---
title: Antimicrobial Stewardship
description: A comprehensive clinical reference on the principles and practices of antimicrobial stewardship programs in healthcare settings.
keywords: [antimicrobial stewardship, antibiotic resistance, antibiotic stewardship, antimicrobial resistance, infection control, antibiotic optimization]
category: clinical
---

## Introduction to Antimicrobial Stewardship

Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics, antifungals, antivirals, and antiparasitics) to improve patient outcomes, reduce antimicrobial resistance, and decrease the spread of infections caused by multidrug-resistant organisms. Effective antimicrobial stewardship involves a multidisciplinary team approach to ensure the judicious use of antimicrobials across all healthcare settings.

## Core Principles of Antimicrobial Stewardship

The core principles of antimicrobial stewardship include:
1. Appropriate antimicrobial selection: Selecting the right antimicrobial agent, dose, duration, and route of administration based on the suspected or confirmed pathogen, patient factors, and institutional susceptibility patterns.
2. Antimicrobial de-escalation: Narrowing the spectrum of antimicrobial coverage once the causative pathogen is identified or when clinical improvement is observed.
3. Antimicrobial discontinuation: Stopping antimicrobial therapy when the infection has resolved or when continued use is not clinically indicated.
4. Antimicrobial dose optimization: Adjusting antimicrobial doses and dosing intervals to maximize efficacy and minimize toxicity based on patient-specific factors, such as renal function and pharmacokinetic/pharmacodynamic properties of the antimicrobial.
5. Antimicrobial cycling and rotation: Periodically changing the antimicrobial agents used within a healthcare facility to prevent the emergence of resistant pathogens.

## Antimicrobial Stewardship Interventions

Effective antimicrobial stewardship programs employ a variety of interventions, including:
1. Prospective audit and feedback: The antimicrobial stewardship team reviews the appropriateness of antimicrobial therapy and provides real-time feedback to prescribers.
2. Preauthorization requirements: Certain antimicrobials may require approval from the antimicrobial stewardship team before they can be prescribed.
3. Clinical decision support: Providing clinicians with evidence-based guidelines, treatment algorithms, and decision-support tools to guide antimicrobial prescribing.
4. Antimicrobial restriction and formulary management: Limiting the availability of certain antimicrobials or requiring justification for their use.
5. Educational initiatives: Providing ongoing education and training to healthcare providers on antimicrobial stewardship principles and best practices.

## Antimicrobial Resistance Monitoring and Surveillance

Effective antimicrobial stewardship programs rely on robust antimicrobial resistance monitoring and surveillance systems. This includes:
1. Tracking antimicrobial resistance patterns within the healthcare facility, including the prevalence of multidrug-resistant organisms.
2. Monitoring antimicrobial utilization and consumption data to identify areas for improvement.
3. Participating in national and regional antimicrobial resistance surveillance networks, such as the National Healthcare Safety Network (NHSN) and the Antimicrobial Resistance Monitoring System (ARMS).
4. Regularly reviewing and updating antimicrobial susceptibility data to guide empiric antimicrobial therapy.

## Antimicrobial Stewardship in Specific Clinical Scenarios

Antimicrobial stewardship principles can be applied in various clinical scenarios, including:
1. Sepsis and septic shock: The Surviving Sepsis Campaign guidelines recommend early administration of appropriate antimicrobial therapy, with de-escalation based on culture results and clinical response. The qSOFA (quick Sequential Organ Failure Assessment) score can be used to identify patients at high risk of poor outcomes.
2. Community-acquired pneumonia: The CURB-65 (Confusion, Urea, Respiratory rate, Blood pressure, Age ≥65 years) score can guide the initial antibiotic selection and duration of therapy. The GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines provide recommendations for antimicrobial therapy in acute exacerbations of COPD.
3. Urinary tract infections: The IDSA (Infectious Diseases Society of America) guidelines recommend using narrow-spectrum antibiotics, such as nitrofurantoin or fosfomycin, as first-line therapy for uncomplicated cystitis. The KDIGO (Kidney Disease: Improving Global Outcomes) guidelines provide guidance on antimicrobial therapy for acute pyelonephritis.
4. Clostridioides difficile infection: The IDSA/SHEA (Society for Healthcare Epidemiology of America) guidelines recommend the use of oral vancomycin or fidaxomicin as first-line treatment for CDI, with consideration of bezlotoxumab for patients at high risk of recurrence.

## Antimicrobial Stewardship Outcomes and Metrics

Antimicrobial stewardship programs should regularly monitor and report on key outcomes and metrics, including:
1. Antimicrobial consumption: Measuring the volume and appropriateness of antimicrobial use, such as defined daily doses (DDDs) per 1,000 patient-days.
2. Antimicrobial resistance rates: Tracking the incidence of multidrug-resistant organisms and the impact of stewardship interventions on resistance patterns.
3. Patient outcomes: Assessing the impact of antimicrobial stewardship on clinical outcomes, such as length of stay, mortality, and adverse drug events.
4. Cost savings: Estimating the cost savings associated with reduced antimicrobial use and prevention of antimicrobial-resistant infections.

Effective antimicrobial stewardship programs should be multidisciplinary, data-driven, and continuously evolving to address the changing needs of the healthcare facility and the challenges of antimicrobial resistance.