What’s New in the Patient Safety World

December 2016

Update on Ambulatory Antibiotic Stewardship



In our November 2015 What's New in the Patient Safety World column “Medications Most Likely to Harm the Elderly Are…” we noted the paucity of evidence in the literature about antibiotic stewardship programs in ambulatory care or other outpatient settings. CDC had previously published on the core elements for hospitals (CDC 2014) and nursing homes (CDC 2015). Now CDC has published the “Core Elements of Outpatient Antibiotic Stewardship” (Sanchez 2016).


The Core Elements of Outpatient Antibiotic Stewardship are:

  1. Commitment: Demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety.
  2. Action for policy and practice: Implement at least one policy or practice to improve antibiotic prescribing, assess whether it is working, and modify as needed.
  3. Tracking and reporting: Monitor antibiotic prescribing practices and offer regular feedback to clinicians, or have clinicians assess their own antibiotic prescribing practices themselves.
  4. Education and expertise: Provide educational resources to clinicians and patients on antibiotic prescribing, and ensure access to needed expertise on optimizing antibiotic prescribing.


Regarding commitment, CDC notes that declaring commitment to antibiotic stewardship in a public fashion (eg. posters in examination rooms) has been shown to reduce inappropriate prescription of antibiotics. In larger practices and healthcare organizations, designating a leader for antibiotic stewardship programs is recommended. CDC also recommends not only educating all staff on antibiotic stewardship but also making it part of their job descriptions and evaluation. CDC stresses that all members of the healthcare team have an important role in antibiotic stewardship.


Under Action for policy and practice they recommend adherence to the evidence-based practices recommended in specialty society guidelines. They note that use of delayed prescribing practices or watchful waiting, when appropriate, may be successful strategies. This requires good communication skills and consistent messages. Systems should provide clinical decision support tools for clinicians and have informational printouts available for patients and families. Various triage systems (eg. nurse call lines) should also reinforce principles of appropriate antibiotic prescribing and may help reduce unnecessary office/clinic/ER visits. They also recommend documentation in the medical record of rationale for decisions not to prescribe antibiotics.


Tracking and reporting consists of audit and feedback, which has been shown to reduce inappropriate antibiotic prescribing. Items to track should include whether antibiotics were appropriate, whether the correct antibiotic was prescribed, and whether the duration of therapy recommended was appropriate. Some systems or practices might choose a high priority condition, like acute bronchitis, to monitor. Others might look at percentage of overall visits at which antibiotics are prescribed. Feedback to individual prescribers can be compared to peers. Some systems may also track adverse drug events related to antibiotics.


Education applies both to prescribers and patients. Communication with patients or families should take into account health literacy issues. Continuing educational activities should be available for healthcare providers and timely access to persons with expertise (eg. pharmacists, infectious disease staff) should be made available.


See also our November 2015 What's New in the Patient Safety World column “Medications Most Likely to Harm the Elderly Are…” for other recommendations and links to some of the other studies on antibiotic stewardship in the outpatient setting.



Some of our prior columns on antibiotic stewardship:





CDC. Core elements of hospital antibiotic stewardship programs [Internet]. Atlanta, GA: US Department of Health and Human Services, CDC; 2014; last updated May 25, 2016




CDC. Core elements of antibiotic stewardship for nursing homes [Internet]. Atlanta, GA: US Department of Health and Human Services, CDC; 2015; last updated August 18, 2016




Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elements of Outpatient Antibiotic Stewardship. Recommendations and Reports. MMWR 2016; 65(6): 1-12







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