Antibiotic stewardship in hospital outpatient departments: a qualitative study of alignment with existing guidance.

Objective: This study examined antibiotic stewardship in hospital outpatient departments (HOPDs) and alignment with CDC Core Elements for outpatient settings. It also explored challenges that The Joint Commission accredited hospitals face when implementing hospital-based interventions in outpatient settings. Design: Qualitative study using in-depth interviews. Setting: HOPDs included hospital-affiliated primary care, urgent care, emergency departments, specialty care, surgical centers, wound care, and dental clinics. Participants: Respondents included Antibiotic Stewardship Program (ASP) lead pharmacists and physicians with and without infectious disease specialization, clinical pharmacists, and accreditation coordinators. Methods: We conducted in-depth interviews with ASP leaders from a cross-section of hospitals of varied size and system membership. We used MAXQDA 2022 (VERBI Software, 2021) and the Framework Method to organize and analyze interview transcripts. Results: We interviewed 42 ASP leaders from 28 hospitals. Findings show that ASPs encountered financial constraints in expanding stewardship into HOPDs. Few hospitals had dedicated leaders or extra staffing for outpatient stewardship. Many hospitals did not have outpatient clinics represented on their ASP committee. Although most hospitals had treatment guidelines, tracked antibiotic use, and provided education for HOPDs, these often focused on inpatient priorities. Challenges in implementing hospital-based interventions in HOPDs included staffing limitations, clinical and operational differences between settings, interpreting requirements, and electronic health record and information technology limitations. Conclusion: Our research suggests that improving antibiotic stewardship within HOPDs necessitates recognizing the unique attributes of these settings, identification of specific resource requirements, and development of tailored strategies, rather than employing inpatient approaches.