Antimicrobial Stewardship—a practical guide to implementation in hospitals

Graphical Abstract Graphical Abstract

The objective of this booklet is to provide practical recommendations for healthcare workers in hospitals to improve the quality of antibiotic prescribing and thereby improve patient clinical outcomes.
Most of the recommendations within this booklet have been adapted from the IDSA Guidelines [Dellit et al., 2007;Tamar F et al., 2016], the Australian Hospital Stewardship Guidance [Duguid et al., 2011], National Stewardship Guidance from Scotland [Nathwani et al., 2006], the UK [Start smart then Focus DOH, 2011;NICE Guideline [NG15], 2015] as well as from low and middle income countries Cox et al., 2017].
A key component of stewardship is the availability of clinical practice guidelines to support empiric and targeted prescribing. Although a high volume of such guidance is now being produced, for example the National Treatment Guidelines for Antimicrobial Use in Infectious Diseases in India, there is consistent evidence that guidelines on empirical antibiotic use did not routinely consider local resistance patterns in their recommendations. Decision-makers should analyze and report the extent of local resistance patterns to allow better decision-making [Elias et al., 2017]. For this reason we have not referred to any specific clinical practice treatment guidelines.
We hope that this booklet will inform, encourage and support health professionals wishing to pursue the implementation of hospital Antimicrobial Stewardship initiatives, as well as combating antimicrobial resistance. Furthermore, we wish to highlight the importance of conducting hospital stewardship programs in tandem with stewardship in the community and other settings. The importance of stewardship in the animal setting is also recognized as in the "One Health" approach to AMR and stewardship recommended by WHO, FAO & OIE.

WHY IMPLEMENT ANTIMICROBIAL STEWARDSHIP IN HOSPITALS?
1 Antimicrobial use Misuse and over-use of antibiotics The last 50 years have witnessed the golden age of antibiotic discovery and their widespread use in hospital and community settings. Regarded as very effective, safe and relatively inexpensive, antibiotics have saved millions of lives. However, this has led to their overuse and misuse in the human, animal and other sectors ( Figure 1).
Globally, between 2000 and 2010 there has been a massive rise in overall antimicrobial consumption (Figure 2), largely as a consequence of uncontrolled prescription or over-the-counter sales.
More recent global data on the quality of antimicrobial prescribing in hospitals, undertaken using a global point prevalence survey method [Global PPShttp://www.global-pps.com] reveals significant variation in practice against commonly used metrics of the quality of prescriptions ( Figure 3). Such real world data is beginning to provide much needed intelligence of what the problem is, the scale of the problem and ways of measuring the effectiveness of our interventions.  At global level, 70% of antibiotics are used for animals [O'Neill report, 2016]. In the US, this is 85% (Figure 1).
In hospitals, up to 50% of antimicrobial use is inappropriate [Dellit et al., 2007].  Relative contribution of factor as a driver for antimicrobial resistance Evidence that factor is contributing to antimicrobial resistance The rising threat of antimicrobial resistance Antimicrobial resistance has been identified as a major threat by the World Health Organization [WHO, 2012] due to the lack of new antibiotics in the development pipeline and infections caused by multi-drug resistant pathogens becoming untreatable [Goossens et al., 2011;Carlet et al., 2011]. In 2015, the WHO set out the global action plan for AMR [WHO, 2015] and a subsequent broader stewardship framework.
To achieve this approach, an integrated stewardship approach has been advocated, encompassing antimicrobial stewardship, diagnostic stewardship and infection control ( Figure 5).

