By Stan Deresinski, MD, FACP, FIDSA

Professor of Clinical Medicine, Stanford University

Dr. Deresinski reports no financial relationships relevant to this field of study.

SYNOPSIS: The implementation of antibiotic stewardship principles in all outpatient settings is crucial to the struggle against growing antimicrobial resistance and to optimal patient outcomes.

SOURCE: Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep 2016;65:1-12.

Outpatient pharmacies in the United States in 2013 dispensed approximately 269 million antibiotic prescriptions. The entire population of the country in that year was only 316.5 million. One-fifth of pediatric and one-tenth of adult outpatient visits result in an antibiotic prescription, and 143,000 recipients of those taking an antibiotic end up with an emergency department visit because of a resultant adverse event. Approximately one-third of the estimated 453,000 cases of Clostridium difficile infection in the United States in 2011 were community acquired. Perhaps even more importantly, the promiscuous use of antibiotics contributes to the global public health crisis of antimicrobial resistance.

In response to these unfortunate statistics and the resultant problem of antibiotic resistance, CDC has developed Core Elements of Outpatient Antibiotic Stewardship. The intended audience for this statement is broad and includes “clinicians (e.g., physicians, dentists, nurse practitioners, and physician assistants) and clinic leaders in primary care, medical and surgical specialties, emergency departments, retail health and urgent care settings, and dentistry, as well as community pharmacists, other healthcare professionals, hospital clinics, outpatient facilities, and healthcare systems involved in outpatient care.”

CDC encourages organization leaders to establish a commitment to the optimization of antibiotic prescribing and patient safety with a single responsible clinical leader but with expectations that this be a goal of all members of the organization. Among the recommended initial steps is to identify high-priority conditions associated with inappropriate prescribing, such as upper respiratory infections, sore throats not due to Streptococcus pyogenes, acute uncomplicated sinusitis, and early acute otitis media. Watchful waiting with delayed prescriptions may be optimal in the last two conditions. In addition, circumstances in which antibiotic prescribing opportunities may be missed should be identified, such as sexually transmitted diseases. Barriers to appropriate prescribing, such as gaps in clinician knowledge, misperception of patient desires, and concern about patient satisfaction, as well as time pressure, must be identified. Evidence-based standards for antibiotic prescribing should be implemented within the clinical setting.

It is also recommended that at least one of the following be implemented:

  • Provide communications skill training for clinicians1;
  • Require explicit written justification in the medical record for antibiotic prescribing outside the recommended norm;
  • Provide clinical decision support; and
  • Use call centers, nurse hotlines, or pharmacist consultation systems to prevent unnecessary visits.

Critical to altering clinician behavior is tracking and reporting (i.e., audit and feedback), preferably at the individual level — an activity that has been clearly demonstrated to improve prescribing practices.

A key element of reducing inappropriate antibiotic use in the clinic is education, not only of clinicians, but of patients as well. Effective strategies that impart knowledge to patients about when antibiotics are not needed and about the potential harm of antibiotic administration should be implemented. CDC provides a wide array of educational material for patients that are freely available online at Education of clinicians may consist of “academic detailing,”continuing education activities, and by the availability of timely access to expert input.

The implementation of stewardship principles in all outpatient settings is crucial to any hope of slowing the onslaught of antibiotic resistance. This has been recognized by many groups and is a requirement for accreditation by The Joint Commission as of Jan. 1, 2017. Many obstacles must be overcome, however, such as the increasing pressure on clinicians to generate RVUs. In addition, having to face Press Ganey reports of patient satisfaction is undoubtedly an important barrier to the reduction in antibiotic prescribing for many clinicians.


  1. “To Prescribe or Not To Prescribe? Antibiotics and Outpatient Infections.” The target audience is outpatient clinicians (including the Emergency Department) who prescribe antibiotics. This 1.5 hour course is also case-based and interactive and illustrates the incorporation of stewardship principles into daily practice. It addresses the problem of dealing with societal/patient pressures to prescribe when antibiotics are indicated and, using actors, illustrates approaches to dealing with them.