Rural facilities as antibiotic stewards: A practice improvement pilot in implementing symptom-based treatment guidelines



Purpose: Associated with evolving requirements set forth by the Centers for Medicare and Medicaid Services (CMS), critical access facilities must implement prospective processes to address antibiotic stewardship. The purpose of this pilot project was to implement and evaluate a multifaceted, team-based approach to reduce the inappropriate prescribing of antibiotics for female patients diagnosed with uncomplicated UTIs, in a midwestern rural primary care clinic.

Sample:  A cumulative 104 patient cases were abstracted associated with the data collection implementation phase.  Consisting of female patients between the ages of 18 and 55 years.  Eleven rural primary care providers practicing in a Midwestern Kansas rural community participated in pilot surveys.

Methods:  A Quality Improvement (QI) design was employed. A retrospective chart audit was completed to establish baseline knowledge of pre-implementation processes and treatment patterns coupled with a post-implementation chart audit for comparative analysis. A pre-test/post-test survey tool was administered to evaluate the knowledge and attitudes of providers. Standardized patient triage, clinical treatment pathways, delayed antibiotic prescriptions, symptom-based palliative “prescriptions”, over-the-counter take-home kits, and patient-centered provider-driven education were the foundation of this pilot.              

Findings:  Post-intervention data supports the implementation of team-based strategies and standardized treatment pathways as an effective mechanism in promoting adherence to evidence-based guidelines to reduce inappropriate antibiotic prescribing.

Conclusions: Despite limited resources which are often identified in the literature as barriers in rural settings, this pilot demonstrated that a team-based approach appraising clinic processes aids in determining potential gaps in the provision of safe and evidence-based care. Educating ancillary staff and rural providers alike serves to improve antibiotic stewardship outcomes. Patients must be an integral component of the change process which may be facilitated using tangible resources to treat symptoms when antibiotics are not indicated at the initial point of patient/provider contact.

Keywords: antibiotic stewardship, UTI, rural health


Author Biographies

  • Michele E. Reisinger, DNP, APRN, FNP-BC, Washburn University
    Assistant Professor, School of Nursing


  • Amanda L. Hartman, DNP, APRN, FNP-C, Washburn University
    Assistant Professor, School of Nursing