Antimicrobial Stewardship

full update February 2026

Thirty percent of antibiotic courses prescribed in US hospitals are inappropriate.¹⁸ Inappropriate antibiotic use contributes to the development of bacterial resistance.¹⁸ Resistance is increasing faster than new antibiotics can be developed, threatening the ability to treat certain infections.²³ Each year, almost three million people in the US become infected with an antibiotic-resistant pathogen leading to more than 35,000 deaths.¹⁸ Antimicrobial stewardship is a set of coordinated strategies to optimize and measure antimicrobial use to improve patient safety and outcomes, limit antimicrobial resistance, and decrease unnecessary costs.²³ This toolbox provides information and resources to reduce infections and optimize the use of antibiotics.

Goal	Suggested Strategies or Resources
Learn about antimicrobial stewardship from available resources.	Resources from the CDC (educational resources, training opportunities): Antibiotic stewardship training (continuing education): https://www.cdc.gov/antibiotic-use/hcp/training/. Core Elements of Antibiotic Stewardship: https://www.cdc.gov/antibiotic-use/hcp/core-elements/index.html. Core Elements of Hospital Antibiotic Stewardship Programs: https://www.cdc.gov/antibiotic-use/hcp/core-elements/hospital.html. Contains information on pharmacist involvement. Core Elements of Outpatient Antibiotic Stewardship: https://www.cdc.gov/antibiotic-use/hcp/core-elements/outpatient-antibiotic-stewardship.html Core Elements of Antibiotic Stewardship for Nursing Homes: https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html Antibiotic Stewardship Resource Bundles (educational resources for outpatient, dental, nursing home, acute care, and transitions of care; includes patient information materials: https://www.cdc.gov/antibiotic-use/hcp/educational-resources/stewardship/ The Agency for Healthcare Research and Quality has a Toolkit to Improve Antibiotic Use in Acute Care Hospitals at https://www.ahrq.gov/antibiotic-use/acute-care/index.html See evidence-based guidelines from the IDSA on developing an antimicrobial stewardship program at https://academic.oup.com/cid/article/62/10/e51/2462846?searchresult=1 The American Hospital Association has tips for interdisciplinary collaboration, nursing resources, and more at https://www.aha.org/antibiotic-stewardship See a compilation of resources from the Association for Professionals in Infection Control and Epidemiology at https://apic.org/professional-practice/antimicrobial-stewardship/
Take steps to develop and improve your antimicrobial stewardship program.	Choose your program’s multidisciplinary team (optimally an infectious diseases pharmacist and/or infectious diseases physician as the leader, clinical microbiologist, information system specialist, hospital epidemiologist, infection control professional, and representative from nursing and quality assessment and performance), with at least one member having formal antimicrobial stewardship training.^36-38 Establish goals and objectives (e.g., improve patient safety and outcomes, manage resistance, prevent selection of pathogenic organisms such as Clostridioides difficile, reduce costs).³⁷ Define key outcome measures (e.g., antibiotic use, Clostridioides difficile infections, resistance, cost) and process measures (e.g., acceptance of recommendations, timeliness of preauthorization, guideline adherence).¹⁸ Educate prescribers, pharmacists, and nurses about antibiotic resistance, adverse effects, and optimal prescribing.¹⁸(See resources in this document). Case-based education is especially effective.¹⁸ Pair education with prospective audit and feedback.¹⁸ Determine monitoring methods for antibiotic prescribing, the impact of interventions, and outcomes.¹⁸ Develop your antibiogram. The Clinical Laboratory Standards Institute offers an on-demand webinar about antibiogram preparation and use (https://clsi.org/standards/products/microbiology/education/m39ed5wr/). Develop facility-specific treatment guidelines.¹⁸ Work with your hospital to implement policies for restricting broad spectrum antibiotics to certain prescribers or indications. Work with information technology to utilize electronic health record features to facilitate your initiatives (e.g., include decision support and relevant information at order entry, facilitate NHSN AUR reporting [see below]).¹⁸ Develop processes for prospective audit with feedback, or preauthorization, to improve antibiotic use.¹⁸ Plan how antibiotic utilization and resistance data will be reported to prescribers, pharmacists, nurses, and administrators.¹⁸ Ensure you have all the core elements (see https://www.cdc.gov/antibiotic-use/hcp/core-elements/hospital.html).
