Intended for healthcare professionals

Clinical Review State of the Art Review

Advances in optimizing the prescription of antibiotics in outpatient settings

BMJ 2018; 363 doi: (Published 12 November 2018) Cite this as: BMJ 2018;363:k3047
  1. Laura M King, health research analyst1,
  2. Katherine E Fleming-Dutra, deputy director1,
  3. Lauri A Hicks, director1
  1. 1Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US
  1. Correspondence to: K E Fleming-Dutra ftu2{at}


The inappropriate use of antibiotics can increase the likelihood of antibiotic resistance and adverse events. In the United States, nearly a third of antibiotic prescriptions in outpatient settings are unnecessary, and the selection of antibiotics and duration of treatment are also often inappropriate. Evidence shows that antibiotic prescribing is influenced by psychosocial factors, including lack of accountability, perceived patient expectations, clinician workload, and habit. A varied and growing body of evidence, including meta-analyses and randomized controlled trials, has evaluated interventions to optimize the use of antibiotics. Interventions informed by behavioral science—such as communication skills training, audit and feedback with peer comparison, public commitment posters, and accountable justification—have been associated with improved antibiotic prescribing. In addition, delayed prescribing, active monitoring, and the use of diagnostics are guideline recommended practices that improve antibiotic use for some conditions. In 2016, the Centers for Disease Control and Prevention released the Core Elements of Outpatient Antibiotic Stewardship, which provides a framework for implementing these interventions in outpatient settings. This review summarizes the varied evidence on drivers of inappropriate prescription of antibiotics in outpatient settings and potential interventions to improve their use in such settings.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: All three authors made substantial contributions to the conception of the manuscript, approved the final version of this manuscript, and agree to be accountable for all aspects of the work. LMK conceptualized the review, performed the literature review, and wrote the article. KEF-D and LAH conceptualized the review and provided critical revisions for important intellectual content. LAH, as guarantor, accepts full responsibility for the work, had access to the references reviewed, and controlled the decision to publish. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • Disclaimer: The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

  • License: This work was conducted by employees of the US Federal Government. For employees of the US Federal Government employees acting in the course of their employment, no copyright exists and the Contribution is in the public domain so no license is required to be granted.

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