Tips for implementing AS programs

1.Hospital Antimicrobial Stewardship Self Asessment Tool

  • Evidence-based toolkit for assessment of antimicrobial stewardship in acute hospitals.
  • Single workable (Excel File) instrument to assess longitudinal progress on antimicrobial stewardship in an individual institution or act as a benchmark with similar organizations.
  • Developed in the United Kingdom trough a National Pharmacy Reference Group established as part of the current work programme of the Prescribing Group of the Department of Health’s Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI)
  • Reference: Methodology is described in Cooke J et al. Antimicrobial stewardship: an evidence-based antimicrobial self asessment tooolkit (ASAT) for acute hospitals. J Antimicrob Chemother. 2010 Dec.;65(12):2669–73.


2. Key Messages for antimicrobial prescribers in hospitals

2.1. Antibiotic Awareness Day (ECDC): Toolkit to briefing materials aimed at hospital prescribers


2.2. “START SMART -THEN- FOCUS”. Guidance for AS in hospitals (England)


1. Do not start antibiotics in the absence of clinical evidence of bacterial infection
2. If there is evidence/suspicion of bacterial infection, use local guidelines to initiate prompt effective antibiotic treatment within one hour of diagnosis (or as soon as possible) in patients with life threatening infections (Avoid inappropriate use of broad-spectrum antibiotics)
3. Document on drug chart and in medical notes: clinical indication, duration or review date, route and dose
4. Obtain Cultures First
– Knowing the susceptibility of an infecting organism can lead to narrowing of broad-spectrum therapy, changing therapy to effectively treat resistant pathogens and stopping antibiotics when cultures suggest an infection is unlikely.
5. Prescribe single dose antibiotics for surgical prophylaxis; where antibiotics have been shown to be effective
– Critical to this advice is that the single dose is administered within the 60 minutes prior to surgical incision or tourniquet inflation to enable peak blood levels to be present at the start of the surgical procedure.
– A repeat dose of antibiotic prophylaxis is required when the operation for prolonged procedures and where there is significant blood loss.
– A treatment course of antibiotics may also need to be given (in addition to appropriate prophylaxis) in cases of dirty surgery or infected wounds.
– The appropriate use and choice of antibiotics should be discussed with Infection specialists for each case


1. Review the clinical diagnosis and the continuing need for antibiotics by 48 hours and make a clear plan of action – the “Antimicrobial Prescribing Decision”
– Antibiotics are generally started before a patient’s full clinical picture is known.
– By 48 hours, when additional information is available, including microbiology, radiographic and clinical information, it is important for clinicians to reevaluate why the therapy was initiated in the first place and to gather evidence on whether there should be changes to the therapy.
2. Five Antimicrobial Prescribing Decision options are Stop, Switch, Change, Continue and OPAT:
1. Stop antibiotics if there is no evidence of infection
2. Switch antibiotics from intravenous to oral
3. Change antibiotics – ideally to a narrower spectrum – or broader if required
4. Continue and review again at 72 hours
5. Outpatient Parenteral Antibiotic Therapy (OPAT).44
It is essential that the review and subsequent decision is clearly documented in the medical notes.

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