Source: Antimicrobial Stewardship in Australian Hospitals(2011)

1.- Structure and governance

  • The overall accountability for antimicrobial management control lies with the hospital administration. They are responsible for ensuring an antimicrobial management program is developed and implemented, and outcomes are evaluated.

  • Hospital management support is needed, including:
  1. providing dedicated resources for stewardship activities, education, and measuring and monitoring antimicrobial use
  2. establishing a multidisciplinary AMS team with core membership (wherever possible) of either an infectious diseases physician, clinical microbiologist or nominated clinician (lead doctor), and a clinical pharmacist
  3. ensuring that AMS resides within the hospital’s quality improvement and patient safety governance structure, and clear lines of accountability exist between the chief executive; clinical governance; drug and therapeutics, and infection prevention and control committees; and the AMS team.

  • Antimicrobial stewardship teams have clearly defined links with the drug and therapeutics committee, infection prevention and control committee, and clinical governance or patient safety and quality units.

  • Team members have clearly defined roles and responsibilities. Team members should be sufficiently supported and trained to enable them to effectively and measurably optimize antimicrobial use by using interventions appropriate to local needs, resources and infrastructure.

  • Antimicrobial stewardship process and outcome indicators should be measured and reported to the hospital executive.

ASP_structure.jpg
Model for antimicrobial prescribing pathways in acute hospitals (Scotland). APP and P_Antimicrobial prescribing policy and practice. Source. Nathwani et al. JAC 2006;57:1189–1196

2.- The AS team


  • Multidisciplinary teams are better suited to implement the kind of improvement and change required for effective AMS.34 There are a range of professions and individuals that have an interest in and responsibility for AMS, each with different perspectives and skills.

  • Involving prescribers, pharmacists, administrators, infection control experts, information systems experts, microbiologists and ID physicians into a well-managed team effectively incorporates their views and expertise.

  • As a minimum, a multidisciplinary AMS team or committee should include (core team members)
  1. an appropriate clinician (a microbiologist or ID physician, if available
  2. and a clinical pharmacist (with ID training, if possible) as

  • Team membership should not be confined to those with professional expertise in antimicrobial usage. Evidence from quality improvement work suggests that effective improvement teams include members with three broad kinds of expertise and authority:
  1. a system leader who has the authority to institute change and overcome barriers (e.g. a senior member of clinical administration)
  2. an individual with technical expertise, such as an ID physician, pharmacist or microbiologist
  3. someone to provide day-to-day leadership with dedicated time allocation. This is the driver of the project who ensures implementation and performance measurement. An AS team comprised solely of technical experts is less likely to be able to effect change and improvement. In an AS team, this person could have one of a variety of professional backgrounds, including a pharmacist with training in quality improvement, or a member of the safety and quality team.

  • The AS team should establish links with existing committees or groups, have representation on the drug and therapeutics committee, and the infection prevention and control committee, and seek endorsement of the hospital executive for formal structural alignment

3.- The AS Plan


  • The AS team will have to develop clear aims and metrics that allow monitoring of improvements, and select changes to consider and test for implementation. See aims and indicators for AM Programs.

  • An AMS policy will need to be developed or updated to underpin these activities. The AMS team should consider whether to develop this policy as their first activity, or in parallel with investigating and testing changes aimed at improved prescribing.

  • As the policy development process can be a useful way to gain multidisciplinary input and engagement, initially focusing on this activity is likely to be particularly important if there has been little progress in AMS to date. However, AMS teams should try to avoid extremely prolonged policy development to the exclusion of other activities, as this will slow progress in developing and testing systems to directly inffuence antimicrobial prescribing.