Antibiotic Use and Stewardship in the United States, 2023 Update: Progress and Opportunities

• In 2021, the CDC launched an agency-wide strategy to integrate health equity principles into public health programs, policies, data systems and funding structures.
• In 2022, the Office of Antibiotic Stewardship conducted a review of published studies to identify antibiotic prescribing health inequities1.
  • The review revealed several gaps in knowledge and found that antibiotic prescribing rates and appropriateness varied by patient and clinician factors, such as patient race and insurance status and clinician type.
  • Findings emphasize the importance of integrating health equity into antibiotic stewardship policies, practices and research.
  • A renewed focus on antibiotic stewardship expertise and interventions will help optimize the diagnosis and treatment of infections, ensure patient safety and combat antimicrobial resistance.

Health systems are an important stakeholder to expand antibiotic stewardship expertise and implementation in outpatient settings. The Pew Charitable Trusts and Intermountain Healthcare, in consultation with CDC, convened partners to discuss approaches for health system-led outpatient stewardship activities. A commentary describing key takeaways from the discussion highlights benefits of health-system led stewardship efforts, including the ability to standardize practices across multiple facilities and leverage centralized resources to support stewardship. The commentary also describes examples of health-system led stewardship activities within the context of the Core Elements of Outpatient Antibiotic Stewardship framework2.

The landscape of healthcare delivery is evolving rapidly, especially during the COVID-19 pandemic. This has led to the expansion of the role of telemedicine, including for common infections managed in outpatient settings. CDC performed a narrative review of studies describing antibiotic prescribing and stewardship in outpatient telemedicine to support the application of the Core Elements of Outpatient Antibiotic Stewardship3. Considerations for technology-driven quality improvement approaches and adapting existing stewardship practices to telemedicine are discussed. Additional implementation research is necessary to inform the application of effective, sustainable and equitable antibiotic stewardship interventions and ensure the delivery of high-quality care across the spectrum of outpatient telemedicine.

State and local health departments play an important role in guiding antibiotic stewardship efforts in various healthcare settings and promoting appropriate antimicrobial use in their communities. CDC, through the American Rescue Plan Act, provided more than $120 million in supplemental funding to 62 state and local health departments to provide access to stewardship expertise and provide recommended stewardship implementation activities. CDC developed the Core Elements of Antibiotic Stewardship for Health Departments to outline the structure of a state and local health department antibiotic stewardship program and provide recommended stewardship implementation activities. State and local health departments can select and adapt stewardship strategies to meet local healthcare needs.

CDC released the intended Core Elements of Hospital Sepsis Programs to optimize the hospital management and outcomes of sepsis. Antibiotic stewardship programs play an important role in improving treating patients with sepsis, including implementing protocols to administer antibiotics quickly in cases of suspected sepsis and review antibiotics after they are started so that healthcare providers can tailor or stop therapy if unnecessary.

CDC monitors outpatient antibiotic prescription data using a variety of data sources to better understand trends in outpatient antibiotic prescribing, identify where interventions are most needed and measure progress. Download the CSV file for outpatient antibiotic prescription data.

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The Antimicrobial Use (AU) Option of the CDC's National Healthcare Safety Network (NHSN) is a surveillance resource that can provide actionable data for antibiotic stewardship programs. Programs can use the data to measure AU across hospitals and before, during and after stewardship interventions. 2,947 acute care hospitals across the United States have submitted at least one month of data to the AU Option as of August 2023. Of those hospitals, 2,751 reported from July 2022– June 2023.

In 2017, the NHSN Antimicrobial Use and Antimicrobial Resistance (AUR) Module reporting was identified as one option to meet the Public Health Registry reporting element within the Centers for Medicare and Medicaid Services (CMS) Medicare Promoting Interoperability (PI) Program for eligible hospitals and critical access hospitals (CAHs). This option continues to be available in calendar year 2023; facilities reporting to the NHSN AUR Module will receive 5 bonus points.

In 2023, CMS finalized changes to the Medicare Promoting Interoperability Program for eligible hospitals and CAHs that include a new AUR Surveillance measure under the Public Health and Clinical Data Exchange Objective. To earn credit for calendar year 2024, eligible hospitals and CAHs must demonstrate active engagement with CDC's NHSN to submit AUR data for the electronic health record (EHR) reporting period, or else claim an applicable exclusion. Learn more about the Promoting Interoperability Program.

Benchmarking measure of antibiotic use Standardized Antimicrobial Administration Ratio (SAAR)

The NHSN AUR module Standardized Antimicrobial Administration Ratio (SAAR) is a risk-adjusted antibiotic use benchmarking measure that can help inform stewardship efforts by enabling hospitals to see how their antibiotic use compares to other facilities. The 2022 NHSN AU Option Report provides a summary of SAAR distributions and percentages of use within the SAAR antimicrobial agent categories in adult, pediatric and neonatal patient care locations.

Visit CDC's Antimicrobial Resistance & Patient Safety Portal to view the latest data on inpatient antibiotic use. Download the CSV file for this data.

