The Current State of Antimicrobial Stewardship: Challenges, Successes, and Future Directions


Purpose of Review

The aim of this study is to examine the current state of the field of antimicrobial stewardship (AS) by highlighting key challenges and successes, as well as exciting future directions.

Recent Findings

AS mandates from the Centers for Medicare and Medicaid (CMS) and the Joint Commission (TJC) will stimulate increased compliance with current AS standards, but overall compliance is currently poor. Key challenges to progress in the field of AS include insufficient workforce and monetary resources, poorly defined AS metrics, and much needed expansion beyond the inpatient hospital setting. Despite these challenges, massive progress has been made in the last two and a half decades since the field of AS emerged. AS metrics are rapidly evolving and transforming the way antimicrobial stewardship programs (ASPs) measure success. Rapid diagnostics and diagnostic test stewardship are proving to be extremely effective when coupled with an ASP. Telehealth may improve access to ASP expertise in resource poor settings, and the role of bedside nurses as ASP team members has the potential to greatly augment ASP efforts. Allergy testing as an ASP strategy remains largely underutilized.


ASPs have made significant gains in the battle against antimicrobial resistance (AR), but considerable advancement is still needed. Awareness of current challenges is critical to ensure progress in the field. The field of AS is expanding and transforming rapidly through integration, technology, and improved processes.

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Fig. 1


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    CDC. Antibiotic Resistance Threats in the United States. 2013. Available at

  2. 2.

    WHO. Global Action Plan on antimicrobial resistance. Geneva: World Health Organization; 2015.

    Google Scholar 

  3. 3.

    Klein EY, Van Boeckel TP, Martinez EM, et al. Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proc Natl Acad Sci USA. 2018;115(15):E3463–70.

  4. 4.

    McGowan JE, Gerding DN. Does antibiotic restriction prevent resistance? New Horiz. 1996;4(3):370–6.

    PubMed  Google Scholar 

  5. 5.

    •• Task Force for Combating Antibiotic-Resistant Bacteria. National Action Plan for Combating Antibiotic Resistant Bacteria The White House. 2015. Key policy that stimulated CMS and TJC changes.

  6. 6.

    The Joint Commission. Approved: new antimicrobial stewardship standard. Joint Commission Perspectives. 2016;36(7).

  7. 7.

    Dellit TH, Owens RC, McGowan JE, 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.

    Article  PubMed  Google Scholar 

  8. 8.

    •• Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62(10):e51–77. Key guideline for developing an ASP in the U.S.

    Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    •• CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at Key recommendations outlining basic components of an ASP.

  10. 10.

    Bernard S, Pakyz A, Kuper K, Nguyen N, Stevens M. How ready are hospitals to meet the centers for Medicare and Medicaid antibiotic stewardship requirements? Open Forum Infectious Diseases. 2016;3(1):968.

    Google Scholar 

  11. 11.

    Fleming-Dutra KE, Hersh AL, Shapiro DJ, Bartoces M, Enns EA, File TM Jr, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864–73.

    Article  PubMed  CAS  Google Scholar 

  12. 12.

    Suda KJ, Hicks LA, Roberts RM, Hunkler RJ, Danziger LH. A national evaluation of antibiotic expenditures by healthcare setting in the United States, 2009. J Antimicrob Chemother. 2013;68(3):715–8.

    Article  PubMed  CAS  Google Scholar 

  13. 13.

    Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep 2016;65(No. RR-6):1–12.

  14. 14.

    CDC. Antibiotic prescribing and use in doctor's offices. 2017;

  15. 15.

    Drekonja DM, Filice GA, Greer N, Olson A, MacDonald R, Rutks I, et al. Antimicrobial stewardship in outpatient settings: a systematic review. Infect Control Hosp Epidemiol. 2015;36(2):142–52.

    Article  PubMed  Google Scholar 

  16. 16.

    Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev. 2005;4:CD003539.

    Google Scholar 

  17. 17.

