Antibiotic Stewardship in the Outpatient Setting

Katherine Fleming-Dutra, MD


November 14, 2016

Editorial Collaboration

Medscape &

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Hello. I'm Katherine Fleming-Dutra, a pediatrician in the Office of Antibiotic Stewardship at the Centers for Disease Control and Prevention (CDC). Today, as part of the CDC Expert Commentary series on Medscape, I would like to talk about antibiotic stewardship in outpatient settings, and CDC's latest resource to support these efforts.

Improving antibiotic use is critical to combating antibiotic-resistant bacteria[1]—an important global public health problem. CDC estimates that at least 30% of outpatient antibiotic prescriptions in the United States are completely unnecessary,[2] illustrating why antibiotic stewardship is needed in outpatient settings.

"Antibiotic stewardship" refers to the efforts aimed at improving and measuring antibiotic prescribing so that antibiotics are used only when needed[3,4]; ensuring that the right drug, dose, and duration are selected; and minimizing misdiagnoses or delayed diagnoses leading to underuse of antibiotics where they are needed.

CDC has now published the Core Elements of Outpatient Antibiotic Stewardship to provide guidance for antibiotic stewardship in outpatient settings. These core elements apply to clinics and clinicians in primary care, medical specialties and subspecialties, emergency departments, retail health and urgent care settings, and dentistry.

There are four core elements:

  • Commitment;

  • Action for policy and practice;

  • Tracking and reporting; and

  • Education and expertise.

Putting the Elements Into Practice

Let's examine each of these in the context of a common clinical scenario: A patient brings a child to the pediatrician displaying symptoms of an earache, but no fever. The pediatrician diagnoses nonsevere acute otitis media. How does each core element apply to this scenario?

Commitment. The first element, commitment, means to "demonstrate dedication to and accountability for optimizing antibiotic use and patient safety."

In our scenario, the pediatrician could display a poster in the examination room with a commitment to use antibiotics appropriately. This has been shown to be effective in reducing inappropriate antibiotic prescriptions for acute respiratory infections.[5] This may also help with communication with the parent when the clinician explains that an antibiotic may not be needed for nonsevere acute otitis media.

Action for policy and practice. The second element, action for policy and practice, means to "implement at least one policy or practice to improve antibiotic use, assess whether it's working, and modify as needed."

An example of implementing this element could be using delayed prescribing practices or watchful waiting, when appropriate. Delayed prescribing and watchful waiting can be used for conditions that usually resolve on their own, but antibiotics might be beneficial if the patient does not improve.

In our scenario, the child has been diagnosed with nonsevere acute otitis media and can be watched and seen again in 2-3 days to see whether she improves before prescribing antibiotics. Or, the pediatrician can use delayed prescribing by giving the parent an antibiotic prescription for the child, providing instructions to fill the prescription after 2-3 days if the child is not better, or instructing the parent to call or return to collect a prescription if the child's symptoms are worsening or not improving.[6,7,8,9,10,11,12,13,14]

Tracking and reporting. The third element, tracking and reporting, means to "monitor antibiotic prescribing practices and offer regular feedback to clinicians or perform self-assessment on antibiotic use."

For example, this might involve implementing tracking and reporting systems (also known as "audit-and-feedback") that routinely measure antibiotic prescribing and promote adherence to clinical practice guidelines by providing comparisons of individual prescribing behaviors with either established recommendations or peer prescribing behaviors.[15,16,17,18] In our scenario, the pediatric clinic could track and report the use of watchful waiting and delayed prescriptions for children who qualify for nonsevere acute otitis media to help providers improve the use of this guideline-recommended treatment strategy.

Education and expertise. The fourth and final element, education and expertise, means to "provide educational resources to clinicians and patients on antibiotic use and ensure access to needed expertise."

For example, clinicians can use effective communication strategies to educate patients about when antibiotics are and are not needed. In the scenario, the pediatrician could inform the parent that some bacterial infections, such as mild ear infections, may improve without antibiotics. The pediatrician could also explain recommendations for symptom management—in this case, pain management. This combination of messages has been associated with visit satisfaction.[19] In addition, providing recommendations for when to seek medical care if the patient is not improving or is worsening (a contingency plan) has been associated with higher visit satisfaction scores among patients who expected but were not prescribed antibiotics.[20]

In the case of acute otitis media, the pediatrician may need the expertise of an otolaryngologist for patients with recurrent otitis media who might benefit from specialty care.

The core elements provide a framework for improving prescribing. It may be helpful to use the core elements with other quality improvement initiatives. For every unique outpatient facility, it is important to identify high-priority conditions that represent opportunities for improvement, to identify barriers to improving antibiotic use, and to establish clear evidence-based standards for antibiotic prescribing.

To view the core elements and learn more about antibiotic stewardship, please see the resources listed below on this page. Thank you.

Web Resources

Get Smart About Antibiotics