BSAC eBook cover - Antimicrobial stewardship from principles to practice
BSAC eBook cover

Principles of stewardship

There are two core, proactive, evidence-based strategies for antimicrobial stewardship.

  • Formulary restriction and pre-authorisation.
  • Prospective audit with intervention and feedback.

Formulary restriction and pre-authorisation

This involves:

  • Limiting the use of antimicrobials to approved indications.

  • The formation of an antimicrobial committee to create and initiate the use of antibiotic guidelines.

  • Designated personnel being made available for the approval process.

This leads to direct control over antimicrobial use at an institutional level and also provides educational opportunities for prescribers when a request is made.

The major challenge is that prescribers can have a perceived loss of autonomy when making clinical decisions. It is also time consuming as personnel need to be available for consultation at all times.

Prospective audit with intervention and feedback

This involves:

  • A daily review of targeted agents for appropriateness.

  • Follow-up interventions - these may involve contacting the prescriber to recommend alternative agents.

  • An antimicrobial committee to develop guidelines for appropriate use of targeted agents and personnel to perform the reviews and follow-up communication on a daily basis.

With this strategy, prescribers may not experience any perceived loss of autonomy, particularly if suggested changes by the reviewers are voluntary. It also allows opportunity for educating prescribers through follow-up.


These two interventions will help physicians adhere to prescribing guidelines and avoid overuse of antibiotics. Guidelines and regulations help to restrict or limit antibiotic prescribing while providing advice and feedback is an enabling measure to help physicians to make more targeted prescribing decisions.

There are however simpler and less intense tactics called “supplemental strategies” which can be used along with either of the core strategies or individually as low hanging fruit to initiate antimicrobial stewardship.

Supplemental strategies include:

  • Education

  • Guidelines and clinical pathways

  • Antimicrobial order forms

  • Streamlining or de-escalation

  • Dose optimisation

  • IV-to-PO switch

Please refer to the e-BOOK Chapter 9 The Stewardship Toolkit (part of “Antimicrobial Stewardship: From Principles to Practice”, in downloads below, and answer the following question:

What role can you play in your hospital or organisation as a/an:

  1. Clinician
  2. Medical microbiologist
  3. IPC professional
  4. Nurse
  5. Pharmacist
  6. Hospital epidemiologist
  7. Information system specialist
  8. ID physician
  9. Laboratory technician/technologist/scientist
  10. Other healthcare worker

If you would like the entire free eBook Antimicrobial Stewardship: From Principles to Practice you can request it here. You will be asked to fill in a form with your details and a contact email address. This email address will only be used for the purpose of sending a link to the pdf / epub. The BSAC full privacy policy is available here.

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