- To combat antibiotic-resistant bacteria, important global public health problem
- 30% of outpatient antibiotic prescriptions in US are completely unnecessary

- = efforts to improve & measure antibiotic prescribing → antibiotics used only when needed
- = ensuring that right drug, dose & duration are selected
- minimizing misdiagnoses or delayed diagnoses leading to underuse of ATBs where they are needed
- CDC “Core Elements of Outpatient Antibiotic Stewardship” to provide guidance for ATB stewardship in outpatient settings apply to clinics & clinicians in primary care, medical specialties & subspecialties, emergency departments, retail health & urgent care settings & dentistry

- Commitment
- Action for policy & practice
- Tracking & reporting
- Education & expertise

Patient brings child to pediatrician displaying symptoms of earache, but no fever. Pediatrician diagnoses non severe acute otitis media

- “To demonstrate dedication to & accountability for optimizing antibiotic use and patient safety”
- Pediatrician could display poster in examination room with commitment to use ATBs appropriately, effective in reducing inappropriate ATB prescriptions for acute respiratory infections
- May help with communication with parent when clinician explains that ATB may not be needed for non-severe acute otitis media

- "To implement at least one policy or practice to improve antibiotic use, assess whether it's working, & modify as needed”
- Using delayed prescribing practices or watchful waiting, when appropriate
- Delayed prescribing & watchful waiting can be used for conditions that usually resolve on their own, but ATBs might be beneficial if the patient does not improve
- The child has been diagnosed with non-severe acute otitis media & can be watched and seen again in 2-3 days to see whether she improves before prescribing antibiotics
- The pediatrician can use delayed prescribing by giving the parent an antibiotic prescription for the child, providing instructions to fill prescription after 2-3 days if child is not better, or instructing parent to call or return to collect a prescription if child's symptoms are worsening or not improving

- = " to monitor antibiotic prescribing practices and offer regular feedback to clinicians or perform self-assessment on antibiotic use"
- Might involve implementing tracking & reporting systems ("audit-and-feedback") measuring ATB prescribing & promoting adherence to clinical practice guidelines by providing comparisons of individual prescribing behaviors with established recommendations or peer prescribing behaviors - Pediatric clinic could track & report use of watchful waiting & delayed prescriptions for children who qualify for non-severe acute otitis media to help providers improve use of this guideline-recommended treatment strategy

- = " To provide educational resources to clinicians and patients on antibiotic use & ensure access to needed expertise"
- Clinicians can use effective communication strategies to educate patients about when ATBs are and are not needed
- Pediatrician could inform parent that some bacterial infections, such as mild ear infections, may improve without antibiotics
- Pediatrician could explain recommendations for symptom management (pain management)
- Can provide recommendations for when to seek medical care if patient is not improving or is worsening → associated with higher visit satisfaction scores among patients who expected but were not prescribed antibiotics
- In acute otitis media, pediatrician may need expertise of otolaryngologist for patients with recurrent otitis media who might benefit from specialty care

- Core elements provide framework for improving prescribing
- May be helpful to use 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, & to establish clear evidence-based standards for ATB prescribing

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