Improving Outpatient Antimicrobial Stewardship: Taking the Next Step

ContagionAugust 2019
Volume 4
Issue 4

In the August Editor-in-Chief's Letter, Dr. Jason Gallagher discusses how we can improve outpatient antimicrobial stewardship.

Prudent outpatient antibiotic use represents the holy grail of antimicrobial stewardship. Antimicrobial stewardship has developed, evolved, and grown largely through hospital-based programs, with snippets of best practices in ambulatory care emerging along the way. Although there is no doubt that the acuity of illness of hospitalized patients justifies maximizing the degree of antimicrobial stewardship efforts in that setting, their impact on antimicrobial resistance is limited primarily to the relatively small proportion of patients who are admitted in hospitals or frequently receive inpatient care.

Antibiotics are the only type of medication for which use in one person affects utility in another. They are a societal good. Given that the majority of human antibiotic use occurs in the outpatient setting, we are missing an enormous opportunity if outpatient antimicrobial prescribing does not become a primary focus of antimicrobial stewardship efforts. Because there were almost 5 antibiotic prescriptions for every 6 Americans in 2013,1 there is a lot of work to do.

In June, The Joint Commission announced that beginning in 2020, new requirements were being put into place for ambulatory health care organizations seeking its accreditation. This follows voluntary guidance on Core Elements of Outpatient Antibiotic Stewardship by the Centers for Disease Control and Prevention published in 2016.2 Although limited in scope to organizations accredited by The Joint Commission, the establishment of requirements—instead of voluntary guidelines—in any ambulatory setting is a step forward.

What are these requirements? They are aimed at establishing antimicrobial stewardship as an institutional priority instead of setting prescriptive requirements on how it is performed. Stringent requirements on practices are inappropriate for several reasons, chief among them limited, but growing publications on successful outpatient antimicrobial stewardship practices.

The audience of Contagion® is not one that primarily needs to hear the message on diligent outpatient prescribing, but it is one that needs to promote it. Physicians and pharmacists involved in the direction of inpatient antimicrobial stewardship programs should investigate ways of becoming involved in the construction and management of outpatient programs. In our previous issue, Christina G. Rivera, PharmD, BCPS, AAHIV-M, described some ways that pharmacists can support these programs. Physician involvement is also key. All of us need to work together to bolster the literature, both to report stories of successful programs and to supplement data describing the effects of minimizing antimicrobial exposure, such as shorter antibiotic courses and delayed antibacterial prescriptions for illnesses likely to be viral.

Outpatient antimicrobial stewardship has a long way to go, but we know long journeys have to start somewhere.

Our feature article this month, by Lindsay Courtney, PharmD, and Meghan Jeffres, PharmD, BCIDP, makes the argument that avoidance of cefazolin due to concerns about cross-reactivity results in measurable patient harm and is not supported by published evidence.

As always, enjoy this issue, and keep up with us at

Gallagher is a clinical professor at Temple University School of Pharmacy and clinical pharmacy specialist in infectious diseases at Temple University Hospital, both in Philadelphia, Pennsylvania. He is also the director of the PGY2 Residency in Infectious Diseases Pharmacy at Temple. *He is an active member of the Society of Infectious Diseases Pharmacists.


  1. CDC. Outpatient antibiotic prescriptions—United States, 2013. CDC website. Accessed July 9, 2019.
  2. Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep. 2016 Nov 11;65(6):1-12. doi: 10.15585/mmwr.rr6506a1.
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