Antibiotic Use and Stewardship in the United States, 2024 Update: Progress and Opportunities

National outpatient antibiotic prescriptions dispensed in U.S. retail pharmacies are reported yearly from the IQVIA® Xponent database by state, age, sex and antibiotic class.

The total antibiotic use rate in 2023 was 756 prescriptions per 1,000 population.

Outpatient prescription data for all antibiotic classes

Visualize and download data on outpatient prescription rates of all antibiotic classes dispensed in the United States.

Prescribing during 2022 achieves WHO AWaRe classification goals

The World Health Organization (WHO) Expert Committee on Selection and Use of Essential Medicines classifies antimicrobials into three groups (Access, Watch, and Reserve), which consider the impact of antibiotics on the development of antimicrobial resistance and emphasizes the importance of their appropriate use. The WHO 13^th Program of Work established a goal that at least 60% of all antibiotics used are in the Access category.

• In 2022, outpatient antibiotic prescribing in the United States exceeded this target by 10.5% (70.5%).
• Also in 2022, 29.5% of antibiotic prescriptions were from the Watch category, and 0.08% were from the Reserve category.

Agents commonly prescribed from the Watch category (e.g., azithromycin, cefdinir, and ciprofloxacin) remain important targets for ongoing antibiotic stewardship efforts.

Prescriptions among Medicare Part D Beneficiaries during 2017-2022

Outpatient antibiotic prescribing utilizes publicly available data by the Centers for Medicare & Medicaid Services (CMS). The population eligible for Medicare Part D enrollment includes adults ages ≥65 years and adults ages <65 years with qualifying disabilities (13-16%). Antibiotic prescribing by state, geographic region and prescriber specialty are included and will be updated yearly.

Antibiotic use

The Antimicrobial Use (AU) Option of the National Healthcare Safety Network (NHSN) is a resource to monitor and benchmark antibiotic use in U.S. acute care hospitals. The Standardized Antimicrobial Administration Ratio (SAAR) is a risk-adjusted summary measure available to hospitals participating in the NHSN AU Option and posted yearly by state, population and agent category.

In 2023, 3,153 acute care hospitals across the United States have submitted at least one month of data to the NHSN AU Option. In the coming years, more hospitals will be reporting to the NSHN AU Option through CMS's Promoting Interoperability Program.

CDC authors outlined how expanded reporting and access to antibiotic use data can identify where prescribing can be improved and provide benchmarks for antibiotic stewardship programs. Enabling regional and national comparisons of antibiotic use, while taking into account antimicrobial resistance and healthcare-associated infection data, will help inform, implement and assess stewardship interventions.1

Inpatient SAAR data for adults

Visualize and download data on inpatient antibiotic use and SAAR in the United States.

Hospital Antibiotic Stewardship Core Elements and Priorities

CDC's Core Elements of Hospital Antibiotic Stewardship provides a framework for the implementation of antibiotic stewardship programs (ASPs). The implementation of antibiotic stewardship programs in acute care hospitals is assessed through the NHSN Patient Safety Component Annual Hospital Survey. Staff in hospitals 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.

• The percentage of hospitals meeting all 7 Core Elements increased from 41% in 2014 to 96% in 2023.

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 ASPs.

Priorities are a subset of effective antibiotic stewardship implementation approaches identified in six of the seven Hospital Core Elements. The Priorities are supported by evidence and/or recommended by antibiotic stewardship experts.

In 2023, the percentage of hospitals meeting all six Priorities was 13% and hospitals meeting five of the six Priorities was 29%.

Antibiotic stewardship programs in acute care hospitals

Visualize and download data on antibiotic stewardship programs in acute care hospitals in the United States.

The NHSN Patient Safety Component Annual Hospital Survey questions from 2014 to 2021 were analyzed to evaluate specific antibiotic stewardship practices.

• Recommended practices which increased during this time period included listing antibiotic stewardship in program leaders' job descriptions, programs co-led by a physician and pharmacist, and audit and feedback interventions.2

National prescribing rates

CDC analyzed antibiotic dispense data from long-term care pharmacies from 2013 to 2021.

• The percent of residents receiving at least one antibiotic each year decreased from 51% in 2013 to 44% in 2021.
• Fluoroquinolone and macrolide prescribing decreased by 49% and 30% respectively, whereas tetracycline prescribing (e.g., doxycycline) increased by 56%.
• Regulatory requirements for antibiotic stewardship programs in long-term care facilities, safety concern for specific antimicrobial agents, and the COVID-19 pandemic may have contributed to these changes.3

Ongoing measurement of antimicrobial use in long-term care is critical to informing antibiotic stewardship efforts.

