Ambulatory Protocols and Stewardship

Clinic Protocols  
Ambulatory Stewardship Information  

Fast Facts from the Centers for Disease Control and Prevention

Antibiotic use is the most important modifiable driver of antibiotic resistance, and antibiotic-resistant infections lead to higher healthcare costs, poor health outcomes, and more toxic treatments 1.

At least 30% of antibiotic courses prescribed in the outpatient setting are unnecessary, meaning that no antibiotic is needed at all. Most of this unnecessary use is for acute respiratory conditions, such as colds, bronchitis, sore throats caused by viruses, and even some sinus and ear infections 2.

Total inappropriate antibiotic use, which includes unnecessary antibiotic use plus inappropriate antibiotic selection, dosing, and duration, may approach 50% of all outpatient antibiotic use. 3, 5.

Antibiotics are the most common cause of adverse drug events (ADEs) in children, accounting for 7 of the top 10 drugs leading to pediatric ADE-related emergency room (ER) visits. Antibiotics are in the top three drug classes leading to ADE-related ER visits for all ages. 6.

Improving antibiotic prescribing can reduce harm. A 10% decrease in inappropriate prescribing in the community can result in a 17% reduction in Clostridium difficile infection, a severe form of diarrhea usually caused by antibiotic exposure 7.

Our antimicrobial stewardship program is collaborating with several Nebraska Medicine clinics to participate in the AHRQ Safety Program for Improving Antibiotic Use.  

We collaborate closely with the Nebraska Antimicrobial Stewardship Assessment and Promotion Program on outpatient antimicrobial stewardship initiatives. For more information:


  1. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States. 16 September 2013. Web. 17 July 2014.
  2. Fleming-Dutra, K., et al. (2016). “Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011.” JAMA: the Journal of the American Medical Association 315(17): 1864-1873.
  3. Centers for Disease Control and Prevention (CDC). Office-related antibiotic prescribing for persons aged ≤14 years — United States, 1993—1994 to 2007—2008. MMWR Morb Mortal Wkly Rep. 2011;60(34):1153-6.
  4. Pichichero ME. Dynamics of antibiotic prescribing for children. JAMA. June 19, 2002;287(23):3133-5.
  5. Shapiro DJ, Hicks LA, Pavia AT, Hersh AL. Antibiotic prescribing for adults in ambulatory care in the USA, 2007–09. J Antimicrob Chemother. 2014;69(1):234-40.
  6. Shehab, N., et al. (2016). “US emergency department visits for outpatient adverse drug events, 2013-2014.” JAMA 316(20): 2115-2125.
  7. Dantes, R., et al. (2015). “Association Between Outpatient Antibiotic Prescribing Practices and Community-Associated Clostridium difficile Infection.” Open forum infectious diseases 2(3): ofv113-ofv113.

Introduction to Antimicrobial Stewardship

Management of Select Upper Respiratory Tract Syndromes