    McDonagh M, Peterson K, Winthrop K, et al. Improving antibiotic prescribing for uncomplicated acute respiratory tract infections. Comparative Effectiveness Review No 163. 2016 (AHRQ Publication No. 15).

  18. 18.

    Ranji SR, Steinman MA, Shojania KG, Gonzales R. Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis. Med Care. 2008;46(8):847–62.

    Article  PubMed  Google Scholar 

  19. 19.

    AAMC. Number of Active Physicians in the Largest Specialties by Major Professional Activity, 2015. AMA Physician Masterfile 2015. Available at

  20. 20.

    George Washington University Health Workforce Institute. Analysis of the NRMP-SMS match for infectious disease for 2016–17 appointment year and trends over-time. 2016.

  21. 21.

    Bonura EM, Lee ES, Ramsey K, Armstrong WS. Factors influencing internal medicine resident choice of infectious diseases or other specialties: a national cross-sectional study. Clin Infect Dis. 2016;63(2):155–63.

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    •• Gauthier TP, Worley M, Laboy V, Hernandez L, Unger NR, Sherman EM, et al. Clinical infectious diseases pharmacists in the United States: a problem of both supply and demand. Clin Infect Dis. 2015;60(5):826–7. Provides insight into workforce shortages.

    Article  PubMed  Google Scholar 

  23. 23.

    Goff DA, Kullar R, Bauer KA, File TM. Eight habits of highly effective antimicrobial stewardship programs to meet the joint commission standards for hospitals. Clin Infect Dis. 2017;64(8):1134–9.

    Article  PubMed  Google Scholar 

  24. 24.

    IDSA. Antimicrobial Stewardship Centers of Excellence 2018;

  25. 25.

    Boucher HW, Murray BE, Powderly WG. Proposed U.S. funding cuts threaten progress on antimicrobial resistance. Ann Intern Med. 2017;167(10):738–9.

    Article  PubMed  Google Scholar 

  26. 26.

    Dall C. IDSA slams proposed budget cuts to AMR programs Center for Infectious Disease Research and Policy News. 2017.

  27. 27.

    Auwaerter P. Public Health, Biomedical research priorities recognized in FY 2018 funding bill: IDSA statement. In: IDSA; 2018. Available at

  28. 28.

    • Moehring RW, Anderson DJ, Cochran RL, Hicks LA, Srinivasan A, Dodds Ashley ES, et al. Expert consensus on metrics to assess the impact of patient-level antimicrobial stewardship interventions in acute-care settings. Clin Infect Dis. 2017;64(3):377–83. Most important, recent recommendations for currently utilizing and developing new ASP metrics.

    Article  PubMed  Google Scholar 

  29. 29.

    Maragakis LL, Perencevich EN, Cosgrove SE. Clinical and economic burden of antimicrobial resistance. Expert Rev Anti-Infect Ther. 2008;6(5):751–63.

    Article  PubMed  Google Scholar 

  30. 30.

    Morris AM, Brener S, Dresser L, Daneman N, Dellit TH, Avdic E, et al. Use of a structured panel process to define quality metrics for antimicrobial stewardship programs. Infect Control Hosp Epidemiol. 2012;33(5):500–6.

    Article  PubMed  Google Scholar 

  31. 31.

    Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Pediatric Infectious Diseases Society. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol. 2012;33(4):322–7.

    Article  Google Scholar 

  32. 32.

    WHO. Defined Daily Dose. 2018;

  33. 33.

    CDC. Antimicrobial Use and Resistance (AUR) Module. 2018. Available at

  34. 34.

    Premier. Be Ready. Antimicrobial Use and Resistance (AUR) Reporting to NHSN. In: 2017. Available at

  35. 35.

    •• Davey P, Marwick CA, Scott CL, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2017;2:CD003543. Most recent systematic review of the effectiveness of ASP strategies.

    PubMed  Google Scholar 

  36. 36.

