Antimicrobial stewardship refers to coordinated programs that promote the appropriate use of antimicrobials (including antibiotics), improve patient outcomes, reduce microbial resistance, and decrease the spread of infections caused by multidrug-resistant organisms. The core elements of an effective ASP include leadership commitment, accountability, drug expertise, action, tracking, reporting, and education. Various healthcare facilities have developed innovative ASP models encompassing these core elements.

Many hospitals have implemented multidisciplinary antimicrobial stewardship teams or committees that meet regularly to review antimicrobial prescribing across the facility. These teams are usually composed of infectious diseases physicians, clinical pharmacists, microbiologists, infection preventionists, and other stakeholders. They monitor antibiotic use; review culture and susceptibility data; generate regular reports on antibiotic use and resistance patterns; develop evidence-based treatment guidelines, order forms, and preauthorization processes; and provide feedback to physicians on opportunities to optimize prescribing for individual patients.

For example, Mayo Clinic in Rochester, Minnesota has a longstanding and highly successful ASP led by an infectious diseases physician and antimicrobial stewardship pharmacist. They conduct prospective audit and feedback on all patients prescribed restricted or intravenous antibiotics, issue facility-wide guidelines and clinical pathways, and perform ongoing education, surveillance and process improvement. Multidrug-resistant organism infections have decreased substantially since the program’s inception in 1995.

Some health systems have implemented ASPs across all affiliated hospitals, clinics, and long-term care facilities in a coordinated manner. For example, Intermountain Healthcare in Utah consolidated its individual hospital ASPs in 2013 into a system-wide program with standard policies, order sets, reporting, and an inter-facility information-sharing infrastructure. Joint strategies are developed that consider resistance patterns and antibiotic use across the entire delivery network.

Several ASPs have also leveraged clinical decision support within electronic health record (EHR) systems. For instance, Johns Hopkins Hospital incorporates “best practice advisories” into physician order entry to prompt reviews of ongoing therapy need, narrowing of broad-spectrum drugs, and switches to oral step-downs. Many EHRs also interface with laboratory systems to automatically suspend non-ICU antibiotics if blood or urine cultures are finalized as negative after 48-72 hours.

Some innovative ambulatory ASP strategies involve primary care clinics. For example, primary care doctors at Kaiser Permanente Northern California can request real-time infectious diseases consultation for guidance on optimal outpatient antibiotic selections. Their ASP specialists also analyze prescribing patterns across clinics and develop quality improvement initiatives accordingly, focusing both on appropriate treatment and mitigating unnecessary use.

Several long-term care facilities have ASPs tailored to their residents. For instance, an ASP was implemented across 31 nursing homes in Sweden from 2014-2018. It focused on structured implementation of diagnostic and treatment algorithms, facilities-based guidelines, environmental improvements like antimicrobial stewardship rounds and education, and local and national reporting of antimicrobial usage and resistance data. Significant reductions were observed in nursing home antibiotic use and costs over the study period.

ASPs have also been initiated in dental practices and dialysis centers, given their extensive antibiotic exposure risk. They employ strategies like prescribing criteria, local guidelines, environmental cleaning enhancements and antimicrobial mouthwashes or prophylaxis as appropriate. Regular staff education is another core ASP activity in these outpatient specialty settings.

There are many organizational models for implementing successful ASPs to improve antibiotic prescribing across healthcare systems. The most impactful programs utilize multidisciplinary teams, real-time decision support, coordinated education, and standardized surveillance to drive culture and policy changes. With leadership commitment and the engagement of prescribers, ASPs have been shown to yield meaningful reductions in antibiotic overuse and resistance across both inpatient and outpatient care settings.