Educate yourself and your colleagues with available resources.	The CDC’s Be Antibiotics Aware educational effort complements the US Antibiotic Awareness Week. A toolkit with key messages for healthcare professionals, and reproducible social media posts and newsletter content, is available at https://www.cdc.gov/antibiotic-use/php/usaaw-partner-toolkit/. Additional CDC Educational Materials for Healthcare Providers are available at https://www.cdc.gov/antibiotic-use/hcp/educational-resources/index.html. In addition to resources for educating prescribers (including dentists), pharmacists, and patients, there is a “return to daycare” letter, and prescriptions for watchful waiting. Visit AMR Aware Canada at https://antibioticawareness.ca/ for patient and provider information, videos, factsheets, and treatment guidelines. The Choosing Wisely campaign aimed to promote conversations between prescribers and patients about treatments, tests, and procedures that might not be appropriate. Antibiotic- related topics include: Otitis Media (American Academy of Family Physicians): https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/cw-otitis-media.html. Sinusitis (American Academy of Family Physicians): https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/cw-sinusitis.html. Using Antibiotics Wisely (Canada): https://choosingwiselycanada.org/primary-care/antibiotics/. Do Bugs Need Drugs? (Alberta Health) is a community program promoting the wise use of antibiotics. Notable features include a long-term care urine testing algorithm, and antibiotic prescribing guides (including dosing). See http://www.dobugsneeddrugs.org. A training module for talking with patients about antibiotics during a primary care office visit is available at https://www.empr.com/home/features/conversations-for-health-an-innovative-educational-tool-for-reducing-antibiotic-overuse/. Know when and how to use newer antibiotics or antibiotics that may be increasingly used due to resistance. Remind colleagues of the significance of antibiotic misuse. For example, taking a prescribed antibiotic was shown to increase resistant bacteria in a patient’s urinary and respiratory tracts with a peak incidence at one month, and some still present at 12 months.⁹ Use these resources to help with appropriate outpatient antibiotic selection: Outpatient Clinical Care for Adults: https://www.cdc.gov/antibiotic-use/hcp/clinical-care/adult-outpatient.html Outpatient Clinical Care for Pediatric Populations. https://www.cdc.gov/antibiotic-use/hcp/clinical-care/pediatric-outpatient.html
Access resources related to accreditation (US).	Joint Commission, New and Revised Antibiotic Stewardship Requirements: Standards FAQ: What are the expectations for a hospital’s antibiotic stewardship program? https://www.jointcommission.org/en-us/knowledge-library/support-center/standards-interpretation/standards-faqs/000002449 NIAHO (National Integrated Accreditation for Healthcare Organizations): https://brandcentral.dnvgl.com/original/gallery/dnvgl/files/original/ecd238b80cbd46c9addf668e7e8c55b0.pdf The CDC’s National Healthcare Safety Network (NHSN) (https://www.cdc.gov/nhsn/index.html) is used to comply with Centers for Medicare and Medicaid Services infection reporting requirements.³⁵ Its Antimicrobial Use and Resistance (AUR) Options feature (https://www.cdc.gov/nhsn/psc/aur/index.html) offers many resources and allows data from your institution’s electronic medication administration record and/or laboratory information system, to be benchmarked with others. Antibiotic use data are shared to help you identify areas for improvement.²²
Develop evidence-based antibiotic guidelines.	Use these resources to help develop facility-specific treatment guidelines (may be required to meet US accreditation requirements).²³ Endocarditis American Heart Association Scientific Statement (endorsed by IDSA) on infective endocarditis in adults: https://www.idsociety.org/globalassets/idsa/practice-guidelines/infective-endocarditis-in-adults-diagnosis-antimicrobial-therapy-and-management-of-complications.pdf. European Society of Cardiology guidelines for the management of infective endocarditis: https://academic.oup.com/eurheartj/article/44/39/3948/7243107 Gastrointestinal Infections Use our FAQ, Acute Infectious Diarrhea, to review appropriate antibiotic use for acute infectious diarrhea. See resources for Clostridioides difficile below. Abdominal Infections IDSA guidelines: https://www.idsociety.org/practice-guideline/intra-abdominal-infections/ SIS guidelines: https://sisna.org/the-surgical-infection-society-guidelines-on-the-management-of-intra-abdominal-infection-2024-update/ MRSA FAQ, Vancomycin Dosing and Monitoring in Adults. Osteomyelitis Chart, Oral Antibiotics for Acute Osteomyelitis in Adults. Respiratory Infections FAQ: Managing Community-Acquired Pneumonia and Aspiration Pneumonia in Adults. FAQ: Hospital-Acquired and Ventilator-Associated Pneumonia. Algorithm: Improving COPD Care. FAQ: Acute Otitis Media. Sepsis Chart, Sepsis Management in Adults: Pharmacotherapy Focus. Skin and Soft Tissue Infections Chart. Skin and Soft Tissue Infections. From IDSA, see Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update at https://www.idsociety.org/practice-guideline/skin-and-soft-tissue-infections/. Urinary Tract Infections Infographic, Urinary Tract Infections. FAQ, Bacterial Prostatitis.
