Antimicrobial Stewardship: Resources for Health Care Providers

General medical conditions continue to grow more complex over time, causing patients to become hospitalized with complicated care. There is also a rising trend of elderly patients admitted to the hospital with multiple medical problems. Surveys have shown that 50% of all hospitalized patients receive an antibiotic during their stay. Per the CDC Core Elements of Hospital Antibiotic Stewardship Programs, (opens external link) about 30% of all antibiotics prescribed in US acute care hospitals are either unnecessary or suboptimal. In Wisconsin, 100% of acute care hospitals reported adopting all seven inpatient core elements in 2022.

Resources for inpatient providers

• CDC Core Elements of Hospital Antibiotic Stewardship Programs (opens external link): Review the core elements of hospital antibiotic stewardship programs and implementation resources for hospitals.
• CDC Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals (opens external link): Small and critical access hospitals face unique challenges to implementing the core elements such as limited staffing, infrastructure, and resources. The CDC shares options that may help small and critical access hospitals ensure each of the core elements are implemented in their facility. Each facility is unique, and therefore flexibility and tailoring implementation to the facility’s specific needs is essential.

In recent years, an increasing numbers of residents have been admitted to long-term care facilities (LTCFs) with complicated conditions. Some types of care and treatments that may have been provided in an inpatient setting years ago are now provided in nursing homes or assisted living facilities. Per the CDC, antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents receiving one or more antibiotic courses per year. Yet, per CDC Core Elements of Antibiotic Stewardship for Nursing Homes, (opens external link) studies have shown that 40–75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate.

While not all nursing homes in Wisconsin report these data, in both 2021 and 2022, 72% of nursing homes reporting these data indicated that they had adopted all seven nursing home AS core elements. You can learn more about efforts to promote antibiotic stewardship in LTCF by visiting the HAIs in LTC Coalition webpage.

Resources for long-term care providers

• Antibiotic Stewardship in LTC Facilities: Where Do You Start? (opens external video): Watch a video describing AS fundamentals from Lake Superior Quality Innovation Network (formerly known as Lake Superior Quality Innovation Network).
• CDC Core Elements of Antibiotic Stewardship for Nursing Homes (opens external link): Review the core elements for nursing home AS programs.
• CDC Antimicrobial Stewardship Implementation Resources for Nursing Homes (opens external link): See fact sheets and additional resources on leadership accountability, drug expertise, and more.
• Toolkit to Improve Antibiotic Use in LTC (opens external link): View education resources and tools on improving antibiotic use in LTC from the Agency for Healthcare Research and Quality (AHRQ).
• Wisconsin LTC Education Webinar Series (opens external video): View a library of educational webinars on a variety of infection prevention and AS topics specific to the LTC setting.
• Wisconsin Long-Term Care Urinary Tract Infection (UTI) Toolkit (opens external link): See resources and tools to standardize the assessment and communication of findings in residents experiencing a change in condition where UTI is suspected; promote the use of active monitoring, delayed urine testing, and delayed antibiotic treatment among residents with low UTI risk; and promote the appropriate use of antibiotics (drug, dose, duration) in residents with high UTI risk.

Eighty to ninety percent of the volume of human antibiotic use occurs in the outpatient setting. Per the CDC Core Elements of Outpatient Antibiotic Stewardship (opens external link), at least 30% of antibiotics prescribed in U.S. doctors’ offices and emergency departments are unnecessary. The majority of infectious disease conditions in the outpatient setting are caused by viral infections for which antibiotics have no effect.

Antibiotic stewardship efforts in the outpatient setting help balance the need for effective treatment of bacterial infections while reducing prescribing for viral illnesses. Many providers around the state of Wisconsin are tracking current prescribing practices and offering targeted education to further advance this important initiative.

Trends in Outpatient Antibiotic Prescribing in Wisconsin 2018–2021, P-03383 (PDF)

To better understand the current state of outpatient antibiotic use in Wisconsin, the DHS HAI Prevention Program partnered with the Wisconsin Health Information Organization (WHIO) to develop a series of outpatient antibiotic use measures. The Trends in Outpatient Antibiotic Prescribing in Wisconsin 2018–2021, P-03383 (PDF) report uses these measures to describe trends in outpatient antibiotic use and identify additional targets for improvement.

