Antimicrobial Stewardship: guiding clinicians to reduce the Antimicrobial Resistance threat

The improper use of antimicrobials—ranging from unnecessary prescriptions to incorrect dosing and duration—is the leading cause of the rise in Antimicrobial Resistance (AMR) and Multi-Drug-Resistant Organisms (MDROs). These two bacterial defense mechanisms increase disease morbidity and mortality by making infections more complicated to treat. With projections indicating up to 10 million deaths annually by 2050, AMR could soon become the leading cause of death worldwide. For this reason, the World Health Organization (WHO) expressed concern and designated AMR as one of the top 10 global crises threatening the future of healthcare. 

Antimicrobial stewardship is a program conceived to assist and educate healthcare providers in counteracting this threat by promoting rational and judicious antimicrobial treatments. This program aims to prevent drug overuse and misuse and reduce microbial exposure to antimicrobials (including antibiotics, antifungals, antivirals, and antiparasitics), with the primary mission of slowing the development and spread of AMR. 

It was John McGowan and Dale Gerding who first introduced the concept of antimicrobial stewardship in 1996, suggesting a link between antimicrobial use and antimicrobial resistance. However, stewardship programs that resemble current interventions have been implemented since the 1970s.  

The Main Principles Driving Antimicrobial Stewardship  

The program primarily focuses on three principles that continually evolve to improve efficiency, expand reach, and implement innovative approaches to patient care. The right Drug, correct Dose, right Drug-route, suitable Duration, and timely De-escalation: these are the 5 “D’s” of antimicrobial therapy on which these principles are based. 

• Promote tailored, evidence-based antimicrobial use. The primary goal of the antimicrobial stewardship program is to promote evidence-based use of antimicrobials. It consists of two main components: conservation, which involves determining when and when not to use antimicrobials, and optimization. The latter involves considering how to use antimicrobials effectively. 

• Develop and distribute rapid diagnostic technologies. A quick diagnostic workflow is essential for guiding antimicrobial therapy. This rapidity can promote targeted, organism-specific therapy, reduce reliance on prolonged empirical antibiotic use, and enable earlier de-escalation or discontinuation of unnecessary antibiotics, improving patient outcomes and helping prevent resistance. Rapid diagnostic technologies, such as MALDI-TOF mass spectrometry, molecular biology techniques, AI, and automated antimicrobial susceptibility testing (AST), serve this scope: allow clinicians to identify pathogens and resistance patterns more quickly.  

• Minimize therapy duration. Longer antimicrobial treatments are a known factor in developing resistance. Stewardship efforts emphasize shorter, evidence-based treatment for many common infections.  

Joint Efforts for Common Objectives  

Antimicrobial stewardship must be an effective and efficient program. Thus, a collaborative, multidisciplinary approach is necessary, involving various healthcare professionals. The key contributors among these are:  

• Physicians, who guide antimicrobial selection, interpret microbiology results, and advise on complex cases involving resistant organisms.  

• Microbiologists. They ensure accurate and timely identification of pathogens and their susceptibility profiles, and work closely with clinicians to interpret results and recommend testing strategies.  

• Infection prevention and control teams, which reduce the spread of resistant organisms through surveillance, isolation protocols, education. They also collaborate with stewardship programs to manage outbreaks of MDROs.  
• Patients. Their involvement is often overlooked. Education about the risks of antibiotic misuse and the importance of completing prescribed courses enables patients to contribute actively to preventing antibiotic resistance.  

Antimicrobial Stewardship Tools and Supporting Technologies  

Novel technologies have the potential to improve the efficiency and effectiveness of Antimicrobial Stewardship programs. First, let’s consider data handling and interpretation: from electronic health records that enable real-time monitoring of antimicrobial prescriptions and patient outcomes to surveillance systems that track antimicrobial use and resistance trends at both the institutional and regional levels, these tools help identify emerging resistance patterns and facilitate prompt action when necessary.  

