Objective: To determine whether an ambulatory care pharmacist (AMCP)-led intervention improved outpatient antibiotic prescribing in a family medicine residency clinic (FMRC) for upper respiratory tract infections (URIs), urinary tract infections (UTIs), and skin and soft-tissue infections (SSTIs). Design: Retrospective, quasi-experimental study comparing guideline-concordant antibiotic prescribing before and after an antimicrobial stewardship program (ASP) intervention. Setting: Family medicine residency clinic affiliated with a community teaching hospital. Participants: Adult and pediatric patients prescribed antibiotics for URI, UTI, or SSTI between November 1, 2017, and April 31, 2018 (pre-ASP group), or October 1, 2018, and March 31, 2019 (ASP group), were eligible for inclusion. Methods: The health-system ASP physician and pharmacist provided live education and pocket cards to FMRC staff with local guidelines as a quick reference. Audit with feedback was delivered every other week by the clinic’s AMCP. Guideline-concordance was determined based on the institution’s outpatient ASP guidelines. Results: Overall, 525 antibiotic prescriptions were audited (pre-ASP n = 90 and ASP n = 435). Total guideline-concordant antibiotic prescribing at baseline was 38.9% (URI, 53.3%; SSTI, 16.7%; UTI, 46.7%) and improved across all 3 infection types to 57.9% (URI, 61.2%; SSTI, 57.6%; UTI, 53.5%; P = .001). Significant improvements were seen in guideline-concordant antibiotic selection (68.9% vs 80.2%; P = .018), dose (76.7% vs 86.2%; P = .023), and duration of therapy (73.3% vs 86.2%; P = .02). Conclusions: An AMCP-led outpatient ASP intervention significantly improved guideline-concordant antibiotic prescribing for common infections within a FMRC.

Introduction Due to the high volume of outpatient antibiotic prescribing, the Joint Commission now requires antimicrobial stewardship program (ASP) expansion to ambulatory practice settings. Unfortunately, ASP resources in these settings are scarce. The purpose of this study was to determine whether the implementation of antibiotic order sentences alongside education would improve antibiotic prescribing for urinary tract infections (UTI) and skin and soft tissue infections (SSTI). Objectives The primary objective was to compare the proportion of total guideline‐concordant antibiotic prescribing before (pre‐ASP) vs after (post‐ASP) implementing order sentences. Guideline concordance was defined as antibiotic selection, dosing, and duration in accordance with the health system's empiric guidelines. Secondary objectives included comparing patient‐centered outcomes, such as infection‐related revisits and Clostridiodes difficile infections between groups. Methods This retrospective, quasi‐experimental study evaluated adult patients treated for uncomplicated UTI or SSTI at an outpatient Family Medicine office between 1 February 2020 and 1 January 2021. The institution's stewardship team provided in‐person education and set prescribing order sentence “favorites” for providers. Patients were excluded who were diagnosed with a complicated UTI, treated only with topical antibiotics, were pregnant, or received care via telephone encounter. Results Two hundred sixty patients were included in this study (pre‐ASP n = 139, post‐ASP n = 121). Total antibiotic appropriateness improved significantly from 24.5% to 39.7% after implementation of order sentences and education (P = .008). Significant improvement was seen for appropriate drug selection (52.5% vs 66.9%, P = .018) and duration (47.5% vs 68.6%, P = .001). There were no differences observed in patient‐centered outcomes between groups. Conclusion Implementing stewardship‐focused order sentences significantly improved outpatient antibiotic prescribing for UTI and SSTI. Tailoring antibiotic order sentences may be a useful tool for ASP expansion into the outpatient setting with limited resources to allocate to stewardship efforts.

Cost can be a barrier to achieving health equity for guideline-directed medical therapy; however, ambulatory care pharmacists who provide services in primary care settings can assist in reducing these barriers. Strategies to reduce drug cost should be tailored to patient-specific factors including insurance type, drugs being prescribed, and availability of local and national assistance programs. Pharmacists can use a team-based approach, when possible, to promote health equity in drug access due to cost. The authors provide recommendations that can be incorporated into clinical practice and improve health equity.ambulatory care, drug cost, health equity, pharmacy, prescription, social determinants of health | INTRODUCTIONDrug cost is a barrier to patients obtaining guideline-directed medical therapy (GDMT). 1 Several clinical practice guidelines recommend drug classes that only include agents available as brand name products.These products have significant retail costs, which many patients are unable to afford with or without prescription insurance. Most prescription insurance companies cover brand name drugs at higher tiers, and therefore, require a higher copay and out-of-pocket expense to the patient. While the Affordable Care Act (ACA) has improved insurance access, drug cost can still leave many GDMTs unobtainable due to high deductibles and/or copays. 2 A 2021 West Health-Gallup poll revealed that 18 million Americans cannot afford their drugs, in particular, patients with three or more chronic conditions, eight or more drugs, and households earning less than $24 000/year. 3 This means patients with chronic conditions who cannot afford brand name GDMTs may opt to be treated with older, inferior drug therapies. 2