Although the need of reducing outpatient antibiotic usage is recognized, no comprehensive recommendations to reduce use in this environment have been developed due to a lack of evidence to guide such efforts. Because the majority (80%) of antibiotic use occurred in the community, a targeted application of antimicrobial stewardship (AMS) principles to the ambulatory setting had the potential to affect the most common indications for systemic antibiotic use, with acute respiratory tract infections being the most common indication.

However, the reasons for the excessive prescription of antibiotics in the community are complex and include consultation time constraints, a lack of understanding of the impact on resistance, significant diagnostic uncertainty, and, perhaps most importantly, patient and parental pressures combined with patient satisfaction surveys. In contrast to institutionalized AMS, few suggestions were made for outpatients, owing to a lack of evidence on effective strategies to address such complicated difficulties in ambulatory care. Antibiotic medications for individuals with self-limiting diseases were unhelpful because they perpetuated the assumption that antibiotics were useful and stimulated repeat prescriptions and consultations. 

As a result, “de medicalization” of self-limiting acute illnesses should be one of the ultimate aims of a community AMS program. In this context, after addressing local impediments to change, multidimensional treatments involving educational interventions on several levels might be successfully deployed to communities. These appear to be the only therapies with large enough effect sizes to lower the prevalence of antibiotic-resistant microorganisms.