Antibiotic Use and Stewardship in the United States, 2025 Update: Progress and Opportunities

In 2016, CDC published the Core Elements of Outpatient Antibiotic Stewardship as a framework for clinics and clinicians to improve antibiotic prescribing in outpatient settings. Increasingly, outpatient care is provided under the umbrella of a health system.

In 2026, CDC will update the Outpatient Core Elements to focus on the role health system leadership can play in supporting the development and expansion of outpatient antibiotic stewardship programs within their networks. This updated guidance is applicable to all outpatient settings, including those with limited stewardship capacity and infrastructure, and aligns with published evidence and recommended best practices. For example, health systems can disseminate treatment recommendations based on national guidelines for common outpatient infections. Treatment recommendations can be integrated into the clinical workflow using clinical decision support tools embedded into electronic health records. The updated Core Elements guidance standardizes antibiotic stewardship implementation to improve the quality and consistency of outpatient care.

Although 10% of people in the United States report a penicillin allergy, less than 1% are truly penicillin allergic. Inaccurate penicillin allergy labels can prevent people from getting the best possible treatment for their infection. The Core Elements highlight the importance of healthcare professionals using effective methods to accurately evaluate if an individual is truly allergic to penicillin. CDC developed resources for healthcare professionals managing patients with penicillin allergy labels.

• The Clinical Features of Penicillin Allergy webpage features updated best practices and resources.
• With CDC funding, the Society for Healthcare Epidemiology of America (SHEA) created the Penicillin Allergy Management - Removing Barriers to Optimal Antibiotic Prescribing training course that provides free continuing education credits to healthcare professionals including physicians, pharmacists and advanced practice providers.

The Core Elements of Hospital Antibiotic Stewardship Programs outline opportunities to improve antibiotic use for common infections such as community-acquired pneumonia (CAP). CDC supported activities aimed at improving the treatment of patients with CAP.

• The American College of Chest Physicians created an interactive infographic on diagnostic and treatment considerations for managing CAP. This clinician educational resource was developed with CDC funding.
• A recent CDC-funded study demonstrated that providing feedback reports to clinicians on their antibiotic prescribing practices can improve adherence to treatment guidelines within a children's health system. These feedback reports were created using data from electronic health records, eliminating the need for manual chart reviews. 1
• With support from CDC, the University of Utah developed electronic clinical quality measures (eCQMs) extracted from electronic health records that focus on the appropriate treatment of hospitalized patients with uncomplicated CAP. eCQMs are designed to assess the quality of care provided to patients. University of Utah researchers submitted the quality measures to the Partnership for Quality Measurement and received "endorsed with conditions" status in April 2025.

More information on the two quality measures can be found here:

• Inappropriately Broad Selection for CAP eCQM
• Excess Duration for CAP eCQM

CDC reported that general dentists continue to prescribe more than 10% of all antibiotics in the outpatient setting. Dental prescribing rates remained unchanged from 2018 to 2022 despite clinical practice guidelines meant to improve antibiotic use in dentistry.2 CDC developed resources to support appropriate antibiotic prescribing in the dental setting, including:

• A guide summarizing the American Dental Association's current recommendations for treating patients with dental pain and swelling.

• A checklist outlining best practices for antibiotic prescribing in dentistry.

• Resources for dental stewardship implementation and an annual dental stewardship summit. with post-conference recordings to enhance dissemination of educational content developed by the Association for Dental Safety with support from CDC.

• Strategies dentists can use to improve patient safety by optimizing antibiotic prescribing as discussed by Dr. Erinne Kennedy on CDC's Safe Healthcare Blog.

Outpatient antibiotic use

National outpatient antibiotic prescriptions dispensed in U.S. retail pharmacies are reported yearly by state, age, sex, and antibiotic class to characterize prescribing trends and inform antibiotic stewardship interventions. In 2024, the overall antibiotic prescribing rate was 752 prescriptions per 1,000 patient population, reflecting a 1% decline from 2023.

Outpatient prescribing rate of all classes by state 2024

This map displays outpatient prescription rates of all classes by state in 2024.

Outpatient antibiotic prescribing data for Medicare Part D enrollees shared publicly by the Centers for Medicare & Medicaid Services (CMS) are also reported by state, geographic region, antibiotic class and prescriber specialty. Outpatient antibiotic prescribing rates differ by prescriber specialty and can vary across states based on local prescribing patterns.

In 2022, family practice, nurse practitioner, and internal medicine clinicians prescribed 52% of the antibiotic prescriptions among Medicare Part D beneficiaries. Engagement with professional societies for specialties with the highest antibiotic prescribing rates provides an opportunity to promote more judicious antibiotic use and improve quality of care.

Outpatient antibiotic prescription rates for Medicare Part D beneficiaries by state

This map displays antibiotic prescription rates per 1,000 Medicare Part D beneficiaries across U.S.

Percentage of antibiotic prescriptions by prescriber specialty

This graph displays the percentage of outpatient antibiotic prescriptions by prescriber specialty.

Hospital antibiotic use

The Antimicrobial Use (AU) Option of the National Healthcare Safety Network (NHSN) is a resource for U.S. acute care hospitals to monitor and compare their antibiotic use data to other facilities. As of January 1, 2025, 4,362 acute care hospitals across the United States have submitted at least one month of data to the NHSN AU Option. While it is anticipated that the remaining hospitals in the United States will be onboard in 2025, hospitals that are already enrolled will continue to report to the NHSN AU Option to fulfill a Centers for Medicare & Medicaid Services (CMS) Promoting Interoperability Program measure requirement.

