Guide: Starting an Outpatient Antibiotic Stewardship Program

Diseases due to multidrug-resistant bacteria resistant to the antibiotics available are increasing at an alarming rate. Use of antibiotics by humans rose by 40% between 2000 and 2010, but the rate of new antibiotic development has slowed. Recent estimates of the burden of antimicrobial resistance suggest that there are approximately 700,000 deaths worldwide every year due to infections with antimicrobial resistant bacteria, with nearly 50,000 of these deaths occurring in the United States and Europe. A report led by economist Jim O’Neil on antimicrobial resistance commissioned by the British government in 2014 projected that the number of annual deaths attributable to antimicrobial resistance would surpass 10 million by the year 2050 if no meaningful interventions occur. These estimates suggests that death related to antimicrobial resistant infections will surpass cancer as the number one cause of mortality worldwide. (O’Neil, J. Review on Antimicrobial Resistance: Tackling a Crisis for the Health and Wealth of Nations. (2014).)

Antibiotic treatment for a single outpatient infection has been shown to influence resistance patterns of future infections. (Paschke AA et al, “Previous antimicrobial exposure is associated with drug-resistant UTI in children”; Pediatrics 2010; 125: 664-672.); Kuster SP et al, “Previous Antibiotic Exposure and Antimicrobial Resistance in Invasive Pneumococcal Disease: Results From Prospective Surveillance,” Clin Infect Dis 2014; 59(7): 944-952.

Prominent examples of increasing antibiotic resistance threats commonly encountered in the outpatient pediatrics setting include:

Streptococcus pneumoniae

  • S. pneumoniae is a common cause of acute otitis media, community-acquired pneumonia, and sinusitis in children.
  • Drug resistant S. pneumoniae is considered a serious by the CDC, with an estimated 2 million infections each year. In more than 30% of infections, the isolate will be resistant to one or more clinically useful antibiotics (CDC, Antibiotic Resistance Threat Report, 2019.)
  • The nationwide Active Bacterial Core pneumococcal surveillance report from 2018 found that 4.7% of invasive pneumococcal isolates were resistant or intermediate to penicillin and 2.6% were resistant or intermediate to cefotaxime. However, resistance rates were alarmingly high to erythromycin (28.2%) and tetracycline (10.3%). (Centers for Disease Control and Prevention. 2018. Active Bacterial Core Surveillance Report, Emerging Infections Program Network, Streptococcus pneumoniae, 2018.)

Staphylococcus aureus

  • Tamma PD, Robinson GL, Gerber JS, Newland JG, DeLisle CM, Zaoutis TE, Milstone AM. Pediatric Antibiotic susceptibility trends across the United StatesInfect Control Hosp Epidemiol. 2013 Dec;34(12):1244-51.
    • A pooled pediatric antibiogram representing 200 pediatric healthcare institutions across the United States from 2005 and 2011 demonstrated that 50% of all Staphylococcus aureus isolates were methicillin-resistant and 21% of S. aureus isolates were resistant to clindamycin.
  • Vicetti M, Mejias A, Leber A, Sanchez PJ. A decade of antimicrobial resistance in Staphylococcus aureus: A single center experience. PLoS One. 2019 Feb 12;14(2):e0212029.
    • Retrospective review of >40,000 S. aureus isolates identified from inpatient and outpatient settings in a large children’s hospital demonstrated resistance to clindamycin and TMP-SMX increased among outpatient isolates between 2005-2014.

Group A Streptococcus

ESBL-Producing Enterobacteriaceae in Children

See the Antibiotic Resistance page for more information.

Overuse can be classified into three categories: 1) prescribing antibiotics when none are indicated, 2) prescribing antibiotic courses that are excessive in spectrum, and 3) prescribing antibiotic courses with excessive duration for the infection being treated. There is substantial evidence suggesting that antibiotics are overused in outpatient settings, and children are no exception.

(1) Unnecessary antibiotic prescriptions

(2) Use of broad-spectrum and non-first-line antibiotics

(3) Antibiotic duration

Antibiotics should prescribed for the minimal effective duration. The following studies and guidelines support the use of shorter duration of therapy than historically used for select infectious conditions:


  • AAP Clinical Practice Guidelines from 2011 recommend treating children with pyelonephritis for 7 to 14 days, citing insufficient data to recommend a more specific treatment duration.
  • A multicenter retrospective cohort study of children with pyelonephritis used an inverse probability of treatment weighted propensity score analysis and found the odds of treatment failure were similar in children treated with a short course (6-9 days) compared with those treated with a long course (10 days or more) (Fox MT et al 2020 ).

Acute otitis media, age < 2 years

Acute otitis media, age > 2 years

  • Based on data suggesting that shorter antibiotic courses in children > 2 years of age with acute otitis media are equally effective, AAP Clinical Practice Guidelines from 2013 recommend a 7 day course of first-line antibiotic therapy for children ages 2-5 years and a 5-7 day course for children ages 6 years and older with mild or moderate AOM.

Regional Variation in Antibiotic Prescribing

Antibiotic Overuse in Various Settings

Children are prescribed antibiotics in a variety of settings: primary care, outpatient subspecialty care, dentistry, emergency departments, urgent care centers, retail clinics, and direct-to-consumer telemedicine. Each presents unique challenges with overuse of antibiotics.