Recognize opportunities to avoid or limit systemic antibiotic use.	See our chart, Antibiotic Therapy: When Are Shorter Courses Better? Otitis externa: treat uncomplicated otitis externa (swimmer’s ear) with topical antibiotics rather than oral antibiotics to minimize resistance. See our chart, Prevention and Treatment of Swimmer’s Ear. Pharyngitis: antibiotic treatment has no proven benefit except for Group A Streptococcus (strep throat), diphtheria, and gonorrhea.²⁴Use a scoring system to help identify which patients should be tested and treated for strep throat.²⁴ Sinusitis: most cases of sinusitis are caused by viruses.²⁷ Consider two to three days of watchful waiting before prescribing an antibiotic.²⁷ Urine cultures are not needed in most patients who do not have urinary symptoms.^34,40Develop a urine culture stewardship program in your facility.³⁴ Acute bronchitis, most coughs, and gastroenteritis are usually caused by viruses.^8,28 Antibiotics may not be appropriate for all cases of acute pancreatitis. See our FAQ, Pancreatitis, for details. Recognize reasons for overdiagnosis of acute bacterial respiratory infections:²⁵ Diagnostic uncertainty. Set up a contingency plan to counter this. Perceived patient expectation for an antibiotic. See “Address patient demand for an antibiotic” and “Proactively manage patient expectations for an antibiotic” sections for countermeasures. Discontinue antimicrobials when appropriate. For example, a patient with uncomplicated Enterococcus bacteremia from a removed catheter line may be treated for as little as five to seven days with IV; switching to oral is not needed.¹⁹
Prevent and treat Clostridioides (Clostridium) difficile infections	Improving infection control and antibiotic prescribing could save 37,000 lives over five years by affecting healthcare-associated C. difficile infections.¹⁴ Reducing C. difficile infections should be a high priority goal for all antimicrobial stewardship programs.²³ See our FAQ, Clostridioides (Clostridium) difficile in Adults. Find educational resources for healthcare professionals and the general public at https://www.cdc.gov/c-diff/. Find more information in the IDSA/SHEA 2021guidelines on management of C. difficile in adults at https://academic.oup.com/cid/article/73/5/e1029/6298219.
Appropriately treat acne to limit resistance.	Limit duration of oral antibiotics for acne (e.g., three to four months).^4,6 Combine topical antibiotics with topical benzoyl peroxide, and avoid oral antibiotic monotherapy to help limit development of resistant organisms.^4,6 See our chart, Pharmacotherapy of Acne.
Prevent central line and surgical site infections.	Use appropriate antibiotic prophylaxis in surgery to help reduce the risk of surgical site infections. See Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery from ASHP, IDSA, SIS, and SHEA at https://www.ashp.org/surgical-guidelines See the WHO’s Global Guidelines for the Prevention of Surgical Site Infection for information on antibiotic timing, duration of therapy, and use of intranasal mupirocin at https://www.who.int/publications/i/item/9789241550475. See the CDC’s Checklist for Prevention of Central Line Associated Blood Stream Infections at https://www.cdc.gov/healthcare-associated-infections/media/pdfs/checklist-for-CLABSI-P.pdf.
Use testing to limit inappropriate antibiotic use.	Use rapid identification tests to facilitate your antimicrobial stewardship initiatives (i.e., to distinguish viral vs bacterial etiologies, identify bacterial pathogens, determine susceptibilities), with active support for interpretation and response.^23,38 Procalcitonin testing, in conjunction with clinical judgment, can help support the decision to discontinue antibiotic therapy in hospital- or ventilator-associated penumonia.¹⁷ Consider offering point-of-care tests in the pharmacy to evaluate whether antibiotics are necessary (e.g., influenza, strep, COVID-19).³³
Be aware of special considerations in pediatric patients.	Be aware that resistance rates for some bacteria may be different from adults (e.g., E. coli).³ Be familiar with conditions requiring higher than typical antibiotic doses (e.g., cystic fibrosis, pediatric bone and joint infections). Work with information technology to ensure max dose caps are updated to prevent weight-based doses in bigger kids (e.g., 50 kg) from exceeding maximum recommended antibiotic doses.²⁶ Find antibiotic dosing guidance from: Cystic Fibrosis The American Thoracic Society: https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201402-050AS. Cystic Fibrosis Canada: at https://cystic-fibrosis.cdn.prismic.io/cystic-fibrosis/aWp3wAIvOtkhBqJe_FinalAntibioticDosingGuidelines-2025.pdf. Bone and Joint Infections PIDS/IDSA (acute bacteria arthritis): https://www.idsociety.org/practice-guideline/acute-bacterial-arthritis-in-pediatrics2/ PIDS/IDSA (acute hematogenous osteomyelitis): https://www.idsociety.org/practice-guideline/bone-and-joint-infections---osteomyelitis/ European Society for Paediatric Infectious Diseases: https://www.espid.org//data/files/Guideline%20Sub-Committee/OD-ESPID-17%20Bone%20and%20Joint%20Infections%20ESPID%20guidelines.pdf. Canadian Paediatric Society: https://cps.ca/en/documents/position/osteoarticular-infections-in-children. Consider observation over immediately prescribing empiric antibiotics in newborns at low risk of early onset sepsis.¹³ Consider using the Kaiser Permanente neonatal early-onset sepsis calculator at https://neonatalsepsiscalculator.kaiserpermanente.org/. Avoid unnecessary antibiotic use. See the row titled “Identify infections at risk of antibiotic overuse.” See the Canadian Paediatric Society’s Antimicrobial Stewardship in Daily Practice: Managing an Important Resource at https://cps.ca/en/documents/position/antimicrobial-stewardship.
