1. Epidemiology and Global Health
  2. Microbiology and Infectious Disease
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Potential impact of outpatient stewardship interventions on antibiotic exposures of common bacterial pathogens

  1. Christine Tedijanto  Is a corresponding author
  2. Yonatan H Grad
  3. Marc Lipsitch
  1. Harvard TH Chan School of Public Health, United States
Research Article
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Cite this article as: eLife 2020;9:e52307 doi: 10.7554/eLife.52307
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The relationship between antibiotic stewardship and population levels of antibiotic resistance remains unclear. In order to better understand shifts in selective pressure due to stewardship, we use publicly available data to estimate the effect of changes in prescribing on exposures to frequently used antibiotics experienced by potentially pathogenic bacteria that are asymptomatically colonizing the microbiome. We quantify this impact under four hypothetical stewardship strategies. In one scenario, we estimate that elimination of all unnecessary outpatient antibiotic use could avert 6 to 48% (IQR: 17 to 31%) of exposures across pairwise combinations of sixteen common antibiotics and nine bacterial pathogens. All scenarios demonstrate that stewardship interventions, facilitated by changes in clinician behavior and improved diagnostics, have the opportunity to broadly reduce antibiotic exposures across a range of potential pathogens. Concurrent approaches, such as vaccines aiming to reduce infection incidence, are needed to further decrease exposures occurring in 'necessary' contexts.

Data availability

Data from the 2015 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) are publicly available from the National Center for Health Statistics. This study also uses data from published literature, including the Human Microbiome Project and other studies summarized in Figure 1 - Source Data File 1.

The following previously published data sets were used

Article and author information

Author details

  1. Christine Tedijanto

    Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, United States
    For correspondence
    Competing interests
    No competing interests declared.
    ORCID icon "This ORCID iD identifies the author of this article:" 0000-0003-3403-5765
  2. Yonatan H Grad

    Department of Immunology and Infectious Diseases, Harvard TH Chan School of Public Health, Boston, United States
    Competing interests
    Yonatan H Grad, Has received consulting income from Merck and GlaxoSmithKline.
    ORCID icon "This ORCID iD identifies the author of this article:" 0000-0001-5646-1314
  3. Marc Lipsitch

    Department of Immunology and Infectious Diseases, Harvard TH Chan School of Public Health, Boston, United States
    Competing interests
    Marc Lipsitch, Reviewing editor, eLife.Has received consulting income from Affinivax, Antigen Discovery, Merck, and Pfizer and research grants through Harvard School of Public Health from Pfizer and PATH.
    ORCID icon "This ORCID iD identifies the author of this article:" 0000-0003-1504-9213


National Institute of General Medical Sciences (U54GM088558)

  • Marc Lipsitch

National Institute of Allergy and Infectious Diseases (R01AI132606)

  • Yonatan H Grad

Centers for Disease Control and Prevention (CK000538-01)

  • Marc Lipsitch

Doris Duke Charitable Foundation

  • Yonatan H Grad

National Institute of Allergy and Infectious Diseases (T32AI007535)

  • Christine Tedijanto

The funders had no role in study design, data collection and interpretation, or the decision to submit the work for publication.

Reviewing Editor

  1. Miles P Davenport, University of New South Wales, Australia

Publication history

  1. Received: September 29, 2019
  2. Accepted: January 28, 2020
  3. Accepted Manuscript published: February 5, 2020 (version 1)
  4. Version of Record published: February 17, 2020 (version 2)


© 2020, Tedijanto et al.

This article is distributed under the terms of the Creative Commons Attribution License permitting unrestricted use and redistribution provided that the original author and source are credited.


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