Figuring out what works in outpatient ambulatory stewardship

Reviewed by Reviewed by Zach Willis, MD, MPH, UNC School of Medicine and Barry Rittmann, MD, MPH, Virginia Commonwealth University Health Systems

Using a large American commercial claims database, Savage, et al., reviewed antibiotic prescriptions for over 3 million episodes of acute bacterial sinusitis in children from 2003 through 2020. Prior to the publication of the IDSA guidelines for acute bacterial sinusitis in 2012, use of amoxicillin and amoxicillin-clavulanate was declining, while azithromycin and cefdinir were rising quickly. Following publication of the guidelines, which identified amoxicillin with or without clavulanate as first-line therapy, these trends largely reversed, with amoxicillin +/- clavulanate rising in utilization in the years since and azithromycin use declining sharply. As a result of these guidelines, many, many children received antibiotics that were both more active for the most common causes of sinusitis and narrower in spectrum than the most popular alternatives. These findings demonstrate the significant impact that antibiotic prescribing guidelines can have in the outpatient setting.

However, there are still many improvements to be made in ambulatory antibiotic prescribing, and clinical trials can identify the most effective strategies.  A cluster randomized trial of English primary care practices by Blair, et al. examined a multi-faceted intervention to optimize antibiotic management in children with acute cough and respiratory tract infections.  The study evaluated children aged 0-9 from 294 English primary care practices from November 2018 to September 2021.  Interventions included eliciting parental concerns during the consultation, providing a clinician-focused prognostic algorithm to risk-stratify children for 30-day risk of hospital admission, with accompanied antibiotic guidance, and a leaflet for care providers including safety net advice.  Primary outcomes were rates of amoxicillin and macrolide prescriptions, and hospital admission for respiratory tract infections over 12 months.  This intervention did not show a reduction in antimicrobial prescribing practices, although subgroup analysis did suggest a decrease in some subsets of patients, particularly in older children, and in smaller practices with fewer prescribing nurses.  Post hoc analysis did suggest less dispensing in the intervention group prior to the COVID-19 pandemic.  It is difficult to interpret this data completely given the unfortunate timing around COVID-19.  Regardless, these studies highlight which interventions could be most impactful when implementing stewardship practices.


  • Savage TJ, Kronman MP, Sreedhara SK, et al. Trends in the Antibiotic Treatment of Acute Sinusitis: 2003–2020. Pediatrics. 2023;151(4):e2022060685. doi:10.1542/peds.2022-060685
  • Blair PS, Young G, Clement C, Dixon P, Seume P, Ingram J, Taylor J, Cabral C, Lucas PJ, Beech E, Horwood J, Gulliford M, Francis NA, Creavin S, Lane JA, Bevan S, Hay AD. Multi-faceted intervention to improve management of antibiotics for children presenting to primary care with acute cough and respiratory tract infection (CHICO): efficient cluster randomised controlled trial. BMJ. 2023 Apr 26;381:e072488. doi: 10.1136/bmj-2022-072488
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