The Standardized Antimicrobial Administration Ratio (SAAR) is a risk-adjusted summary measure available to hospitals participating in the NHSN AU Option. The SAARs were updated using 2023 data, and additional facilities and patient care locations were included. The 2024 AU Option Data Report features the updated SAAR data and provides a summary of SAAR distributions and antibiotic use for each SAAR category across adult, pediatric, and neonatal patient care locations. Data are also reported annually on the Antimicrobial Resistance and Patient Safety Portal, allowing users to explore and visualize SAAR distributions at both national and state levels.

SAAR data by state reporting all for adults in 2023

This map displays 2023 median SAAR values for all SAAR agent categories and SAAR populations.

Hospital Antibiotic Stewardship Core Elements and priorities

The implementation of antibiotic stewardship core elements in acute care hospitals is assessed through the NHSN Patient Safety Component Annual Hospital Survey. Hospital staff complete annual survey questions that assess the uptake of CDC's Core Elements. CDC reports the percentage of hospitals meeting the Core Elements by year and state. In 2024, the percentage of hospitals meeting all 7 core elements was 97%.

Changes over time in Hospital Antibiotic Stewardship

This graph shows the proportion of U.S. hospitals reporting seven Core Elements from 2013-2024.

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 stewardship programs. In 2024, the percentage of hospitals meeting all six Priorities was 16% and hospitals meeting five of the six Priorities was 36%.

Hospital Antibiotic Stewardship implementation by Priority Element

This graph shows the proportion of U.S. hospitals reporting each priority element in 2024

Long-term care antibiotic use

CDC updated resources to support tracking and reporting antibiotic use in long-term care settings. Beginner and advanced versions provide facility staff with an overview of data sources, data elements and antibiotics use measures. CDC is working with long-term care facilities and electronic health record vendors to develop a pilot evaluating the feasibility of reporting antibiotic use data electronically in long-term care settings.

NHSNColab | NHSN |CDC

Long-term care Antibiotic Stewardship Core Elements

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. CDC reports the percentage of long-term care facilities meeting the Core Elements by year and state. The percentage of long-term care facilities meeting all 7 Core Elements was 82% in 2024.

Long-term care Antibiotic Stewardship changes over time

This graph shows the proportion of long-term care facilities reporting Core Elements from 2016-2024.

Antibiotic Prescribing During Outpatient Telemedicine Visits Among Commercially-Insured Patients and Medicare Part D Beneficiaries, 20213

CDC looked at how antibiotics are prescribed during outpatient telemedicine visits for patients with private insurance or Medicare in 2021. Here are the key points:

• In 2021, 7% to 9% of outpatient visits during which antibiotics were prescribed were telemedicine visits.
• Antibiotic prescribing was common for respiratory conditions for which they are not needed, including acute bronchitis and viral upper respiratory infections.
• For sinusitis, about 75% of visits resulted in a prescription. Most patients with acute uncomplicated sinusitis get better without antibiotics, showing there is room for improvement.

This analysis shows that there are opportunities for improving how antibiotics are prescribed in outpatient telemedicine, especially for respiratory conditions. Adapting antibiotic stewardship strategies to virtual visits is important to ensure that antibiotics are prescribed appropriately.

Trends in intravenous antimicrobial start rates in outpatient hemodialysis centers, United States, 2012-20214

Almost one in three people on hemodialysis receives an intravenous antibiotic each year, but nearly half of those antibiotics may not be necessary. A study using NHSN data looked at the trends in new intravenous antibiotics prescription rates for patients on hemodialysis. The important takeaways are:

• From January 2012 to March 2020, the adjusted rates of intravenous antibiotics decreased by nearly 7% each year, and then, during the COVID-19 pandemic, they decreased by ~9% annually until December 2021.
• People on hemodialysis with central venous catheters had much higher rates of receiving intravenous antibiotics compared to those with another type of access like a graft or fistula.

The decrease in antibiotic use rates may be due to greater awareness of infection prevention practices and better messaging on antibiotic stewardship in hemodialysis facilities, particularly during the COVID-19 pandemic. Evaluating how clinical factors contribute to antibiotic use can help support dialysis facility staff in using data reported to NHSN and help describe the impact of stewardship efforts.

Antibiotic and Opioid Prescribing for Medicare Part D Beneficiaries, 20215

Understanding high-volume co-prescribing of antibiotics and opioids by clinicians may help inform the development of initiatives that optimize prescribing practices. A study using 2021 Medicare Part D data describing antibiotics prescribed for older adults found:

• Out of 350, 890 prescribers, the top 10% of antibiotic prescribers by volume were responsible for 12.5 million (36%) antibiotic prescriptions, while the top 10% of opioid prescribers accounted for 22.3 million (52%) opioid prescriptions.
• It was common for clinicians who prescribed a high volume of antibiotics to also prescribe a high volume of opioids.
• Prescribers in the Southern United States and in rural areas were more likely to be high-volume prescribers of both types of medications compared to other regions and urban areas.

This study highlights the potential benefit of engaging with high-volume prescribers of antibiotics and opioids, particularly those prescribing for older adult patients and in rural areas.

Antibiotic and Antiviral Prescribing for Long-Term Care Residents with a COVID-19 Diagnosis, 2020-20236

A study looked at how antibiotics and antivirals were prescribed for long-term care residents with COVID-19 from March 1, 2020, to July 31, 2023, using electronic health record data. Key findings include:

• Prior to FDA authorization of oral antivirals for treatment of COVID-19 in December 2021, 23% of COVID-19 diagnoses were associated with an antibiotic order.

• After the authorizations in December 2021, this number dropped to 17%, while 18% were associated with an antiviral prescription.

These results suggest that the availability of an effective alternative to an antibiotic (i.e., antiviral) may have reduced the inclination to prescribe antibiotics. This highlights the need to improve treatment of viral infections by using appropriate antiviral therapy and avoiding unnecessary antibiotics.