• Innovation in Action

Aug 3, 2021

Antibiotic Stewardship Core Element 4: Actions to Support Optimal Antibiotic Use

Book about Antimicrobial stewardship (AMS)

Core Element 4 of the Antibiotic Stewardship Programs (ASP) series focuses on actions to support optimal antibiotic use. These actions include systematic evaluation of ongoing treatment need after a set period of initial treatment. Interventions should focus on your specific facility’s needs where evidence shows room for improvement, and they should have measurable outcomes monitored by the ASP and reported to hospital leadership and providers. 

Read through the examples of actions to support optimal antibiotic use below to see if your organization is on the right track. 

Basic (Systemwide Interventions) 
1  Policy for review of antibiotic orders for specified drugs by a physician or pharmacist based on local needs 
2  Require documentation of diagnosis/indication, drug, dose and duration for all antibiotic orders 
3  Establish guidance for antibiotic allergy assessment (e.g., penicillin allergy assessment protocol, including recommendations on which patients might benefit from skin testing) 
4  Develop facility-specific treatment recommendations based on national guidelines and local susceptibility data 
5  Standardize order forms for common clinical syndromes based on facility guidelines 
Intermediate (Patient-Specific Interventions) 
1  Establish a process to review antibiotics prescribed after 48-72 hours 
2  Establish guidance on automatic changes from IV to oral dosing in identified situations 
3  Establish guidance on dose adjustment for cases of organ dysfunction 
4  Develop dose optimization recommendations, especially for organisms with reduced susceptibility 
5  Automatic alerts for potentially duplicative drug therapy 
6  Implement time sensitive automatic stop orders for specified antibiotics (e.g., use of agents for surgical prophylaxis or empiric therapy) 
7  ASP works with the ICU to develop optimized antibiotic treatment protocols for possible sepsis cases 
8  Ensure that discussions of patient care (e.g., rounds) include information on antibiotics 
Advanced (Diagnosis- and Infection-Specific Interventions) 
1  Use real time rapid diagnostics such as pathogen identification assays (e.g., influenza and MRSA) and biomarkers (e.g., procalcitonin) to improve appropriate antibiotic use 
2  Assure timely and appropriate culture collection and transport 
3  Realize important evidence-based opportunities and methods to improve antibiotic use for several infections and situations, e.g.: 

  • community-acquired pneumonia 
  • urinary tract infections 
  • skin and soft tissue infections 
  • surgical prophylaxis 
  • surgical site infections 
  • empiric treatment of suspected MRSA 
  • critical evaluation of need for continued non-CDI antibiotic therapy in new cases of CDI 
  • culture-proven invasive infections (e.g., bloodstream) 
  • intra-abdominal infections 
  • sepsis 
  • S. aureus bacteremia (including central line) 
  • inappropriate use of antibiotics with overlapping spectra 
  • inappropriate treatment of culture contaminants 
  • inappropriate treatment of colonization 


Challenges to implementing actions to support optimal antibiotic use could include providers and ASP team feeling overwhelmed by the scope of interventions, resistance from providers to proposed interventions, providers being unaware of treatment recommendations and alert fatigue. The ASP can be prepared to deal with those obstacles using these solution ideas. 

  • Develop a priority matrix and start with one intervention based on the facility’s local needs and available data and guidance so that team members are not overwhelmed 
  • Assess antibiotic use to look for areas where there is clear evidence of need for improvement (e.g., evaluate most commonly seen or most severe infections to identify areas for improvement) 
  • Engage bedside nurses in ASP actions to help expand the stewardship workforce 
  • Provide provider-specific dashboards with deidentified peer group comparisons 
  • Partner with providers to determine the best ways to implement interventions into a normal workflow 
  • Participate in a regional/state collaborative to allow for peer benchmarking 
  • Implement clinical decision support (CDS) to ensure guidelines are easily accessible 
  • Embed CDS in the EHR with standardized antibiotic order sets 
  • Provide regular antibiotic stewardship to all relevant staff 
  • Ensure providers receive only the most important alerts 
  • Work with CDS developers to increase sensitivity and specificity of alerts 

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