Hospital Antimicrobial Stewardship: Case, Team, Rollout, Metrics

1. Slide 1 · Antimicrobial Stewardship: Building Our Hospital Programme

   Antimicrobial Stewardship: Building Our Hospital Programme

   Why we need it, how to implement it, how we will measure success

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   Speaker notes

   Good morning, colleagues. Today I want to make a focused case for a formal antimicrobial stewardship programme in our hospital. I will not spend time on basic definitions; you all know the problem of resistance at the bedside. Instead, I will cover four things: the evidence that stewardship changes consumption and outcomes, who needs to be on the team, a realistic twelve-month implementation plan, and the metrics we will report. I will close with the specific decisions I am asking for. Please keep one question in mind throughout: what would it take for your own department to engage with this programme?

2. Slide 2 · Executive summary: stewardship cuts use, improves outcomes

   Executive summary: stewardship cuts use, improves outcomes

   ASPs associated with ~28% lower consumption and ~10% fewer prescriptions

   Guideline-adherent empirical therapy and de-escalation linked to lower mortality

   Core team: ID physician lead, ID pharmacist, microbiologist, IPC, data analyst

   12-month phased rollout, starting with ICU and high-consumption wards

   Today's ask: mandate, protected staff time, IT and rapid diagnostics funding

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   Speaker notes

   Let me start with the bottom line. A 2023 meta-analysis of 52 studies, about 1.8 million patients, associated stewardship programmes with a 28% reduction in antibiotic consumption and a 10% reduction in prescriptions. A Lancet Infectious Diseases meta-analysis linked guideline-adherent empirical therapy and de-escalation to lower mortality, though the evidence quality is generally low. The programme needs a small multidisciplinary core team and a phased rollout over twelve months. What I need from leadership is a formal mandate, protected time for key staff, and investment in IT and rapid diagnostics. Everything that follows supports these points.

3. Slide 3 · Evidence: stewardship delivers measurable impact

   Evidence: stewardship delivers measurable impact

   −28%

   Antibiotic consumption (DDD/100 patient-days) associated with ASPs

   −10%

   Proportion of patients receiving an antibiotic prescription

   −35%

   Relative mortality reduction with guideline-adherent empirical therapy

   −29 h

   Time to optimal therapy in bacteraemia: rapid diagnostics + ASP vs culture alone

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   Speaker notes

   These four numbers frame the business case. Consumption falls by roughly a quarter, and fewer patients are started on antibiotics at all. On outcomes, guideline-adherent empirical therapy carried a 35% relative risk reduction in mortality, and de-escalation an even larger 56%, but remember these are mostly observational studies with substantial heterogeneity, so treat them as direction, not precision. The bloodstream infection data are striking: rapid diagnostics only reduced mortality when coupled with stewardship, with an odds ratio of 0.72, and time to optimal therapy fell by 29 hours. The lesson: technology without a team does not deliver.

4. Slide 4 · Core team: clear roles and accountability

   Core team: clear roles and accountability

   Role	Core responsibilities	Accountable for
   ID physician (programme lead)	Audit and feedback, bedside consults, local guidelines	Clinical quality, prescriber engagement
   Clinical (ID) pharmacist	Restricted-agent review, IV-to-PO, TDM, dose optimisation	Process metrics, intervention log
   Clinical microbiologist	Antibiogram, rapid diagnostics, selective susceptibility reporting	Turnaround time, resistance data
   Infection prevention and control	C. difficile and MDRO surveillance, outbreak linkage	HAI and MDRO rates
   IT / data analyst	EHR alerts, DOT and DASC dashboards	Timely, reliable reporting
   Executive sponsor and ward champions	Mandate, resources, local adoption	Budget, policy enforcement

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   Speaker notes

   Stewardship succeeds or fails on people. The two non-negotiable roles are an infectious diseases physician who leads, and a clinical pharmacist with ID training who does most of the daily review. Microbiology is the engine of de-escalation, so turnaround time and selective reporting matter. Infection prevention links prescribing to C. difficile and MDRO transmission. Do not underestimate the data analyst: without automated reporting, the team spends its time on spreadsheets rather than patients. Finally, each high-consumption ward needs a named physician champion. A practical tip: put the lead's accountability in writing, reporting to the medical board, not just to pharmacy.