Limit adverse drug reactions associated with antibiotics.	Help patients avoid potential drug interactions by asking about their use of over-the-counter meds and supplements. Counsel patients on ways to minimize antibiotic adverse effects (e.g., take nitrofurantoin with food; take clindamycin with a full glass of water).¹ Recognize antibiotics that can cause QT prolongation (e.g., macrolides, quinolones) and at-risk patients.¹ Clarify whether a patient’s history of drug allergy necessitates a broader spectrum antibiotic. Resources include: our FAQ, Managing Beta-Lactam Allergies. our algorithm, Investigating Possible Drug Allergy. CDC resource for community pharmacists, Verify Penicillin Allergy at https://www.cdc.gov/antibiotic-use/media/pdfs/Community-Penicillin-Allergy-Poster-508.pdf. Choose appropriate antibiotics during pregnancy and lactation.
Target bacteria at high risk of developing antibiotic resistance.	Become familiar with the details on national plans, strategies, and solutions: US National Action Plan for Combating Antibiotic-Resistant Bacteria at https://aspe.hhs.gov/reports/national-action-plan-combating-antibiotic-resistant-bacteria-2020-2025. Pan-Canadian Action Plan on Antimicrobial Resistance at https://www.canada.ca/en/public-health/services/publications/drugs-health-products/pan-canadian-action-plan-antimicrobial-resistance.html. The US National Action Plan specifically mentions these worrisome trends:⁵ the discovery of new resistant pathogens (e.g., Candida auris). an increase in community-acquired drug-resistant group A Strep infection. community-acquired infections with extended-spectrum beta-lactamase-producing Enterobacterales. an increase in resistant Neisseria gonorrhoeae infections. See the CDC’s Carbapenem-Resistant Enterobacterales (CRE) Infection Control for information on transferring patients with CRE, testing, and isolation guidance at https://www.cdc.gov/cre/hcp/infection-control/?CDC_AAref_Val=https://www.cdc.gov/hai/organisms/cre/cre-facilities.html. See our FAQ, Resistant Gram-Negative Bacterial Infections.
Use vaccines to prevent infection.	Influenza Our FAQ, Communicating About Flu Vaccination, answers questions about efficacy, administration with other vaccines, use in immunocompromised or pregnant patients, and more. Use our chart, Flu Vaccines (US)(Canada) to choose the best vaccine for patients. Public education materials about flu vaccination are available from the CDC (e.g., Seasonal Flu Vaccine Basics https://www.cdc.gov/flu/vaccines/index.html) and Health Canada (e.g., Flu (seasonal influenza): Get Your Flu Vaccine (flu shot) [https://www.canada.ca/en/public-health/services/diseases/flu-influenza/get-your-flu-shot.html]). Pneumonia See our algorithm, Pneumococcal Vaccination in Adults. COVID-19 Use our chart, COVID-19 Vaccines (US)(Canada) to choose the most appropriate vaccine for patients. The chart includes a “frequently asked questions” section to help address misconceptions. Other immunization resources: Our FAQ, Vaccinating Immunocompromised Patients. Our checklist, Vaccine Adherence: Addressing Myths and Hesitancy.
