What do clinical guidelines say about antibiotic stewardship in primary care?

The Four Core Elements (CDC Framework)

The CDC's 2016 Core Elements of Outpatient Antibiotic Stewardship remains the most widely referenced framework for primary care stewardship and is applicable across outpatient settings:

1. Commitment: demonstrate leadership dedication to optimising prescribing and patient safety
2. Action: implement at least one policy or practice to improve prescribing, assess its effectiveness, and modify as needed
3. Tracking and reporting: monitor prescribing practices and provide regular feedback to clinicians
4. Education and expertise: provide educational resources to clinicians and patients, and ensure access to expertise on optimising prescribing

An updated version of the Outpatient Core Elements is expected in 2026, with emphasis on the role of health system leadership in supporting stewardship program development.

Practical Strategies for General Practice

Prescribing Interventions

• Use evidence-based diagnostic criteria and treatment recommendations (e.g. eTG Antibiotic in Australia)
• Employ delayed prescribing or watchful waiting when appropriate, particularly for acute respiratory tract infections
• Require explicit written justification in the medical record for non-guideline antibiotic prescriptions
• Integrate clinical decision support into electronic health records to prompt guideline-concordant prescribing

Communication and Patient Education

• Provide consistent messaging from front-desk to clinician that viral infections will not result in antibiotic prescriptions
• Use patient information leaflets and shared decision-making resources, which have been shown to reduce unnecessary prescribing
• Communication skills training for clinicians is recommended to help manage patient expectations

Point-of-Care Testing

• Point-of-care CRP testing is receiving increasing attention as a clinically and cost-effective AMS tool that helps clinicians determine whether patients are likely to benefit from antibiotics

Monitoring and Feedback

• Regular audit and feedback of antibiotic prescribing rates to individual clinicians is a core component of effective stewardship programs
• In Australia, the Practice Incentives Program (PIP) Quality Improvement incentive supports AMS activities in general practice

Australian Context

Australia's National Antimicrobial Resistance Strategy (2015) calls for the introduction of AMS across all healthcare sectors, including primary care. Key Australian-specific considerations include:

• Therapeutic Guidelines: Antibiotic (eTG) is the nationally endorsed evidence-based prescribing guideline for general practice
• PBS restrictions on certain antibiotics (notably azithromycin and other macrolides) serve as a structural stewardship measure limiting inappropriate broad-spectrum prescribing
• The ACSQHC (Australian Commission on Safety and Quality in Health Care) has published guidance on AMS implementation in Australian health care
• Collaborative models between GPs and pharmacists are being developed to strengthen AMS in Australian primary care

Summary Table