Antibiotic Stewardship Throughout the Primary Care Visit: Opportunities for Office Staff


Engaging office staff will make your practice's antibiotic stewardship efforts more effective.

Fam Pract Manag. 2021 Nov-Dec;28(6):10-14.

Author disclosures: The practice improvement work that is the basis for this article was funded by a State University Partnership contract between the Kentucky Department for Medicaid Services and the University of Louisville. This article represents the view of the authors only. No other relevant financial affiliations.

Antibiotic stewardship is an important strategy for reducing the development of antimicrobial resistance and harmful side effects. Approximately 85%–95% of antibiotic use occurs in the outpatient setting, and at least 30% of prescriptions are considered unnecessary.1,2 In 2016, the Centers for Disease Control and Prevention (CDC) published the “Core Elements of Outpatient Antibiotic Stewardship” with recommendations on how to combat inappropriate prescribing.3 While physicians and other prescribers have an important role in these efforts and should serve as practice leaders (see the related article), there are opportunities for all medical office staff to be involved. By incorporating antibiotic stewardship education and appropriate communication practices throughout the primary care visit, practices have the potential to change the culture and expectations of antibiotic prescribing for sick visits.


  • While physicians and other prescribers have a key role to play in antibiotic stewardship, it's important to get all medical office staff involved as well.

  • Staff training should include recommended ways to communicate with patients about antibiotic use.

  • From appointment scheduling to the exam room, patients should receive consistent messages and educational resources about the appropriate use of antibiotics.


To lay the groundwork for antibiotic stewardship among staff, practices should take the following steps:

1. Identify champions to lead antibiotic stewardship efforts. Consider appointing at least two champions: a prescriber and a support staff person, such as a nurse or medical assistant. Champions will be responsible for leading and maintaining stewardship initiatives. If possible, add these roles to formal job descriptions.

2. Require all office staff to complete antibiotic stewardship training. Practices can use existing resources for training. We recommend the CDC's free, online Antibiotic Stewardship Training Series4 or an in-person summary of the CDC training concepts led by office champions. The first six CDC modules offer introductory information about antibiotic use, resistance, stewardship, and communication, which can be helpful to office staff. Prescribers can benefit from additional modules that discuss specific clinical conditions.

3. Organize an antibiotic communication discussion at a staff meeting. An important piece of the CDC training is the communication module. Based on robust research from Seattle Children's Research Institute,5 it summarizes messages that physicians and office staff can use to help manage patient expectations about antibiotic use. (See “Messages to improve antibiotic stewardship” and “Examples of appropriate staff responses to patient comments.”) Staff should discuss and practice these res


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Dr. Wattles is a clinical pharmacist at the Department of Pediatrics Child and Adolescent Health Research Design and Support Unit at the University of Louisville School of Medicine, in Louisville, Ky. She leads the Kentucky Antibiotic Awareness campaign....

Dr. Vidwan is the director of the Antimicrobial Stewardship Program (ASP) at Norton Children's Hospital and faculty at the University of Louisville Division of Pediatric Infectious Diseases.

Dr. Smith is the medical director of the Pediatric ASP at Duke University Medical Center in Durham, N.C.

Author disclosures: The practice improvement work that is the basis for this article was funded by a State University Partnership contract between the Kentucky Department for Medicaid Services and the University of Louisville. This article represents the view of the authors only. No other relevant financial affiliations.


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1. Duffy E, Ritchie S, Metcalfe S, Van Bakel B, Thomas MG. Antibacterials dispensed in the community comprise 85%–95% of total human antibacterial consumption. J Clin Pharm Ther. 2018;43(1):59–64....

2. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among U.S. ambulatory care visits, 2010–2011. JAMA. 2016;315(17):1864–1873.

3. Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep. 2016;65(6):1–12.

4. CDC's antibiotic stewardship training series. Centers for Disease Control and Prevention. Accessed Oct. 2, 2021.

5. Mangione-Smith R, Zhou C, Robinson JD, Taylor JA, Elliott MN, Heritage J. Communication practices and antibiotic use for acute respiratory tract infections in children. Ann Fam Med. 2015;13(3):221–227.

6. Antibiotic prescribing and use: patient education and promotional resources. Centers for Disease Control and Prevention. Reviewed March 24, 2021. Accessed Oct. 2, 2021.

7. Harper R, Temkin T, Bhargava R. Optimizing the use of telephone nursing advice for upper respiratory infection symptoms. Am J Manag Care. 2015;21(4):264–270.

8. Harris RH, MacKenzie TD, Leeman-Castillo B, et al. Optimizing antibiotic prescribing for acute respiratory tract infections in an urban urgent care clinic. J Gen Intern Med. 2003;18(5):326–334.

9. Meeker D, Knight TK, Friedberg MW, et al. Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA Intern Med. 2014;174(3):425–431.

10. American Nurses Association. Redefining the antibiotic stewardship team: recommendations from the American Nurses Association/Centers for Disease Control and Prevention workgroup on the role of registered nurses in hospital antibiotic stewardship practices. 2017. Accessed Oct. 2, 2021.

11. Monsees E, Goldman J, Popejoy L. Staff nurses as antimicrobial stewards: an integrative literature review. Am J Infect Control. 2017;45(8):917–922.


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