    • Kelly AA, Jones MM, Echevarria KL, Kralovic SM, Samore MH, Goetz MB, et al. A report of the efforts of the veterans health administration national antimicrobial stewardship initiative. Infect Control Hosp Epidemiol. 2017;38(5):513–20. Best example of the effectiveness of centralized implementation AS across a large health system.

    Article  PubMed  Google Scholar 

  37. 37.

    Davey P, Brown E, Charani E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2013(4):Cd003543.

  38. 38.

    Mehta JM, Haynes K, Wileyto EP, Gerber JS, Timko DR, Morgan SC, et al. Comparison of prior authorization and prospective audit with feedback for antimicrobial stewardship. Infect Control Hosp Epidemiol. 2014;35(9):1092–9.

    Article  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Tamma PD, Avdic E, Keenan JF, Zhao Y, Anand G, Cooper J, et al. What is the more effective antibiotic stewardship intervention: Preprescription authorization or Postprescription review with feedback? Clin Infect Dis. 2017;64(5):537–43.

    PubMed  Google Scholar 

  40. 40.

    Bond CA, Raehl CL. Clinical and economic outcomes of pharmacist-managed aminoglycoside or vancomycin therapy. Am J Health Syst Pharm. 2005;62(15):1596–605.

    Article  PubMed  Google Scholar 

  41. 41.

    Momattin H, Zogheib M, Homoud A, Al-Tawfiq JA. Safety and outcome of pharmacy-led vancomycin dosing and monitoring. Chemotherapy. 2016;61(1):3–7.

    Article  PubMed  CAS  Google Scholar 

  42. 42.

    Park SM, Kim HS, Jeong YM, Lee JH, Lee E, Lee E, et al. Impact of intervention by an antimicrobial stewardship team on conversion from intravenous to oral fluoroquinolones. Infect Chemother. 2017;49(1):31–7.

    Article  PubMed  PubMed Central  Google Scholar 

  43. 43.

    Pasquale TR, Trienski TL, Olexia DE, Myers JP, Tan MJ, Leung AK, et al. Impact of an antimicrobial stewardship program on patients with acute bacterial skin and skin structure infections. Am J Health Syst Pharm. 2014;71(13):1136–9.

    Article  PubMed  Google Scholar 

  44. 44.

    Brumley PE, Malani AN, Kabara JJ, Pisani J, Collins CD. Effect of an antimicrobial stewardship bundle for patients with Clostridium difficile infection. J Antimicrob Chemother. 2016;71(3):836–40.

    Article  PubMed  CAS  Google Scholar 

  45. 45.

    Ohashi K, Matsuoka T, Shinoda Y, Fukami Y, Shindoh J, Yagi T, et al. Evaluation of treatment outcomes of patients with MRSA bacteremia following antimicrobial stewardship programs with pharmacist intervention. Int J Clin Pract. 2018;72:e13065.

    Article  PubMed  CAS  Google Scholar 

  46. 46.

    CDC. Antibiotic resistance patient safety atlas.

  47. 47.

    Duke University School of Medicine. DASON - Duke antimicrobial stewardship outreach network. 2014–2018;

  48. 48.

    Madden GR, Weinstein RA, Sifri CD. Diagnostic stewardship for healthcare-associated infections: opportunities and challenges to safely reduce test use. Infect Control Hosp Epidemiol. 2018;39(2):214–8.

    Article  PubMed  Google Scholar 

  49. 49.

    Frazee BW, Enriquez K, Ng V, Alter H. Abnormal urinalysis results are common, regardless of specimen collection technique, in women without urinary tract infections. J Emerg Med. 2015;48(6):706–11.

    Article  PubMed  Google Scholar 

  50. 50.

    Pallin DJ, Ronan C, Montazeri K, Wai K, Gold A, Parmar S, et al. Urinalysis in acute care of adults: pitfalls in testing and interpreting results. Open Forum Infect Dis. 2014;1(1):ofu019.

    Article  PubMed  PubMed Central  Google Scholar 

  51. 51.