Educate patients on infection prevention.	Teach patients simple ways to prevent spreading germs: Avoid those who are sick and stay home when you are sick. Cover your mouth and nose when sneezing or coughing. Wash your hands and avoid touching your eyes, nose, or mouth. Visit the following sites for more information on: Cough etiquette (the CDC’s Cover Your Cough) at https://www.cdc.gov/flu-resources/media/pdfs/2024/08/covercough_hcp11x17.pdf. Handwashing Hand Washing: Reducing the Risk of Common Infections (Canadian Centre for Occupational Health and Safety) at https://www.ccohs.ca/oshanswers/diseases/washing_hands.html and the Handwashing Facts (CDC) at https://www.cdc.gov/clean-hands/data-research/facts-stats/index.html (CDC). Encourage vaccination.⁷
Proactively manage patient expectations for an antibiotic.	One tool shown to decrease unnecessary prescriptions in an outpatient clinic is to have a poster-sized letter signed by all the clinicians and posted in exam rooms stating their commitment to decreasing inappropriate antibiotic use (e.g., for acute respiratory infections).¹² Many great resources are available from the CDC at https://www.cdc.gov/antibiotic-use/community/materials-references/print-materials/index.html. Try some of these: brochure: Antibiotics Aren’t Always the Answer (https://www.cdc.gov/antibiotic-use/pdfs/AntibioticsArentAlwaystheAnswer-H.pdf). chart: Viruses or Bacteria. What’s Got You Sick? (https://www.cdc.gov/antibiotic-use/pdfs/VirusOrBacteria-Original-P.pdf). poster: Can I Feel Better Without Antibiotics? (https://www.cdc.gov/antibiotic-use/media/pdfs/can-i-feel-better-508.pdf). Try these slogans on your pharmacy or office materials, newsletters, websites, etc: “Coughs, colds – take care, not antibiotics.” “Antibiotics – misuse them and you may lose them.”
Address patient demand for an antibiotic.	Tell patients that antibiotics don’t help viral infections like colds, the flu, bronchitis, and many ear infections.⁷ Dispel the myth that discolored mucus means patients need antibiotics. Thickened, yellow or green mucus just means that your body is fighting an infection which could be viral or bacterial.¹⁰ Patient satisfaction is highest, and the number of unneeded antibiotic prescriptions is lowest if patients receive a combination of both positive (e.g., use saline to help with congestion) and negative (e.g., this is a viral infection and antibiotics won’t help) treatment recommendations AND a contingency plan.¹¹ Contingency plans can include:¹¹ Watch and wait to see if there is improvement in symptoms over a couple of days. Tell the patient when to return. Let patients know how to easily follow-up with providers. Give a post-dated prescription. Follow-up with patients in two or three days with the potential for a prescription at that time. Give patients with an acute viral respiratory infection a “prescription” so they don’t leave empty-handed. It gives them instructions to help with typical symptoms, lets them know their diagnosis, and tells them that antibiotics won’t help. Use the CDC’s symptom relief for viral illness Rx at https://www.cdc.gov/antibiotic-use/media/pdfs/rcx-relief-viral-illness-sm-v8-508.pdf. In Canada, a similar Rx is available from Choosing Wisely (https://choosingwiselycanada.org/primary-care/antibiotics/). There is an Rx for adults, one for pediatrics, and a delayed prescription. Prescribers can find a dialogue to help them have effective conversations with patients at https://nccid.ca/wp-content/uploads/sites/2/2016/11/PatientDialogue.pdf. This is an evidence-based “script” aimed at reducing unnecessary antibiotic prescriptions and reassuring patients. When an antibiotic is not indicated, try these tips and talking points to curtail antibiotic demand: Emphasize potential antibiotic-associated harm to the patient (e.g., C. difficile, yeast infection) or others close to them (e.g., resistant bacteria can spread between people), as opposed to societal harm (e.g., increased healthcare expenditures, widespread antibiotic resistance).³¹ Other examples: Taking an antibiotic may harm your “good bacteria,” making it easier for you to get another infection.³¹ Antibiotics are the most common cause of emergency department visits for adverse drug reactions in children.³¹ Resistant bacteria can be found in your gut years after taking an antibiotic.³¹ Refer to bronchitis as a “chest cold” to limit expectations of an antibiotic.⁷ Inform patients that they can expect a cold to last up to 10 days, and a cough can persist for up to two months.²⁰ Empower nurses, technicians, etc to educate and increase awareness of antibiotic overuse/inappropriate use. Let patients know that they’ve been heard.
Empower patients for self-care.	Patient guides for symptom-targeted treatment of common infections are available at: CDC: Treatment of Common Illnesses, at https://www.cdc.gov/antibiotic-use/?CDC_AAref_. Canada (Alberta Health): Guide to Wise Use of Antibiotics, at https://dobugsneeddrugs.org/guide-to-wise-use-of-antibiotics/. Discourage patients from using an antibiotic they find available internationally or online for self-diagnosed infections. Tell patients not to save any leftover antibiotics and never to use any of these medications. Instruct patients on how to dispose of their old medications.