Resources for outpatient providers

• CDC Core Elements of Outpatient Antibiotic Stewardship (opens external link): Review the core elements of AS in outpatient settings.
• CDC MITIGATE Toolkit (opens external link): See strategies to implement AS in emergency department and urgent care settings.
• CDC Print Materials on Antibiotic Prescribing and Use (opens external link): See posters, infographics, handouts, and other downloadable patient and provider education materials.
• CDC Treatment Recommendations for Health Care Professionals (opens external link): See antibiotic prescribing information for clinicians.
• Improving Antibiotic Stewardship Video Series (opens external video): Watch educational videos on improving AS in the outpatient setting from the Lake Superior Quality Innovation Network.
• Trends in Outpatient Antibiotic Prescribing in Wisconsin, 2018–2021, P-03383 (PDF): View Wisconsin outpatient antibiotic prescribing trends and data from Wisconsin DHS.
• DHS Viral prescription pad (PDF): Complete and share this prescription pad with patients with symptoms that indicate viral respiratory illnesses. Use the viral prescription pad to initiate conversations with patients on when antibiotics are not needed, and to provide patients with steps they can take to help themselves feel better. Viral prescription page in Spanish. (PDF)
• Sample patient assessment scripts: Use the following scripts from Wisconsin DHS to assess patients who present with various conditions.
  • Viral Upper Respiratory Infection and Acute Bronchitis, P-02095 (PDF)
  • Cough, P-03039 (PDF)
  • Dysuria, P-03046 (PDF)
  • Sinusitis, P-03047 (PDF)

Several dental studies (opens external link) noted findings of up to 85% of antibiotic prescriptions as “suboptimal” or “not indicated.”

Dentists also account for 1 in 10 antibiotic prescriptions in the outpatient setting, which makes them the third to fourth highest antibiotic prescribers (opens external link) by volume following family medicine, internal medicine, and pediatrics.

The scope of antibiotic prescribing and use in the dental setting makes it an ongoing area of focus for antibiotic use tracking and evidence-based prescribing reduction.

Trends in Dental Antibiotic Prescribing in Wisconsin, 2018–2021, P-03383a (PDF)

Resources for dental and oral health providers

• Acute Dental Pain Management (PDF) (opens external link): Read a report from the American Dental Association (ADA) with guidelines for antibiotic use for the urgent management of dental pain and swelling.
• Antibiotics Before Dental Procedures in Patients with Artificial Joints, P-03155 (PDF): Download, print, and share a Wisconsin DHS fact sheet with information for patients who have artificial joints and their dental care teams.
• Antibiotic Stewardship Program Dental Update Newsletters: See a library of newsletter issues for dental and oral health settings from DHS.
• CDC antibiotic stewardship resources for dental settings: (opens external link) View a fact sheets, online training modules, tools, and guidance.
• Dentists Are Antibiotic Stewards, P-03009 (PDF): Download and customize a Wisconsin DHS poster for your dental office.
• Oral Health Antibiotic Toolkit, P-03109 (PDF): See information from Wisconsin DHS to make informed and evidence-based antibiotic prescribing decisions and effectively communicate them with patients and medical team members.
• Prophylaxis for Cardiac Conditions (opens external link): Review antibiotic prophylaxis recommendations from the American Heart Association to prevent viridans group streptococcal infective endocarditis in cardiac patients undergoing invasive procedures.
• Trends in Dental Antibiotic Prescribing in Wisconsin, 2018–2021, P-03383a (PDF): View Wisconsin dental antibiotic prescribing trends and data from DHS.

The right drug, right dose, de-escalation of therapy, and duration of therapy are all important concepts in establishing a successful AS practice. Pharmacists are trained in optimizing drug regimens and potential adverse effects, making them key members of AS activities across all areas where antibiotics are prescribed. Drug expertise is a component across all the AS core elements.

Resources for pharmacists

Achieving Core Measure Success in the Community Pharmacy Setting (opens external video): Watch the educational video on improving AS in the pharmacy setting from the Lake Superior Quality Innovation Network.