Antimicrobial stewardship

Antimicrobial stewardship (AMS) refers to coordinated efforts to promote the optimal use of antimicrobial agents, including drug choice, dosing, route, and duration of administration.^[1][2] AMS has been an organized effort of specialists in infectious diseases, both in Internal Medicine and Pediatrics with their respective peer-organizations, hospital pharmacists, the public health community and their professional organizations since the late 1990s.

Every time an antimicrobial agent is used, it applies selection evolutionary pressure to microbial populations which can result in disruption to the normal microbiome (dysbiosis) as well as resistance to that agent, and even cross-resistance to other agents. Resistance can then spread to other microbes and to other host organisms. Antimicrobial agents can also have direct toxic effects on people and animals, including damage to kidneys, endocrine glands, liver, teeth and bones. Antimicrobial therapy is justified when the benefits outweigh these risks.

Contrary to popular belief, AMS does not aim to reduce the overall volume or frequency of antimicrobial use, although that often happens to occur with successful AMS interventions. The aims of AMS are to:

• reduce/eliminate any unnecessary applications of antimicrobials, i.e. to stem antimicrobial overuse, e.g. giving antibacterial drugs for viral infections, and thus antimicrobial resistance,
• ensure that human and animal patients who need antimicrobials receive the optimal drug for them, at the correct time, at an effective dose, via the correct route, for the minimum effective duration
• minimise environmental contamination with antimicrobial agents
• improving patient safety and reducing healthcare costs.

AMS interventions were first implemented in human hospitals, but have become increasingly common in every setting where antimicrobials are used, including primary care, aged care, dental care and veterinary medicine. Although AMS interventions often focus on prescribers, the general public also has an important role to play in AMS, in ensuring they always use and dispose of antimicrobials wisely.

AMS is a key focus of the World Health Organization and the World Organization for Animal Health.

In the U.S., within the context of physicians' prescribing freedom (choice of prescription drugs), AMS had largely been voluntary self-regulation in the form of policies and appeals to adhere to a prescribing self-discipline until 2017, when the Joint Commission prescribed that hospitals should have an Antimicrobial Stewardship team, which was expanded to the outpatient setting in 2020.

As of 2019, California and Missouri had made AMS programs mandatory by law.^[3][4]