Sarah Kabbani, MD, MSc, public health physician, CDC, delineated antibiotic stewardship challenges and opportunities during an IDWeek 2023 session titled Outpatient Antibiotic Use, the Core Elements of Outpatient Antibiotic Stewardship and National Stewardship Priorities. Dr. Kabbani emphasized the importance of educational outreach, monitoring, and maintaining a focus on antibiotic-related adverse drug events, in addition to addressing antibiotic overprescribing and resistance issues, to optimize health outcomes.

Dr. Kabbani highlighted the current threat of antibiotic resistance in the United States, reporting that antibiotic-resistant bacteria and fungi are responsible for at least 2,868,799 infections and 35,900 deaths annually.

“Spending on antibiotic prescriptions in outpatient settings,” Dr. Kabbani said, “is more than double the spending in hospital settings.” From 2010 to 2015, she said, spending (nonfederal) on antibiotic treatments in the outpatient settings significantly outpaced expenditures in healthcare settings—$33.2 billion compared with $16.4 billion. Spending in long-term care and federal facilities accounted for an additional $6.5 billion during that time period.

While the focus is often on increasing antibiotic resistance, antibiotic use can also lead to adverse events and other complications, Dr Kabbani said. One in 1,000 prescriptions lead to an ED visit for an adverse event, and antibiotics are the most common cause of ED visits for adverse drug events among children aged younger than 18 years. “We want clinicians to focus more on adverse events rather than the threat of antibiotic resistance,” she stressed.

Overall antibiotic prescribing rates declined during 2011-2022, Dr. Kabbani pointed out, dropping by 19.11% in adults. The COVID-19 years also saw a lowering in the number of antibiotic prescriptions compared with 2019, falling by 16.7% in 2021 and 7.7% in 2022.

Dr. Kabbani cited CDC statistics that at least 28% of antibiotic prescriptions are “completely unnecessary,” outlining several opportunities to better managing antibiotic prescribing practices. For example, she remarked that antibiotics are often prescribed or longer than necessary, particularly for respiratory infections. For example, she said the current clinical practice recommendation for sinusitis antibiotic prescriptions is for 5 to 7 days; however, most prescriptions are given for 10 days.

She also offered statistics that inappropriate antibiotic prescribing is especially common in urgent care settings and telemedicine visits. Nevertheless, she cautioned that “by volume, office visits still contribute the highest amount [of inappropriate antibiotic prescribing].”

Health equity is an additional influencing factor driving antibiotic prescribing trends, Dr. Kabbani said. Among certain populations, including adults aged older than 65 years, those with private health insurance, non-Hispanic whites, and during ED visits, antibiotic prescribing rates are increasing. In contrast, prescribing rates among older children, younger adults, non-Hispanic blacks, patients with public health insurance, and in physician and pediatrician offices.  

In conclusion, Dr. Kabbani described the CDC’s Core Elements of Outpatient Antibiotic Stewardship: Commitment (demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety); 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); Tracking and Reporting (monitor antibiotic prescribing practices and offer regular feedback to clinicians or have clinicians assess their own antibiotic prescribing practices themselves); and Education and Expertise (provide educational resources to clinicians and patients on antibiotic prescribing and ensure access to needed expertise on optimizing antibiotic prescribing).

Dr. Kabbani wrapped up her presentation by highlighting U.S. Antibiotic Awareness Week, November 18-24, 2023; information about this event is available at www.cdc.gov/antibiotic-use.