Use antibiotic prophylaxis appropriately before dental procedures.	Know when antibiotics are needed and when they are NOT needed before dental procedures. For the prevention of endocarditis, see the American Heart Association wallet card: https://www.heart.org/-/media/Files/Health-Topics/Infective-Endocarditis/Infective-Endocarditis-Wallet-Card.pdf?sc_lang=en For information on antibiotic prophylaxis in patients with hip or knee prostheses, see the American Academy of Orthopaedic Surgeons/American Association of Hip and Knee Surgeons guideline (endorsed by the IDSA) at https://www.aaos.org/globalassets/quality-and-practice-resources/dental/dental-2024/prevention-of-total-hip-and-knee-arthroplasty-pji-in-patients-undergoing-dental-procedures-cpg.pdf.
Dose antibiotics correctly.	Verify appropriate antibiotic dosing for patients with poor renal function or who are obese (e.g., for aminoglycosides, beta-lactams, colistin, daptomycin, sulfamethoxazole/trimethoprim, vancomycin). See our FAQ, Medications and Kidney Function.
Switch from IV to oral when appropriate.	Limit IV to PO stepdown therapy to patients who are hemodynamically stable, who can tolerate and absorb oral medications (e.g., has not vomited in the past 24 hours), who have been afebrile for 24 hours, whose white blood cell count and C-reactive protein are normalizing, and who will be adherent.^15,16,30 Generally avoid switching to oral without specialist consultation if source control has not been achieved (e.g., undrained abscess, empyema), or if the patient has meningitis, a severe or necrotizing soft tissue infection, infections requiring high antibiotic tissue levels or prolonged IV therapy, infection associated with a foreign body, immunocompromise, a deep-seated infection, a critical infection with high mortality, or septic arthritis.^15,16,29 Certain patients with gram positive endocarditis could be switched to oral therapy after about two weeks of IV therapy.² Bacteremia with the most evidence for IV to PO switch stems from enterobacterales urinary tract infections and community-acquired pneumonia caused by Streptococcus pneumoniae.^29,30 There is emerging evidence to support IV to PO stepdown therapy for gram-positive bacteremia.³⁰ Oral Antibiotics for Acute Osteomyelitis in Adults may be appropriate. See our chart, Considerations for IV-to-PO Conversions for drug-specific considerations.
Monitor antibiotic therapy and ensure appropriate follow-up.	Follow up on and modify treatment based on the results of the culture and sensitivities. Choose oral antibiotics based on culture results, source of infection, adverse effects, and bioavailability.²⁹ For example, for uncomplicated Staphylococcus aureus bacteremia, consider linezolid (high bioavailability) over doxycycline, a beta-lactam (low serum concentrations), or fluoroquinolone/rifampin (adverse effects).^30,32 Where appropriate, consider adding a requirement to antibiotic orders of a stop date and the indication for the antibiotic. In the long-term care setting, the antibiotic start date (in the hospital) would also be helpful. Develop a follow-up program where someone (prescriber, nurse, pharmacist) calls to see if a patient’s symptoms have improved, if patients have any questions about symptom relief, etc.
Know best practices for infusing beta-lactams.	Extended infusions are infused over 3 to 4 hours, continuous infusions are infused over the entire dosing interval, and traditional intermittent infusions are infused over 30 to 60 minutes.³⁹ Data supports use of continuous infusions in critically ill patients with severe, drug-resistant gram negative infections to improve survival or clinical cure.^21,39But in theory, continuous infusion should benefit all infections.²¹ Antibiotics with the most data as continuous infusions are ceftazidime, piperacillin-tazobactam, and meropenem.^21,39Penicillin G has been studied mostly in stable patients, such as in home health patients.⁴¹ Consider potential drawbacks (e.g., need for a dedicated line, antibiotic stability constraints).²¹ Suggest a one-time loading dose before starting a continuous infusion.³⁹It is unclear if a loading dose given before an extended infusion is beneficial.³⁹ Therapeutic drug monitoring can be considered.³⁹ When therapeutic drug monitoring is done, the suggested target level for continuous infusions is ≥4 times the MIC.³⁹For extended infusions, it is suggested that the level remain above the MIC 50% to 70% of the time.³⁹
Prevent readmissions.	Use our Transitions of Care Checklist, to keep medication lists up to date. Ensure appropriate post-discharge follow-up is scheduled and communicated to the patient. Use our toolbox, Medication Adherence Strategies, to help patients stay on their meds.