5. Slide 5 · Two core strategies: front-end and back-end

   Two core strategies: front-end and back-end

   Front-end: restriction and preauthorisation

   Restricted list for Reserve and selected Watch agents, e.g. carbapenems, colistin

   Immediate control over broad-spectrum starts

   Needs 24/7 approval access to avoid delayed first doses

   Restricted-list use linked to benefit in meta-analysis

   Back-end: prospective audit and feedback

   Day 2–3 review of targeted regimens with culture results

   Drives de-escalation, IV-to-PO switch and shorter durations

   High acceptance: 90% of recommendations implemented in one programme

   Preserves prescriber autonomy but demands more staff time

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   Speaker notes

   There are two classic levers and we will use both. Front-end restriction gives immediate control over the agents that drive resistance, but it has a real safety risk if approval is slow at night, so we will allow a first dose before approval in sepsis. Back-end audit and feedback is where most of the clinical value sits: reviewing regimens around day three, once cultures are back, is the natural point to de-escalate, switch to oral or set a stop date. In an obstetric programme, nine out of ten recommendations were accepted. My tip: deliver feedback in person on rounds, not only through electronic notes.

6. Slide 6 · High-yield interventions prioritised by evidence

   High-yield interventions prioritised by evidence

   Intervention	Evidence signal	Phase
   Guideline-adherent empirical therapy	Mortality RR 0.65 (low-quality evidence)	Phase 1
   De-escalation around day 3	Mortality RR 0.44 (low-quality evidence)	Phase 1
   IV-to-oral switch, TDM, bedside consults	Benefit on ≥1 of outcomes, adverse events, cost, resistance	Phase 1
   Surgical prophylaxis audit and feedback	Improved protocol adherence in 85.7% of studies	Phase 1
   Rapid diagnostics + ASP in bacteraemia	Mortality OR 0.72 vs blood culture alone	Phase 2
   ED stewardship per ESCMID 2024	Biomarkers, blood cultures, delayed prescribing, culture follow-up	Phase 2

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   Speaker notes

   Not every intervention is equal, so we will sequence by evidence and effort. Phase one covers low-cost, high-yield actions: local empirical guidelines, structured day-three de-escalation, IV-to-oral switch, therapeutic drug monitoring, and surgical prophylaxis audit, where stewardship improved adherence in most studies, although study quality was low to very low. Phase two adds capital-dependent pieces: rapid blood-culture diagnostics, which only showed a survival benefit when paired with an active stewardship team, and emergency department stewardship following the 2024 ESCMID guideline, including structured follow-up of cultures pending at discharge. This sequencing lets us show early results before asking for larger investment.

7. Slide 7 · 12-month phased implementation roadmap

   12-month phased implementation roadmap

   Months 0–6: foundation

   Leadership mandate and ASP charter reporting to medical board

   Baseline point-prevalence survey plus DOT/DDD extraction

   Local guidelines for top syndromes; restricted list live

   Audit and feedback in ICU, haematology and surgery

   Months 6–12: scale and optimise

   Rapid blood-culture diagnostics with real-time ASP alerting

   Extend to ED, including post-discharge culture follow-up

   EHR time-outs, IV-to-PO prompts, automatic stop dates

   Quarterly ward-level feedback and internal benchmarking

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   Speaker notes

   Here is the timeline. The first six months are about foundations: a charter that gives the team authority, a baseline point-prevalence survey so we know where we start, local guidelines for the syndromes that drive most use, such as pneumonia, urinary and intra-abdominal infection, and audit and feedback in the three highest-consuming areas. In the second half we scale: rapid diagnostics, the emergency department, and EHR automation. The main risks are well documented internationally: limited funding, weak IT infrastructure, poor data access and workforce shortages. Each of those maps directly onto a decision I will ask for shortly.

8. Slide 8 · Metrics dashboard: consumption, process, outcomes

   Metrics dashboard: consumption, process, outcomes

   Domain	Metric	Comment
   Consumption	DOT per 1,000 days present; DDD per 100 bed-days	DOT needs patient-level IT data; DDD enables WHO benchmarking
   Spectrum	DASC; AWaRe Access vs Watch/Reserve share	Captures narrowing that DOT alone misses
   Process	Guideline adherence, day-3 de-escalation, IV-to-PO, acceptance rate	Point-prevalence surveys and intervention logs
   Clinical outcomes	C. difficile incidence, mortality, LOS, readmissions	Shift focus from cost to clinical impact
   Resistance	MDRO incidence, antibiogram trends	Lagging indicator; reversal may take years
   Financial	Antimicrobial spend per patient-day	Report annually to the board

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   Speaker notes

   What gets measured gets managed, but we must measure the right things. Days of therapy per thousand days present is our primary consumption metric; DDDs remain useful for WHO-style comparisons. DOT alone can mislead, because a hospital can use fewer days of very broad agents, so we will add a spectrum measure such as DASC and the WHO AWaRe split. Process measures tell us whether the interventions are happening. For the board, the emphasis should move from savings to clinical outcomes. Be patient with resistance: it is a lagging indicator, and collateral damage can persist for years after consumption falls.

