Why Outpatient Antibiotic Prescriptions Should Always Include Indications

It's time to focus on verifying the missing element to antibiotic prescriptions: the indication.

The CDC published a list of core elements for successful hospital antibiotic stewardship programs in 2014. One of the core elements is to improve documentation on antibiotic orders, which should include dosage, duration, and indication. Because many health care providers are involved in a single patient’s care, documenting an indication is a way to improve communication between physicians, nurses, pharmacists, and any other health care providers who may look at a medication order. Documenting an indication also saves pharmacy staff time that would have been spent digging through a patient’s chart or lab orders to determine if the dosage is appropriate.

Community pharmacists needs to verify that the outpatient therapy for a patient is appropriate and safe. Although it’s simple to identify the dose on a drug that’s approved for only one indication, it can be a challenge to verify doses and duration on antibiotic prescriptions due to the wide variety of infection types and pathogens. Although most pharmacists are familiar with common indications, it’s frustrating when a patient comes in for a prescription that hasn’t been filled yet because the pharmacist is trying to verify the indication and dose with a hospital or doctor’s office. The true challenge arises when the prescription needs to be filled on a weekend or late evening, when most offices are closed. A simple fix that would save both pharmacists and physicians’ time is to document the indication on all outpatient prescriptions for antibiotics. This would also allow the pharmacist to provide appropriate patient counseling on the antibiotic and infection to the patient.

Currently, writing an indication on an outpatient prescription is considered a good practice but not a requirement. Certain forms of insurance require diagnosis codes to be used (such as billing for diabetic testing supplies), but even these must be tracked down by pharmacists more often than not. When a pharmacist is aware of what an antibiotic is being used for, he or she can also provide alternative recommendations in the event that a drug interaction is identified.

So how can community pharmacists encourage physicians to write an indication on a prescription? When calling the office to verify indications, take the time to specifically request that all antibiotic prescriptions have a documented indication for patient safety. Most prescription pads and electronic prescription systems have a line for it! Emphasize that this practice will save physicians from answering phone calls in the middle of the day when they’re busy with appointments, or from being paged after they leave the hospital. If you’re receiving a prescription via fax, it’s also easy to write “Please include indication and re-fax” on the fax before sending it back.

In the situation that the prescriber cannot be contacted and the patient is ready to pick up, try to verify the indication with the patient. By informing patients you want to ensure that this is a safe and effective dosage for them (or their child), you’ll establish your role as a pharmacist involved in their care and develop trust. Antibiotic stewardship isn’t just a practice for hospital and clinical pharmacists to take part in. With resistance increasing to many antibiotics used on an outpatient basis due to incorrect dosages, community pharmacists should take the initiative to apply their clinical knowledge and ensure patient safety.