Increased Need for Antibiotic Stewardship in Outpatient Settings

Doctor writing a prescription
Doctor writing a prescription
A review summarizes outpatient prescription practices and identifies factors that may influence physician prescribing behaviors.

Antibiotic resistance is a growing threat to public health and antibiotic use is a major contributor to that resistance. The majority of antibiotics are prescribed in the outpatient setting, so a review1 published in Pediatrics summarized outpatient prescription practices, identified factors that may influence physician prescribing behaviors, and highlighted the role of healthcare stakeholders in expanding stewardship efforts.

Investigators found that outpatient prescription practices have been on a slow but consistent decline in the United States in recent years. One study attributed the decline in the numbers of outpatient prescriptions filled to the drop in prescriptions for infants and children2. However, US prescribing rates remain high compared with other countries.

Primary care providers are the largest prescribers of antibiotics and therefore are key targets for outpatient antibiotic stewardship efforts. Investigators also found the highest prescription rates in the Southern states and the lowest in the Western states.

Data from the reviewed studies showed that for all ages up to 30% of prescriptions may be unnecessary and the majority of these were written to treat acute respiratory conditions.3 The factors identified that are driving inappropriate prescription behaviors are patient satisfaction and pressure, time constraints, diagnostic uncertainty, and feelings of externalized responsibility.

In order to combat unnecessary prescriptions, the Centers for Disease Control and Prevention (CDC) released a report in 2016 highlighting core elements of outpatient antibiotic stewardship.4 These interventions range in time, cost, and implementation effort and the investigators highlighted a need for further research into what resources are available for outpatient clinics and what policies or incentives might support the scaling up of these initiatives.

Investigators further noted that aside from more research a collective action from various healthcare stakeholders will be required. Stakeholders include not only physicians but healthcare systems, insurance providers, and public health agencies. Healthcare systems can provide access to specialists like infectious disease physicians for help in implementing stewardship practices and — along with insurance providers — leverage shared electronic records to facilitate prescription practice audits and feedback.

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Public health agencies can play a role by providing information and materials to clinicians and patients that will communicate and facilitate stewardship practices.

Investigators conclude that “through this collective action, stakeholders can leverage shared resources to reduce inappropriate prescribing and minimize the threat of antibiotic resistance.”


  1. Zetts RM, Stoesz A, Smith BA, Hyun DY. Outpatient antibiotic use and the need for increased antibiotic stewardship efforts. Pediatrics. 2018;141:e20174124
  2. Antibiotic prescription fill rates declining in the US. Blue Cross Blue Shield.2017.Antibiotics. Report. www.bcbs. com/sites/default/files/fileattachments/health-of-america-report/HoA. Accessed June 13, 2018.
  3. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315:1864-1873.
  4. Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep. 2016; 65:1-12.