What Is Antibiotic Stewardship—and How Does It Work?

Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate. That means prescribing the right drug at the right dose at the right time for the right duration. Initiatives dedicated to improving antibiotic use are commonly referred to as antibiotic stewardship programs (ASPs).

These programs are critically important because alarming new types of antibiotic-resistant bacteria continue to emerge and too few new drugs in development have even the potential to treat the most dangerous superbugs. In the Q&A below, I explain how stewardship efforts work and their benefits, both for individual patients and more broadly.

Q: How does stewardship help to combat antibiotic resistance?

A: The more antibiotics are used, the less effective they become. As bacteria are exposed to antibiotics, the bacteria adapt and become increasingly able to defeat the drugs. This evolution can happen gradually or quickly, but all antibiotic use accelerates the process. Unfortunately, data show high levels of unneeded antibiotic prescribing across health care settings in the United States. For example, 1 in 3 antibiotic prescriptions written in doctors’ offices, emergency rooms, and hospital-based clinics—about 47 million prescriptions annually—is completely unnecessary. Effective antibiotic stewardship can reduce this type of misuse and help slow the emergence of resistance.

Stewardship programs also help ensure that when antibiotics are needed, they’re used appropriately. Proper usage helps to slow the emergence of resistance as well by optimizing a patient’s course of therapy. For example, an analysis of antibiotic selection in the U.S. conducted by the Centers for Disease Control and Protection and The Pew Charitable Trusts showed that for some common conditions, only half of patients receive the recommended first-line antibiotic in accordance with medical guidelines. That research also found that when patients receive an inappropriate antibiotic, it’s most commonly a broad-spectrum medication such as azithromycin. Broad spectrum means that the drug works against a wide range of bacteria, but studies show that people given these drugs are more likely to develop resistant infections than those treated with more targeted antibiotics.

Q: Does antibiotic stewardship help individual patients?

A: Yes. Inappropriate and unnecessary antibiotic use not only drives the emergence of resistant bacteria, it also jeopardizes patient safety. Like any medication, antibiotics carry certain risks. While they are critical for treating a wide range of conditions—from strep throat and urinary tract infections to bacterial pneumonia and sepsis—these drugs can have harmful side effects or cause allergic reactions. Antibiotics can also kill off “good” bacteria in the gut, which enables previously latent “bad” bacteria to multiply and increases a patient’s chances of developing secondary illnesses such as a Clostridioides difficile infection that can result in life-threatening diarrhea and colitis. Antibiotic stewardship helps address these dangers by ensuring that antibiotics are used only when needed.

Stewardship also ensures that patients receive the most effective treatment option and that it is administered correctly, which is key to protecting individuals’ health and helping them recover as quickly as possible. This is especially crucial for sepsis patients, who can rapidly suffer tissue damage, organ failure, and even death if they do not receive antibiotics quickly enough or if their antibiotic treatment does not work.

Q: How do we know that antibiotic stewardship programs are effective?

A: A large and growing body of research shows that hospital-based antibiotic stewardship programs reduce antibiotic resistance, improve patient outcomes, and save money. Evidence from a variety of inpatient facilities, including different types of hospitals and long-term care facilities, with a wide range of staffing or financial resources demonstrates both the feasibility of implementing ASPs and the improved outcomes from such efforts. In the outpatient setting, studies show that supplying health care providers with professional education, data about their own prescribing rates compared with that of their peers, and tools to help make clinical decisions—such as medical guidelines and electronic alerts—can significantly improve antibiotic use. Examining the reasons and patterns behind prescription rates is critical. Interventions using behavioral science, for example, can enhance stewardship strategies.

Q: What is Pew doing to expand and improve antibiotic stewardship in the U.S.?

A: According to CDC, about 64 percent of acute-care hospitals had implemented programs aligned with the centers’ core elements of successful hospital ASPs as of 2016. To expand stewardship efforts, Pew has been advocating for the finalization and implementation of new policies at the Centers for Medicare & Medicaid Services that would require health care facilities to have ASPs in order to participate in the Medicare and Medicaid programs. Pew is also conducting research to identify strategies to implement effective stewardship in outpatient settings and long-term care facilities.

Pew’s ongoing collaboration with CDC has produced national-level data on antibiotic use, which serve as the basis for national targets to reduce inappropriate antibiotic use by 2020. Pew also advocates for mandatory reporting of antibiotic resistance and use data to the center’s National Healthcare Safety Network to help track resistance trends and improve antibiotic prescribing.

David Hyun, M.D., works on The Pew Charitable Trusts’ antibiotic resistance project.