I used to think that trying to establish antibiotic stewardship in Singapore in an outpatient setting, just like in private hospitals, was a relatively futile exercise. Multiple factors (or so I thought) contribute to the failure of any serious effort that goes beyond public or physician education, including:

• Patients who insist on antibiotics (and who can easily obtain them by hopping over to the next clinic, never returning again).
• Prescribing antibiotics contributes to any clinic’s bottomline, since most outpatient clinics have their own in-house dispensaries.
• Time – it takes far too long to explain to any patient why they should not get antibiotics for their URTIs (and also affects the bottomline negatively, see above).
• It would be next to impossible to audit outpatient clinics to determine appropriateness of antibiotic prescription, or even to chart the volume of antibiotics prescribed.
• Lack of useful rapid diagnostic tests – most patients do not really wish to wait 48 hours as well as pay for bacterial cultures, especially when payment is out of pocket, as if often the case in the general practice setting.

But an astonishing amount of work has been done in other countries to try to bridge this gap. In the UK, a rather interesting trial was conducted where general practices that had been in the top 20% with regards to volume of antibiotics prescribed were randomized to either receiving a “social norm feedback” letter from the Chief Medical Officer of England (the equivalent of the local Director of Medical Services, albeit with somewhat different job scopes) or no communication. And the group that received the letters prescribed less antibiotics in the following six months compared to those who were left alone. Now I cannot imagine our DMS sending personal letters to hundreds of GP’s (and we would not be able to easily find out how much antibiotics was prescribed by each GP in any case), but it does drive home the point that behaviour change is crucial for any antibiotic stewardship programme to succeed.

Sample “social norm feedback” letter from the Chief Medical Officer of England, screenshot obtained from the Supplemental Appendix of the Lancet article.

The US Centers for Disease Control and Prevention (CDC) has gone one step further by actually putting up a framework for antibiotic stewardship in the outpatient setting. The core elements (directly lifted from the paper) are:

• Commitment: Demonstrate dedication to and accountability for optimising antibiotic prescribing and patient safety.
• Action for policy and practice: Implement at least one policy or practice to improve antibiotic prescribing, assess whether it is working, and modify as needed.
• Tracking and reporting: Monitor antibiotic prescribing practices and offer regular feedback to clinicians, or have clinicians assess their own antibiotic prescribing practices themselves.
• Education and expertise: Provide educational resources to clinicians and patients on antibiotic prescribing, and ensure access to needed expertise on optimizing antibiotic prescribing.

There are recommendations for solo and large practices with regards to the above (solo practice recommendations shown in the photo below).

Screenshot from the US CDC Core Elements of Outpatient Antibiotic Stewardship.

It is very difficult to track antibiotic prescription in the outpatient setting in the U.S. just like it is in Singapore, which is why a lot of it is about behaviour modification and self-empowerment. In particular, I like the idea of writing and displaying public commitments in support of antibiotic stewardship in the clinic setting.

I am not sure that what US CDC has put up will work at all, but it is a start. We must similarly find some innovative way to improve antibiotic prescribing in the outpatient setting in Singapore.