    Sloane PD, Kistler CE, Reed D, Weber DJ, Ward K, Zimmerman S. Urine culture testing in community nursing homes: gateway to antibiotic overprescribing. Infect Control Hosp Epidemiol. 2017;38(5):524–31.

    Article  PubMed  Google Scholar 

  52. 52.

    Cheung A, Karmali G, Noble S, Song H. Antimicrobial stewardship initiative in treatment of urinary tract infections at a rehabilitation and complex continuing care hospital. Can J Hosp Pharm. 2017;70(2):144–9.

    PubMed  PubMed Central  Google Scholar 

  53. 53.

    Naik AD, Skelton F, Amspoker AB, Glasgow RA, Trautner BW. A fast and frugal algorithm to strengthen diagnosis and treatment decisions for catheter-associated bacteriuria. PLoS One. 2017;12(3):e0174415.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  54. 54.

    Chen S, Gu H, Sun C, Wang H, Wang J. Rapid detection of Clostridium difficile toxins and laboratory diagnosis of Clostridium difficile infections. Infection. 2017;45(3):255–62.

    Article  PubMed  CAS  Google Scholar 

  55. 55.

    McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66(7):987–94.

    Article  PubMed  Google Scholar 

  56. 56.

    Olans RN, Olans RD, DeMaria A. The critical role of the staff nurse in antimicrobial stewardship--unrecognized, but Already There. Clin Infect Dis. 2016;62(1):84–9.

    Article  PubMed  Google Scholar 

  57. 57.

    CDC, American Nurses Association. White paper—redefining the antibiotic stewardship team:recommendations from the American Nurses Association/Centers for Disease Control and Prevention workgroup on the role of registered nurses in hospital antibiotic stewardship practices. 2017. Available at

  58. 58.

    Minejima E, Wong-Beringer A. Implementation of rapid diagnostics with antimicrobial stewardship. Expert Rev Anti-Infect Ther. 2016;14(11):1065–75.

    Article  PubMed  CAS  Google Scholar 

  59. 59.

    Perez KK, Olsen RJ, Musick WL, et al. Integrating rapid diagnostics and antimicrobial stewardship improves outcomes in patients with antibiotic-resistant gram-negative bacteremia. J Inf Secur. 2014;69(3):216–25.

    Google Scholar 

  60. 60.

    Suzuki H, Hitomi S, Yaguchi Y, Tamai K, Ueda A, Kamata K, et al. Prospective intervention study with a microarray-based, multiplexed, automated molecular diagnosis instrument (Verigene system) for the rapid diagnosis of bloodstream infections, and its impact on the clinical outcomes. J Infect Chemother. 2015;21(12):849–56.

    Article  PubMed  Google Scholar 

  61. 61.

    Schuetz P, Wirz Y, Sager R, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev. 2017;10:CD007498.

    PubMed  Google Scholar 

  62. 62.

    Sager R, Kutz A, Mueller B, Schuetz P. Procalcitonin-guided diagnosis and antibiotic stewardship revisited. BMC Med. 2017;15(1):15.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  63. 63.

    Parmar P, Mackie D, Varghese S, Cooper C. Use of telemedicine technologies in the management of infectious diseases: a review. Clin Infect Dis. 2015;60(7):1084–94.

    PubMed  Google Scholar 

  64. 64.

    Siddiqui J, Herchline T, Kahlon S, Moyer KJ, Scott JD, Wood BR, et al. Infectious Diseases Society of America position statement on telehealth and telemedicine as applied to the practice of infectious diseases. Clin Infect Dis. 2017;64(3):237–42.

    Article  PubMed  Google Scholar 

  65. 65.

    Parameters JTFoP. American Academy of Allergy AtaI, American College of Allergy AtaI, Joint Council of Allergy AtaI. Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol. 2010;105(4):259–73.

    Article  Google Scholar 

  66. 66.

