Antibiotic Awareness Week 2025

Antimicrobial Stewardship & Diagnostic Stewardship Across the Healthcare Continuum

Antimicrobial stewardship (AMS) is a cornerstone of modern healthcare, aiming to optimize antibiotic use to combat antimicrobial resistance (AMR). Yet, as care delivery becomes increasingly fragmented, spanning ambulatory clinics, acute care hospitals, long-term care facilities, rehabilitation centers, home health settings and long-term acute care hospitals —the lack of electronic medical record (EMR) interoperability threatens the effectiveness of stewardship efforts. This fragmentation means that antibiotic prescriptions initiated in one setting may not be visible to providers in another. For example, a patient discharged from an acute care hospital to a rehab facility may continue receiving antibiotics without reassessment, simply because the rehab team lacks access to the original prescribing rationale. This lack of communication among facilities inadvertently increases the potential for resistant patterns, resulting in multidrug resistant organisms (MDROs).

Antibiotic pressure drives the emergence of MDROs. The Centers for Disease Control and Prevention (CDC) 2023 update on stewardship highlights how inappropriate prescribing varies by setting, clinician type, and patient demographics. In outpatient settings, overprescribing for viral infections remains a challenge. In inpatient and post-acute care settings, broad-spectrum antibiotics are often used empirically and continued unnecessarily due to poor documentation, reevaluation of diagnostics, and communication. This cumulative pressure across the continuum fosters resistance.

The rise of MDROs—including carbapenem-resistant Enterobacteriaceae (CRE), methicillin-resistant Staphylococcus aureus (MRSA), and Candida auris—is a direct consequence of unchecked antibiotic pressure. Furthermore, there is a need to improve diagnostic stewardship to reduce the overuse of antimicrobial treatments, which has the potential to reduce the risk of MDROs across the continuum of care. Diagnostic stewardship is a systematic approach to ensure the right diagnostic tests are ordered for the right patient at the right time to optimize clinical care and improve outcomes. It involves a collaborative effort across disciplines like laboratory medicine, pharmacy, nursing, and clinicians to improve test ordering, performance, and reporting. There is substantial evidence demonstrating the importance and effectiveness of both diagnostic stewardship and AMS in identifying and treating conditions such as asymptomatic bacteriuria, C. difficile infections, and bloodstream infections (BSIs). For example, implementing diagnostic stewardship interventions can optimize blood culture practices, such as ordering and collection techniques, to reduce the number of blood cultures in low-risk patients and decrease contamination rates. This, in turn, can lead to shorter hospital stays, reduce the need for further testing, and prevent the overuse of antibiotics due to misdiagnosed BSIs. Diagnostic stewardship and AMS are closely linked and work together to enhance patient safety and improve the quality of healthcare provided to patients.

Diagnostic stewardship and AMS approaches have core components that require leadership commitment, multidisciplinary collaboration, action, reporting, and education that can be supported in various ways by infection prevention. Infection preventionists, hospital epidemiologists, and members of the antimicrobial stewardship team play a crucial role in improving diagnostic efforts related to infectious diseases and healthcare-associated infections (HAIs). These professionals often educate healthcare staff on best practices for diagnosing infections and regularly analyze the outcomes of their interventions to measure success and make necessary adjustments. Infection Preventionists can integrate diagnostic and AMS interventions into broader HAI quality improvement efforts. This ensures a comprehensive approach to patient care and supports initiatives by training staff and assessing their impact.

In conclusion, antimicrobial stewardship must evolve beyond institutional boundaries and include the integration of diagnostic stewardship with AMS. Bridging EMR gaps and coordinating stewardship across the healthcare continuum is essential to reduce antibiotic pressure and curb the rise of MDROs. The path forward demands collaboration, innovation, and a commitment to systemic change.