices reduced overall antibiotic prescriptions from 18% to 9% of visits and prescriptions associated with acute respiratory infections from 39% to 25%. The AHRQ Toolkit to Improve Antibiotic Use in Ambulatory Care has been developed based on integration of the educational material used in the AHRQ safety program and the experiences of the participating practices.⁷

Most ambulatory practices do not have an existing leadership structure for antibiotic steward-ship; therefore, critical first steps include engaging practice leadership and establishing antibiotic stewardship leaders. These individuals can garner support for antibiotic stewardship and related activities from clinicians and staff. Accessing and sharing data on antibiotic prescribing are central to assessing and improving current practices and should be early steps in antibiotic stewardship activities so that all members of a practice understand their performance relative to others.

The toolkit includes presentations on developing, implementing, and maintaining antibiotic stewardship activities (e.g., clinical decision support approaches); a gap analysis tool; and a guide to accessing and reporting antibiotic prescription data. Practices can use these tools to build their antibiotic stewardship teams and start working on initiatives.

Applying strategies to improve communication about antibiotic use among clinicians and staff and between clinicians, staff, and patients is essential for decreasing inappropriate antibiotic use across a practice. Physicians may struggle to communicate to patients and families why antibiotics are not always needed for infections such as acute bronchitis and sinusitis. Practices that implement statements into their patient-clinician communications about why antibiotic prescribing is not indicated can increase patient satisfaction and lead to sustainable improvements in antibiotic prescribing.^8–11 To avoid patients receiving mixed messages about antibiotic indications, it is important for practices to come to a consensus about management strategies for common infections, particularly when antibiotics will and will not be prescribed and options for symptom management. The toolkit contains presentations, scripts, and posters to help clinicians and staff communicate with patients and families about antibiotic prescribing.⁷ Discussion guides can be used at regularly scheduled practice meetings to hold each other accountable and foster a consensus about antibiotic prescribing.

The toolkit includes resources for learning best practices for the management of common infections. The 4 Moments of Antibiotic Decision Making framework was developed to facilitate application of these best practices.¹² The framework asks the prescriber to (1) consider whether the patient has an infection that requires antibiotics; (2) question the need for diagnostic testing; (3) choose the narrowest, safest, and shortest regimen when antibiotics are indicated; and (4) ensure that the patient understands what to expect and the follow-up plan. To promote recognition of the indications for antibiotic therapy for acute respiratory tract infections, the program categorizes diagnoses based on how often antibiotics are needed in their treatment: never necessary (e.g., upper respiratory tract infections, acute bronchitis, influenza, respiratory syncytial virus), sometimes necessary (e.g., bacterial sinusitis, pharyngitis, otitis media), or usually necessary (e.g., community-acquired pneumonia). Toolkit resources include slide presentations with scripts organized according to the 4 Moments of Antibiotic Decision Making that can be used for teaching; one-page documents for each infectious syndrome that can be used as a poster, handout, or template for local guidelines; and patient handouts.

Improving antibiotic prescribing in ambulatory care is an urgent need. Using the AHRQ Toolkit to Improve Antibiotic Use in Ambulatory Care can help practices meet their antibiotic stewardship goals.

This work was funded and guided by the Agency for Healthcare Research and Quality (HHSP233201500020I/HHSP23337003T). The findings in this manuscript are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this manuscript should be construed as an official position of AHRQ or the U.S. Department of Health and Human Services. None of the authors report any conflict of interest.