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. Staff who work in long-term care facilities, including skilled nursing facilities/nursing homes, complete annual surveys. 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 increased from 43% in 2016 to 82% in 2023.

Uptake of Core Elements in long-term care facilities

Visualize and download data on uptake of the Core Elements in long-term care facilities in the United States.

Implementation between 2019-2022

In 2022, most facilities completing the NHSN long-term care annual facility survey reported having access to electronic health records, with medication order and medication administration capabilities.

• Tracking antibiotic use was performed using manual tracking (48%), electronic health records (31%), and pharmacy data (25%).
• Electronic reporting of antibiotic use may help reduce burden on long-term care staff and provide standardized AU reports for identifying improvement opportunities and assessing the intervention effectiveness.4

CDC characterized antibiotic prescribing by general dentists during 2018–2022 to assess whether antibiotic use changed after the release of American Dental Association (ADA) guidelines for the treatment of dental pain and swelling in 2019. The results highlight the importance of antibiotic stewardship in the dental setting.

• Despite evidence of opportunities to improve antibiotic use and the release of the ADA guidelines, total antibiotic prescribing by general dentists remained relatively stable during 2018–2022.
• Meanwhile, general dentists' relative share of all outpatient antibiotic prescriptions increased to over 10% in recent years.5

CDC examined antibiotic prescribing patterns for outpatient visits for acute sinusitis among privately-insured adults <65. The study emphasizes the opportunity to improve antibiotic prescribing for acute sinusitis in adults, especially in rural and urgent care settings.

• Approximately 30% of patient encounters resulted in antibiotic prescriptions that weren't consistent with clinical practice guideline recommendations.
• A large portion of first- (75%) and second-line (63%) agents prescribed exceeded the recommended duration for therapy.
• People living in rural areas or seeking care in urgent care settings were less likely to receive antibiotic prescriptions consistent with guideline recommendations.6

• Multiplex molecular syndromic panels are rapid diagnostic assays that can detect multiple bacteria and antimicrobial resistance genes simultaneously. This increased test sensitivity can make clinical decision-making more complex because test results do not reliably predict whether bacteria, pathogens, and resistance genes are the causes of a disease.
• Multiplex molecular panels for the diagnosis of urinary tract infections (UTIs) lack clinical data supporting their use in routine clinical care. They also have the potential to exacerbate inappropriate antibiotic use.
• The number of Medicare claims for multiplex molecular tests for urinary tract infections increased over a 50-fold between 2016-2023.
• The median cost of multiplex testing is over 70 times higher than the median cost of a urine culture, which are recommended by clinical guidelines for the diagnosis of urinary tract infections.7

CDC's Core Elements of Hospital Diagnostic Excellence described key elements and actions to improve diagnosis of infections in the hospital.

Outpatient antibiotic prescribing volume (prescriptions per 1000 persons) was lower during 2020 to 2022 compared to 2019.

• However, CDC observed that antibiotic prescribing approached or exceeded this 2019 baseline in the last quarter of 2022 for all antibiotics, including for azithromycin, suggesting a return to antibiotic prescribing trends observed prior to the pandemic.
• Effective implementation of antibiotic stewardship combined with tracking of antibiotic prescribing are needed to optimize antibiotic use in outpatient settings following the COVID-19 pandemic.8

• From January 2019 through July 2022, although increases in antibiotic use were expected early in the pandemic while the incidence of secondary bacterial infections and antibiotic treatment benefits were unclear, rates of azithromycin and ceftriaxone use increased during each subsequent COVID-19 wave even though data emerged showing antibiotics provide no benefit.
• This emphasizes the need for effective communication and healthcare facility resiliency and support to maintain antibiotic stewardship program activities during pandemics.9

CDC described antibiotic use among U.S. adults discharged with a COVID-19 diagnosis from 711 hospitals between March 2020-June 2022.

• Despite a decrease in overall antibiotic use, most patients hospitalized with COVID-19 were started on antibiotics during their hospital admission (88.1%), regardless of critical care status.
• Since antibiotics do not treat COVID-19, this suggests that antibiotic use may be higher than necessary among patients with COVID-19, highlighting that more efforts are needed to optimize antibiotic therapy in hospitalized patients with COVID-19. 10