Core Elements of an Antibiotic Stewardship Program

Core Elements of an Antibiotic Stewardship Program

Improving clinical outcomes with optimized antibiotic prescribing

Treating infections. Protecting patients. Antibiotic resistance. To achieve these goals, health leaders worldwide are driving the adoption of antibiotic stewardship programs that help clinicians improve the way they prescribe antibiotics. The result is not just reduced antibiotic resistance but also better clinical outcomes.1,2

First introduced in 2014 by the Centers for Disease Control and Prevention (CDC), the Core Elements of Hospital Antibiotic Stewardship Programs were updated in 2019 to incorporate new evidence and learnings across seven key areas: hospital leadership commitment, accountability, pharmacy expertise, action, tracking, reporting, and education.

While these elements are applicable in all hospitals, regardless of size, there is no single template for an antibiotic stewardship program that leads to optimal antibiotic prescribing. Programs are expected to be customized due to the complex medical decision-making surrounding antibiotic use and the differences in hospital size and care. But no matter what each hospital’s approach looks like, an effective antibiotic stewardship program is always attainable with the right mix of support, leadership, and commitment.

Hospital antibiotic stewardship programs can increase infection cure rates while reducing:2-4

  • Treatment failures
  • C. difficile (C. diff) infections
  • Adverse effects
  • Antibiotic resistance
  • Hospital costs and lengths of stay

The CDC's Core Elements of hospital antibiotic stewardship programs5

The CDC outlines seven core elements that provide basic framework for a successful antibiotic stewardship program.

  1. Hospital Leadership Commitment
    Dedicate necessary human, financial, and information technology resources.
  2. Accountability
    Appoint a leader or co-leaders, such as a physician and pharmacist, responsible for program management and outcomes.
  3. Pharmacy Expertise
    Appoint a pharmacist, ideally as the co-leader of the stewardship program, to lead implementation efforts to improve antibiotic use.
  4. Action
    Implement interventions, such as prospective audit and feedback or pre-authorization, to improve antibiotic use.
  5. Tracking
    Monitor antibiotic prescribing, impact of interventions, and other important outcomes such as C. diff infection and resistance patterns.
  6. Reporting
    Regularly report information on antibiotic use and resistance to prescribers, pharmacists, nurses, and hospital leadership.
  7. Education
    Educate prescribers, pharmacists, and nurses about adverse reactions from antibiotics, antibiotic resistance, and optimal prescribing.

Key to successful antibiotic stewardship programs—teamwork and support

The CDC’s Core Elements highlight the importance of teamwork in antibiotic stewardship success. Implementing a hospital-wide antibiotic stewardship program requires building a core team whose members have clearly defined expectations, as well as putting in place a critical support network. Here’s how to do it.

Establish a core team

Appoint a core team responsible and accountable for the program management and outcome. The composition of this team will depend on the resources available at each hospital, as not every role will be available in all hospitals. As the British Society for Antimicrobial Chemotherapy points out, the team should comprise at least one infectious disease physician, a clinical microbiologist, and a clinical pharmacist.6

Core team

Infectious disease physician

Clinical microbiologist

Clinical pharmacist


Optional members



Infectious control specialists

IT resources

Figure 10: Members of an ABS team (adapted from BSAC. Antimicrobial Stewardship: From Principles to Practice - eBook 2018)4

It’s especially important to engage hospitalists because they are among the largest groups of prescribers of antibiotics in hospitals.5 They also often have experience with quality-improvement work.7,8

Assign team members to complete these five essential steps every day

Set the expectation that on a daily basis, the antibiotic stewardship team will be responsible for the following tasks:

  • Consult on individual patient management at the request of clinicians.
  • Review prescriptions for antimicrobial therapy.
  • Advise on the optimization of antimicrobial therapy.
  • Promote conversion from intravenous medication to oral options.
  • Educate through formal teaching sessions or ad hoc education while on ward rounds.

Create a support network to ensure buy-in

While putting together a team takes time, it’s not the only hurdle a hospital may face. Getting buy-in is key to successful implementation. It is vital that all clinicians are fully engaged in and supportive of efforts to improve antibiotic use. Hospital leadership can help ensure other groups and departments are aware of antibiotic stewardship efforts and facilitate collaboration.

Antibiotic stewardship programs are greatly enhanced by support from the following groups:5

  • Infection preventionists and hospital epidemiologists can assist with educating staff and with analyzing and reporting data on antibiotic resistance and C. diff infection trends.
  • Quality improvement, patient safety, and regulatory staff can help advocate for adequate resources and integrate stewardship interventions into other quality improvement efforts, especially sepsis management.
  • Information technology staff are critical to integrating stewardship protocols into existing workflow.
  • Promote conversion from intravenous medication to oral options.
  • Nurses are being increasingly recognized as important ambassadors for hospital stewardship efforts.
Adopting an antibiotic stewardship program starts with knowing the CDC’s Core Elements and engaging the right people. But it can only succeed with the ongoing dedication of all participants—in the core team and across the organization.
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  1. Dellit TH, Owens RC, McGowan JE, Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44(2):159–77.
  2. Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2013(4).   
  3. Karanika S, Paudel S, Grigoras C, Kalbasi A, Mylonakis E. Systematic review and meta-analysis of clinical and economic outcomes from the implementation of hospital-based antimicrobial stewardship programs. Antimicrob Agents Chemother. 2016 Aug;60(8):4840-52.
  4. Baur D, Gladstone BP, Burkert F, Carrara E, Foschi F, Dobele S, et al. Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: A systematic review and meta-analysis. Lancet Infect Dis. 2017 Sep;17(9):990-1001.
  5. Centers for Disease Control and Prevention. Core elements of antibiotic stewardship [Internet]. Atlanta, GA, USA. [updated 2019 Aug 15; cited 2020 Dec 8] Available here.
  6. British Society for Antimicrobial Chemotherapy. Antibiotic stewardship from principles to practice. Birmingham (UK). 2018. [cited 2020 Dec 15] Available here.
  7. Rohde JM, Jacobsen D, Rosenberg DJ. Role of the hospitalist in antimicrobial stewardship: A review of work completed and description of a multisite collaborative. Clin Ther. 2013 Jun 1;35(6):751-
  8. Srinivasan A. Engaging hospitalists in antimicrobial stewardship: The CDC perspective. J Hosp Med. 2011 Jan;6 Suppl 1:S31-3.
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