Anti-Microbial Stewardship (AMS) on Antibiotic use in patients with Upper Respiratory Tract Infection (URTI): A case study from Singapore

Introduction: Upper Respiratory Tract Infection (URTI) may be inappropriately treated with antibiotics in primary care which can lead to antibiotic resistance. Antimicrobial stewardship (AMS) is critical to mitigate such risks. SingHealth Polyclinics (SHP), a group of 10 out-patient primary care clinics, in Singapore started its AMS program in 2017 to monitor and manage the antibiotics prescription rates of its primary care physicians (PCPs) in URTI treatment. Method: SHP AMS comprises multi-prong strategies: (1) developing a standardized URTI clinical guide for PCPs to use conveniently during consultation in clinic and remotely, augmented by an online course. Newly hired or posted PCPs to SHP use it for discussion during induction sessions; (2) educating patients and caregivers via posters and videos telecast at polyclinic waiting areas to provide information on appropriate antibiotics usage; (3) establishing an antibiotic tracking system to track its prescription rate, defined as number of patients being prescribed with antibiotics among patients diagnosed with URTI, at micro- (PCP), meso- (Clinic) and macro (SHP) levels respectively. Polyclinic directors will meet PCPs with exceptionally high antibiotic prescription rate to discuss their prescribing behavior in patients with URTI. SHP AMS Taskforce shares the meso- and macro-level prescription rates during senior management meetings to identify issues and develop solutions. Results: In 2015-2016, 13.9% of SHP patients with URTI received antibiotic prescriptions. The institution prescription rate steadily decreased to 9.6% (7.7% to 12.6% monthly) in 2018 and 7.2% (6.9% to 8.3% monthly) in 2019. During the COVID-19 pandemic, it dropped further to 3% (1.7% to 4.3% monthly) in 2022. After relaxation of COVID-19 related community measures in Feb 2023, it rose to 5% in May 2023. Conclusion: Inappropriate antibiotic prescription by PCPs for patients with URTI is reduced by a multi-pronged AMS program. Continual surveillance and feedback to PCPs is important to minimize antibiotic misuse.