9. Slide 9 · Decisions requested from leadership today

   Decisions requested from leadership today

   Approve ASP charter with authority over restricted antimicrobials

   Fund protected time for ID physician lead and ID pharmacist

   Prioritise IT: EHR alerts, DOT/DASC dashboard, microbiology integration

   Invest in rapid blood-culture diagnostics tied to ASP review

   Endorse KPI set and quarterly reporting to the medical board

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   Speaker notes

   So here are the five decisions. First, a charter that gives the team real authority, including restriction of reserve agents. Second, protected time: stewardship done in the margins of a clinical job does not survive. Third, IT, because inadequate infrastructure and data access are among the most frequently reported barriers. Fourth, rapid diagnostics, but only coupled to active stewardship review, since that is where the survival benefit appeared. Fifth, endorsement of the metrics so we report against agreed targets every quarter. If we approve these today, the baseline survey can start next month and you will see the first dashboard within one quarter.

10. Slide 10 · References

    References

    1. 1.Zay Ya K, Win PTN, Bielicki J, et al. Association Between Antimicrobial Stewardship Programs and Antibiotic Use Globally: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2023. doi:10.1001/jamanetworkopen.2022.53806
    2. 2.Schuts EC, Hulscher MEJL, Mouton JW, et al. Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Lancet Infect Dis. 2016. doi:10.1016/S1473-3099(16)00065-7
    3. 3.Peri AM, Chatfield MD, Ling W, et al. Rapid Diagnostic Tests and Antimicrobial Stewardship Programs for the Management of Bloodstream Infection: What Is Their Relative Contribution to Improving Clinical Outcomes? A Systematic Review and Network Meta-analysis. Clin Infect Dis. 2024. doi:10.1093/cid/ciae234
    4. 4.Tamma PD, Cosgrove SE. Antimicrobial stewardship. Infect Dis Clin North Am. 2011. doi:10.1016/j.idc.2010.11.011
    5. 5.Masterton RG. Antibiotic de-escalation. Crit Care Clin. 2011. doi:10.1016/j.ccc.2010.09.009
    6. 6.Wong JMH, Wooding DJ, Leung SE, et al. Establishing obstetrics-specific metrics and interventions for antimicrobial stewardship. J Assoc Med Microbiol Infect Dis Can. 2023. doi:10.3138/jammi-2022-0032
    7. 7.Martinez-Sobalvarro JV, Júnior AAP, Pereira LB, et al. Antimicrobial stewardship for surgical antibiotic prophylaxis and surgical site infections: a systematic review. Int J Clin Pharm. 2022. doi:10.1007/s11096-021-01358-4
    8. 8.Schoffelen T, Papan C, Carrara E, et al. European society of clinical microbiology and infectious diseases guidelines for antimicrobial stewardship in emergency departments (endorsed by European association of hospital pharmacists). Clin Microbiol Infect. 2024. doi:10.1016/j.cmi.2024.05.014
    9. 9.Mudenda S, Chizimu JY, Daka V, et al. Antimicrobial Stewardship Program Implementation, Perceptions, and Barriers in Zambia: A Cross-Sectional Study Among Healthcare Professionals. Antibiotics (Basel). 2025. doi:10.3390/antibiotics14111094
    10. 10.Brotherton AL. Metrics of Antimicrobial Stewardship Programs. Med Clin North Am. 2018. doi:10.1016/j.mcna.2018.05.008
    11. 11.Kakiuchi S, Livorsi DJ, Perencevich EN, et al. Days of Antibiotic Spectrum Coverage: A Novel Metric for Inpatient Antibiotic Consumption. Clin Infect Dis. 2022. doi:10.1093/cid/ciab1034
    12. 12.Cižman M, Plankar Srovin T. Antibiotic consumption and resistance of gram-negative pathogens (collateral damage). GMS Infect Dis. 2018. doi:10.3205/id000040
    13. 13.Durlak U, Kapturkiewicz C, Różańska A, et al. Is Antimicrobial Stewardship Policy Effectively Implemented in Polish Hospitals? Results from Antibiotic Consumption Surveillance before and during the COVID-19 Pandemic. Antibiotics (Basel). 2024. doi:10.3390/antibiotics13070636

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11. Slide 11 · Questions and next steps

    Questions and next steps

    Stewardship is a patient-safety programme: mandate it, staff it, measure it

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    Speaker notes

    Thank you. To summarise in one sentence: stewardship is fundamentally a patient-safety programme that also reduces unnecessary consumption, and it works when it has a mandate, dedicated people and good data. I would welcome your questions, particularly from department heads about how audit and feedback will work on your wards, and from finance about the investment profile. After this meeting, I will circulate the draft charter and the proposed KPI definitions for comments within two weeks, so that we can move straight into the baseline point-prevalence survey.

This presentation was generated automatically to show what Doctoria can do and has not been reviewed as clinical guidance. Clinical cases in the examples are fictional.