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Resist the ResistanceAct now. Act how?Strategy to prevent catastropheSurveil. SurvivePolicy for Purpose
Strategy to prevent catastrophe

Antibiotics, antifungals, antivirals, and antiparasitics.1–3 Regardless of the target pathogen, the issue at hand is the same: infection-causing microbes have developed resistance. Medicines are becoming less effective.1,2

The time for talking about antimicrobial resistance has passed. It’s time to enact real antimicrobial stewardship.


Antimicrobial resistance is a complex problem, so stewardship approaches are often multifaceted with varied interventions.1 One way to formalize and add structure is through an antimicrobial stewardship program. Put the principles of stewardship into practice, to improve the quality of care, patient outcomes, and public health.2

Establishing a stewardship program in a hospital or healthcare setting is a process that, just like slowing the expansion of antimicrobial resistance, requires a collaborative and coordinated response. All team members need to be engaged.2 Stewardship is all of our responsibility.

For some, the first step in setting up a program is establishing a multidisciplinary team of healthcare professionals.2–5 This team is central to ensuring the programme is effective. They guide and support decision-making and help implement day-to-day stewardship activities in the healthcare facility.2

Most multidisciplinary stewardship teams include either an infectious disease physician or a pharmacist (with or without specialized training in infectious disease) or both. Every hospital should work within its resources to create an effective team given its budget and personnel constraints.2,6 If establishing such a team is challenging in resource-limited settings or small facilities, a singular stewardship champion can be appointed instead. The champion could be a physician, pharmacist, or nurse with a special interest in stewardship, and they must have access to expert advice.2

All stewardship champions (acting as an individual or a team member) should also stay abreast of global and local guidance on antimicrobial use and carry out internal audits, where possible, to capture prescribing insights.2,3


Historically, antimicrobial stewardship interventions have overwhelmingly focused on antibiotics, due to the proliferation of resistant bacterial strains.

Now, antifungal resistance is also emerging as a clinical threat, with so far, comparatively little attention and resources.5,7

Antibacterial and antifungal stewardship may differ in their targets, interventions, and clinical priorities, but they ultimately share a common goal: to optimize clinical outcomes while promoting judicious drug use.5,7,8


      Antibacterial  stewardship                             
Antifungal stewardship
Target drug Antibiotics Antifungals 
Setting Primary and secondary care Mainly secondary care
Specialities involved All Few 
Mainly haemato-oncology, organ transplantation, critical care, gastrointestinal surgery, and repiratory
Typical drug use Treatment or single-dose prophylaxis Prolonged prophylaxis and treatment
Drug availability cost Many drugs, $-$$ Fewer drugs, $$-$$$
Resistance Increasing multi-drug resistance Mainly single-drug resistance
Surveil. Survive.

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AMR, antimicrobial resistance; WHO, World Health Organization.ReferencesWorld Health Organization. Antimicrobial resistance. Available at: Accessed May 2023.World Health Organization. Antimicrobial stewardship programmes in health-care facilities in low-and middle-income countries: a WHO practical toolkit. 2019. Available at: Accessed May 2023.World Health Organization. Policy guidance on integrated antimicrobial stewardship activities. 2021. Available at: Accessed May 2023.CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Available at: core-elements/hospital.html. Accessed May 2023.Hart E et al. Ann Clin Microbiol Antimicrob 2019;18:24.Doron S and Davidson LE. Mayo Clin Proc 2011;86(11):1113–1123.Hamdy RF et al. Virulence 2017;8(6):658–672.Whitney L and Bicanic T. Antimicrobial Stewardship. In: Laundy M, Gilchrist M, Whitney L, editors. Oxford Medicine Online; 10.1093/med/9780198758792.001.0001: Oxford University Press; 2016.
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