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Hospital antibiotic stewardship core elements

CDC's Core Elements of Hospital Antibiotic Stewardship provides a framework for implementation of antibiotic stewardship programs. The implementation of antibiotic stewardship programs in acute care hospitals is assessed through the NHSN Patient Safety Component Annual Hospital Survey [PDF – 19 pages]. Staff in hospitals complete annual surveys. Survey questions relating to antibiotic stewardship gauge a hospital's uptake of CDC's Core Elements of Hospital Antibiotic Stewardship Programs (ASPs). The percentage of hospitals meeting all 7 Core Elements increased to 97% in 2022. Additionally, the percentage of hospitals meeting 6 of the 7 Core Elements was 2%. Download the CSV file for antibiotic stewardship programs in acute care hospitals data.

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With robust national uptake of the Core Elements, CDC released Priorities for Hospital Core Element Implementation (Priorities) in Fall 2022 to enhance the quality and impact of hospital antibiotic stewardship programs. Key actions in six of the seven core elements were identified and are a subset of especially effective stewardship implementation approaches that are supported by evidence and/or recommended by stewardship experts. In 2022, the percentage of hospitals meeting all six Priorities was 10% and hospitals meeting five of the six Priorities was 24%. Download CSV file for hospital priority element reporting data.

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Healthcare providers commonly prescribed antibiotics to residents in long-term care settings. The increasing uptake of the Core Elements of Antibiotic Stewardship highlights how long-term care facilities are incorporating stewardship as a resident care priority. This is especially important in light of CMS regulations that require nursing homes to implement an antibiotic stewardship program that includes a system to monitor antibiotic use.

Similar to hospitals, CDC monitors the uptake of the Core Elements of Antibiotic Stewardship in Nursing Homes through the NHSN Long Term Care Facility Component—Annual Facility Survey [PDF – 6 pages]. Staff who work in long-term care facilities, including certified skilled nursing facilities/nursing homes, complete annual surveys. Survey questions relating to antibiotic stewardship gauge a facility's uptake of CDC's Core Elements of antibiotic stewardship.

Visit CDC's Antimicrobial Resistance & Patient Safety Portal to view the latest data on the uptake of the Core Elements in long-term care facilities. Download CSV file for this data.

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CDC analyzed acute respiratory tract infection (ARTI) outpatient visits for individuals younger than 65 years old using the 2017 IBM® MarketScan® Commercial Database. After controlling for clinical factors, including patient age, comorbidities, prescriber specialty, care setting, and ARTI diagnosis, the study found that patients in the Southern United States were the most likely to receive an inappropriate antibiotic prescription for an ARTI in multivariate models. These findings indicate that higher antibiotic prescribing in the South is likely due, in part, to non-clinical factors such as regional differences in clinicians' prescribing habits and patient expectations. Better defining these factors can inform regional and local stewardship interventions.4

Rates of inappropriate antibiotic prescribing are higher in urgent care centers compared with other outpatient settings. Researchers conducted a CDC-funded study at Intermountain Healthcare and the University of Utah to characterize the impact of a multifaceted antibiotic stewardship intervention on antibiotic prescribing in urgent care. Findings showed an improvement in antibiotic prescribing for respiratory conditions from a baseline of 47.8% to 33.3% during the intervention period. Among conditions for which antibiotics are not recommended, such as acute bronchitis or the common cold, antibiotic prescribing decreased from a baseline of 18.7% to 7.5%. CDC suggests using the approaches in this study as a model for health systems to improve antibiotic prescribing in urgent care settings5.

This CDC study compared outpatient antibiotic prescriptions among adults 65 years and older using two nationally representative data sources that public health organizations and researchers can leverage to improve antibiotic use. The distributions of antibiotic prescriptions by geography, antibiotic class, and prescriber specialty were similar in the Centers for Medicare and Medicaid Services (CMS) Part D Prescriber Public Use Files and the proprietary IQVIA Xponent® dataset. This finding suggests that public health organizations and healthcare systems can use the publicly available CMS Part D data to track antibiotic use and guide antibiotic stewardship interventions to improve prescribing for older adults.6

CDC assessed the association of patient characteristics with receiving an antibiotic prescription for adults 65 years and older using the National Health Interview Survey data linked with Medicare part D. The analysis showed variation in antibiotic prescribing by race and ethnicity, sex, geography, and health status in an older adult population with continuous healthcare coverage. This study highlights the importance of integrating health equity science in data analyses and incorporating a health equity perspective in efforts to improve antibiotic prescribing for older adults7.

Antibiotic prescribing practices among physicians and advanced practice clinicians (APCs, physician associates/assistants and nurse practitioners) were compared for respiratory conditions using national survey data from 2010 through 2018. APCs prescribed antibiotics more frequently than physicians (58% compared to 52%). No differences in selection of guideline recommended first-line agents were observed, suggesting similar quality of antibiotic selection between these two groups. APCs now account for about 2 out of 5 antibiotic prescriptions in the United States and should be included in stewardship education and in outpatient stewardship program development and leadership. Improving antibiotic prescribing by all clinicians, including APCs, is important for ensuring high quality, equitable health care.8