    Pichichero ME, Zagursky R. Penicillin and cephalosporin allergy. Ann Allergy Asthma Immunol. 2014;112(5):404–12.

    Article  PubMed  Google Scholar 

  67. 67.

    Kaye KS, Pogue JM. Infections caused by resistant gram-negative bacteria: epidemiology and management. Pharmacotherapy. 2015;35(10):949–62.

    Article  PubMed  CAS  Google Scholar 

  68. 68.

    Charneski L, Deshpande G, Smith SW. Impact of an antimicrobial allergy label in the medical record on clinical outcomes in hospitalized patients. Pharmacotherapy. 2011;31(8):742–7.

    Article  PubMed  Google Scholar 

  69. 69.

    Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin "allergy" in hospitalized patients: a cohort study. J Allergy Clin Immunol. 2014;133(3):790–6.

    Article  PubMed  Google Scholar 

  70. 70.

    McDanel JS, Perencevich EN, Diekema DJ, et al. Comparative effectiveness of beta-lactams versus vancomycin for treatment of methicillin-susceptible Staphylococcus aureus bloodstream infections among 122 hospitals. Clin Infect Dis. 2015;61(3):361–7.

    Article  PubMed  CAS  Google Scholar 

  71. 71.

    Blumenthal KG, Parker RA, Shenoy ES, Walensky RP. Improving clinical outcomes in patients with methicillin-sensitive Staphylococcus aureus bacteremia and reported penicillin allergy. Clin Infect Dis. 2015;61(5):741–9.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  72. 72.

    Blumenthal KG, Shenoy ES, Huang M, Kuhlen JL, Ware WA, Parker RA, et al. The impact of reporting a prior penicillin allergy on the treatment of methicillin-sensitive Staphylococcus aureus bacteremia. PLoS One. 2016;11(7):e0159406.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  73. 73.

    Romano A, Gaeta F, Arribas Poves MF, Valluzzi RL. Cross-reactivity among beta-lactams. Curr Allergy Asthma Rep. 2016;16(3):24.

    Article  PubMed  CAS  Google Scholar 

  74. 74.

    Pre-Pen (benzylpenicilloyl polylysine) package insert,. In. Plainville, CT: Hospira, Inc, AllerQuest LLC; 2009.

  75. 75.

    Macy E, Mangat R, Burchette RJ. Penicillin skin testing in advance of need: multiyear follow-up in 568 test result-negative subjects exposed to oral penicillins. J Allergy Clin Immunol. 2003;111(5):1111–5.

    Article  PubMed  Google Scholar 

  76. 76.

    Sogn DD, Evans R, Shepherd GM, et al. Results of the National Institute of Allergy and Infectious Diseases collaborative clinical trial to test the predictive value of skin testing with major and minor penicillin derivatives in hospitalized adults. Arch Intern Med. 1992;152(5):1025–32.

    Article  PubMed  CAS  Google Scholar 

  77. 77.

    Leis JA, Palmay L, Ho G, Raybardhan S, Gill S, Kan T, et al. Point-of-care Beta-lactam allergy skin testing by antimicrobial stewardship programs: a pragmatic multicenter prospective evaluation. Clin Infect Dis. 2017;65:1059–65.

    Article  PubMed  Google Scholar 

  78. 78.

    Jones BM, Bland CM. Penicillin skin testing as an antimicrobial stewardship initiative. Am J Health Syst Pharm. 2017;74(4):232–7.

    Article  PubMed  Google Scholar 

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Correspondence to Jennifer Emberger.

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This article is part of the Topical Collection on Healthcare Associated Infections

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Emberger, J., Tassone, D., Stevens, M.P. et al. The Current State of Antimicrobial Stewardship: Challenges, Successes, and Future Directions. Curr Infect Dis Rep 20, 31 (2018).

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  • Antimicrobial stewardship
  • Antimicrobial utilization
  • Antimicrobial stewardship metrics
  • Diagnostic test stewardship
  • Rapid diagnostics
  • Telemedicine