Abbreviations: ASHP = American Society of Health-System Pharmacists; CDC = Centers for Disease Control and Prevention; IDSA = Infectious Diseases Society of America; PIDS = Pediatric Infectious Diseases Society; SHEA = Society for Healthcare Epidemiology of America; SIS = Surgical Infection Society; WHO = World Health Organization

References

Clinical Pharmacology powered by Clinical Key. Tampa, FL: Elsevier; 2026. http://www.clinicalkey.com. (Accessed February 11, 2026).
Iversen K, Ihlemann N, Gill SU, et al. Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis. N Engl J Med. 2019 Jan 31;380(5):415-424.
Boggan JC, Navar-Boggan AM, Jhaveri R. Pediatric-specific antimicrobial susceptibility data and empiric antibiotic selection. Pediatrics. 2012 Sep;130(3):e615-22.
Reynolds RV, Yeung H, Cheng CE, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2024 May;90(5):1006.e1-1006.e30.
Federal Task Force on Combating Antibiotic-resistant Bacteria. National action plan for combating antibiotic-resistant bacteria. October 2020. https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//196436/CARB-National-Action-Plan-2020-2025.pdf. (Accessed February 11, 2026).
Keow S, Xiong G, Abu-Hilal M. Update to acne vulgaris treatment for Canadian practice. Can Fam Physician. 2025 Jul-Aug;71(7-8):455-466. doi: 10.46747/cfp.710708455. Erratum in: Can Fam Physician. 2025 Oct;71(10):612.
CDC. Antibiotics Aren’t Always the Answer. https://www.cdc.gov/antibiotic-use/media/pdfs/Arent-Always-The-Answer-FS-508.pdf. (Accessed February 11, 2026).
Mayo Clinic. Consumer health. Antibiotics: are you misusing them? April 9, 2024. https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/antibiotics/art-20045720. (Accessed February 11, 2026).
Costelloe C, Metcalfe C, Lovering A, et al. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ. 2010 May 18;340:c2096.
Cleveland Clinic health essentials. What the color of your snot really means. January 14, 2021. https://health.clevelandclinic.org/what-the-color-of-your-snot-really-means/. (Accessed February 12, 2026).
Mangione-Smith R, Zhou C, Robinson JD, et al. Communication practices and antibiotic use for acute respiratory tract infections in children. Ann Fam Med. 2015 May-Jun;13(3):221-7.
Meeker D, Knight TK, Friedberg MW, et al. Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA Intern Med. 2014 Mar;174(3):425-31.
Montaner Ramón A, Castilla Fernández Y, Frick MA, et al. How to assess early-onset neonatal sepsis? Comparison of three detection strategies. An Pediatr (Engl Ed). 2023 Feb;98(2):92-98.
Slayton RB, Toth D, Lee BY, et al. Vital Signs: Estimated Effects of a Coordinated Approach for Action to Reduce Antibiotic-Resistant Infections in Health Care Facilities – United States. MMWR Morb Mortal Wkly Rep. 2015 Aug 7;64(30):826-31.
Harvey EJ, McLeod M, De Brún C, Ashiru-Oredope D. Criteria to achieve safe antimicrobial intravenous-to-oral switch in hospitalised adult populations: a systematic rapid review. BMJ Open. 2023 Jul 7;13(7):e068299.
UK Health Security Agency. Antimicrobial intravenous-to-oral Switch (IVOS) decision aid. 2023. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1133525/Final_IV_to_Oral_Switch_Decision_Aid_based_on_NationalCriteria_UKHSA.pdf (Accessed February 12, 2026).
Modi AR, Kovacs CS. Hospital-acquired and ventilator-associated pneumonia: Diagnosis, management, and prevention. Cleve Clin J Med. 2020 Oct 1;87(10):633-639.
CDC. Core elements of hospital antibiotic stewardship programs: 2019. https://www.cdc.gov/antibiotic-use/media/pdfs/hospital-core-elements-508.pdf. (Accessed February 8, 2026).
Muñoz P, Guembe M, Pérez-Granda MJ, Del Pozo JL, López-Cortés LE, Pittiruti M, Martín-Delgado MC, Bouza E. Vascular catheter-related infections: an endemic disease in healthcare institutions. An opinion paper of the Spanish Society of Cardiovascular Infections (SEICAV). Rev Esp Quimioter. 2024 Oct;37(5):387-400.
Cleveland Clinic. Common cold. February 7, 2023. https://my.clevelandclinic.org/health/diseases/12342-common-cold. (Accessed February 12, 2026).
Ramanan M, Keynan Y, Laupland K. Enough is Enough: Continuous Beta-Lactam Infusions for Treating Serious Infections. J Assoc Med Microbiol Infect Dis Can. 2024 Dec 19;9(4):200-203.