From a diagnostic perspective, rapid diagnostic tools can reduce the time needed for pathogen identification and susceptibility results. Of course, this can enable earlier specific therapy, de-escalation, or discontinuation of treatment. Rapid diagnostics for Antimicrobial Susceptibility Testing (AST) is the primary diagnostic assay that tests an antimicrobial agent’s ability to inhibit bacterial growth (in vitro under standardized conditions) to guide the selection of the best antimicrobial therapy for each patient. However, results typically take a few days after sampling, and when selecting the appropriate antibiotic is critical to prevent the emergence of MDROs and ensure patient survival, this delay cannot be overlooked. New EUCAST frameworks, rapid workflows, and automation have been developed specifically for this purpose: providing faster results than traditional manual methods, allowing for quicker therapy adjustments and potentially better patient outcomes.  

And that’s not all. Other emerging tools, such as telemedicine and AI-powered predictive analytics, aim to support Antimicrobial Stewardship by enabling remote consultations, identifying resistance patterns, forecasting outbreaks, and guiding personalized antibiotic therapies through the analysis of large-scale clinical and epidemiological data. AI also advances the development of diagnostic tools, reducing reliance on broad-spectrum antibiotics and enabling timely, targeted treatments. 

Antimicrobial Stewardship frameworks and programs 

Numerous international and national organizations have established guidelines and frameworks to support the implementation of effective stewardship programs:  

• World Health Organization (WHO). The WHO provides global guidance on antimicrobial stewardship, emphasizing the importance of developing national action plans and implementing integrated surveillance systems.  

• Centers for Disease Control and Prevention (CDC). The CDC’s Core Elements of Hospital Antibiotic Stewardship Programs outline essential components for successful stewardship. These include leadership commitment, accountability, drug expertise, action, tracking, reporting, and education. Additionally, this Organziation leads the Be Antibiotics Aware campaign. The goal? Improve antibiotic prescribing and use, and combat Antibiotic Resistance. 

• European Centre for Disease Prevention and Control (ECDC). The ECDC promotes prudent antibiotic use across Europe through initiatives such as European Antibiotic Awareness Day (held annually on November 18) and guidance on antimicrobial use in both human and veterinary medicine.  

Among other programs actively promoting Antimicrobial Stewardship, worth mentioning are the European Study Group for Antibiotic Policies, which promotes education and research activities on antimicrobial stewardship through an open virtual learning community, and ATLAS, a fully searchable database with antibacterial surveillance data from several international programs. ATLAS is a valuable resource in the fight against antibiotic-resistant infections, allowing physicians to evaluate data and perform complex analyses. 

Challenges and perspectives 

Concluding, integrating Antimicrobial Stewardship into routine clinical workflows enables healthcare institutions to reduce inappropriate antibiotic use and resistance-related costs, prevent the emergence of resistant pathogens, and enhance patient safety. Anyway, several challenges persist despite these evident benefits. These, for example, include scarce resources and limited access to diagnostics. Furthermore, although stewardship programs have proven to improve antibiotic use in developed countries, efforts to contain AMR have been unsuccessful in developing countries, making it urgent to establish, implement, and evaluate effective programs there.  

As traditional antibiotics lose effectiveness, responses to AMR must involve interventions at multiple levels. From infection prevention and treatment strategies to drug development, policy reform, and international collaboration, it all matters. Every healthcare professional plays a crucial role in combating AMR and building strong stewardship programs, whether in hospitals, community clinics, microbiology labs, or patients’ homes: it’s everyone’s responsibility. 

Bibliography 

• https://www.who.int/europe/activities/promoting-antimicrobial-stewardship-to-tackle-antimicrobial-resistance 

• Shrestha J, Zahra F, Cannady, Jr P. Antimicrobial Stewardship. 2023 Jun 20. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. 

• Yoo JH. Antimicrobial Resistance – The ‘Real’ Pandemic We Are Unaware Of, Yet Nearby. J Korean Med Sci. 2025 May 19;40(19):e161. 

• Majumder MAA, Rahman S, Cohall D, et al. Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public Health. Infect Drug Resist. 2020 Dec 29;13:4713-4738. 

• Pennisi F, Pinto A, Ricciardi GE, et al. The Role of Artificial Intelligence and Machine Learning Models in Antimicrobial Stewardship in Public Health: A Narrative Review. Antibiotics. 2025; 14(2):134 

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