CDC. National Healthcare Safety Network (NHSN). Antimicrobial use and resistance module. January 2026. https://www.cdc.gov/nhsn/pdfs/pscmanual/11pscaurcurrent.pdf. (Accessed February 8, 2026).
Barlam TF, Cosgrove SE, Abbo LM, 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 May 15;62(10):e51-77.
Linder JA, Watson ME, Wessels MR, et al. 2025 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Group A Streptococcal (GAS) Pharyngitis: Risk assessment using clinical scoring systems in children and adults. Clin Infect Dis. 2025 Dec 4:ciaf668. doi: 10.1093/cid/ciaf668. Epub ahead of print. PMID: 41343363.
Pavia AT. Reducing diagnostic uncertainty to improve treatment of respiratory infections. Lancet Respir Med. 2017 May;5(5):364-365.
Fusco NM, Nichols K. Common bacterial infections and their treatment in hospitalized pediatric patients. Am J Health Syst Pharm. 2019 Sep 16;76(19):1521-1531.
CDC. Sinus infection basics. https://www.cdc.gov/sinus-infection/about/. (Accessed February 11, 2026).
Mulhem E, Patalinghug E, Eraqi H. Acute Bronchitis: Rapid Evidence Review. Am Fam Physician. 2025 Mar;111(3):214-217.
Hospenthal DR, Waters CD, Beekmann SE, Polgreen PM. Practice Patterns of Infectious Diseases Physicians in Transitioning From Intravenous to Oral Therapy in Patients With Bacteremia. Open Forum Infect Dis. 2019 Aug 30;7(12):ofz386.
Caniff KE, Rebold N, Rybak MJ. Oral stepdown in Gram-positive bloodstream infections: A step in the right direction. Pharmacotherapy. 2023 Mar;43(3):247-256.
Miller BJ, Carson KA, Keller S. Educating Patients on Unnecessary Antibiotics: Personalizing Potential Harm Aids Patient Understanding. J Am Board Fam Med. 2020 Nov-Dec;33(6):969-977.
Ramos-Otero GP, Sarangarm P, Walraven C. A Retrospective Analysis of Intravenous vs Oral Antibiotic Step-Down Therapy for the Treatment of Uncomplicated Streptococcal Bloodstream Infections. J Clin Pharmacol. 2022 Nov;62(11):1372-1378.
Kaspute G, Ivaskiene T. Pharmacist-Led Diagnostics: A New Frontier in Antimicrobial Stewardship. Antibiotics (Basel). 2025 Dec 18;14(12):1286.
CDC. Indwelling urinary catheter culture stewardship: overview. https://www.cdc.gov/uti/hcp/clinical-guidance/. (Accessed February 11, 2026).
NIAHO. Accreditation requirements, interpretive guidelines & surveyor guidance for hospitals and critical access hospitals. Revision 25-1. https://www.dnv.us/publications/niaho-requirements-revision-25-1-updated/. (Accessed February 8, 2026).
The Joint Commission. Standards FAQ. What are the expectations for a hospital’s antibiotic stewardship program? https://www.jointcommission.org/en-us/knowledge-library/support-center/standards-interpretation/standards-faqs/000002449. (Accessed February 8, 2026).
Dellit TH, Owens RC, McGowan JE Jr, Infectious Diseases Society of America; Society for Healthcare Epidemiology of America. 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 Jan 15;44(2):159-77.
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 Apr;33(4):322-7.
Hong LT, Downes KJ, FakhriRavari A, et al. International consensus recommendations for the use of prolonged-infusion beta-lactam antibiotics: Endorsed by the American College of Clinical Pharmacy, British Society for Antimicrobial Chemotherapy, Cystic Fibrosis Foundation, European Society of Clinical Microbiology and Infectious Diseases, Infectious Diseases Society of America, Society of Critical Care Medicine, and Society of Infectious Diseases Pharmacists. Pharmacotherapy. 2023 Aug;43(8):740-777. Erratum in: Pharmacotherapy. 2023 Sep 19.
CDC. Urine culture stewardship in patients without indwelling urinary catheters. March 13, 2024. https://www.cdc.gov/uti/hcp/clinical-guidance/culture-stewardship-without-catheter.html. (Accessed February 11, 2026).
Van Herendael B, Jeurissen A, Tulkens PM, et al. Continuous infusion of antibiotics in the critically ill: The new holy grail for beta-lactams and vancomycin? Ann Intensive Care. 2012 Jul 2;2(1):22.

Cite this document as follows: Clinical Resource, Antimicrobial Stewardship. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber Insights. February 2026. [420263]

Antimicrobial Stewardship

Related Articles