WHY IMPLEMENT ANTIMICROBIAL STEWARDSHIP IN HOSPITALS?
The 30% Rule n ~ 30% of all hospitalized inpatients at any given time receive antibiotics n ~ over 30% of antibiotics are prescribed inappropriately in the community n ~ up to 30% of all surgical prophylaxis is inappropriate n ~ 30% of hospital pharmacy costs are due to antimicrobial use n ~ 10-30% of pharmacy costs can be saved by antimicrobial stewardship programs (Hoffman et al., 2007;Wise et al., 1999;John et al., 1997) 2 Combating Antimicrobial Resistance There are numerous drivers for AMR ( Figure 4). Human antimicrobial misuse and overuse is a key driver factor, as are suboptimal dosing, lack of availability and/or under-use of rapid diagnostics or point of care tests and insufficient infection prevention and control.
To combat AMR, a "three-pillar" approach is recommended: 1. Optimize the use of antimicrobials, 2. Prevent the transmission of drug-resistant organisms, 3. Improve environmental decontamination. Adapted from Dik JH et al. Future Microbiol. 2015;11: 93-102  The prevention of surgical site infections (SSIs) remains one of the most accessible and "doable" areas of antimicrobial stewardship programs (ASPs) usually in combination with infection prevention measures. The effect of ASPs on reducing surgical site infections can be dramatic and of high impact, making SSIs a very visible "quick win" that can encourage buy-in into stewardship programs ( Figure 7). * a systems level "Antimicrobial stewardship is an organisational or healthcare system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness" * an individual/team level "Antimicrobial stewardship: is an inter-professional effort, across the continuum of care, involves timely and optimal selection, dose and duration of an antimicrobial, for the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient, and minimal impact on resistance and other ecological adverse events such as C. difficile."  Studies have shown that ASPs can effectively reduce antibiotic utilization, cost of care and even antimicrobial resistance rates, without increasing mortality. However, ASPs should avoid the perception that the goal of the program is primarily to reduce antibiotic purchases and costs, instead of focusing on improving the quality of care. To address the patient safety concern, data showing no adverse impact on morbidity or mortality is important for reassurance and engagement ( Figure 8).
n Reduce duration of hospital stay, without increasing mortality or infectionrelated readmissions (Figure 8). This Singapore-based study showed that in patients whose physicians accepted suggested ASP interventions, there was: • shorter average length of stay (mean 19.4 days vs. 24.2 days), • significantly shorter hospital stay between ASP intervention and discharge (mean 10.2 days vs 16.6 days), • significant reduction in 14-day re-infection rates between accepted (0%) and rejected (10%) groups, • no difference in all-cause mortality (P = 0.191).
n Reduce C.difficile colonization or infection by controlling the use of "high-risk" antibiotics ( Figure 9). A more recent example in Scotland showed a reduction in C. difficile infection (CDI) applicable at a national level following restriction of high risk antibiotics that included cephalosporins, co-amoxiclav, quinolones and clindamycin [Lawes et al, 2017]. This illustrates the potential for massive impact of stewardship programs at nationwide levels.

Goal 3: Reduce resistance
Restricting relevant agents can reduce colonization or infection with Gram-positive or Gram-negative resistant bacteria ( Figure 10). Numerous other examples of the effect of ASPs on multi-drug resistant Gram-negative bacteria are given in this meta-analysis [Baur et al., 2017] Goal 4: Control healthcare costs (without adversely impacting quality of care) Antibiotic-resistant infections are associated with high costs (Figure 11).

Figures 12a and 12b
are examples of how stewardship programs in hospitals can deliver significant cost savings through improved antimicrobial prescribing practices. Adapted from Roberts RR et al. Clin Infect Dis. 2009;49:1175-1184 Medical costs attributable to ARI

Implementation of Antimicrobial Stewardship Programs
A global survey has outlined the availability of stewardship programs across the continents ( Figure 13).
This remains a unique global survey, although more recent continental data is emerging showing that in Africa, for example, nurses are a key part of hospital stewardship programs ( Figure 14) [Bulabula et al. 2018].  A recent systematic review of antimicrobial stewardship programs in Asia illustrates emerging experience of their impact on a range of outcomes [Lee et al. 2018]. This meta-analysis, which reviewed 77 studies, showed that among those studies: n 91% reported reduced antibiotic usage, n 100% reported cost savings, n duration of antibiotic therapy was reduced in 6 of 7 studies, n rates of all-cause mortality and HAI were not significantly different between the intervention and control groups, n mortality rates were significantly improved by ASPs using drug monitoring, n HAI rates were also improved by ASPs that included infection control or hand hygiene programs.
Antimicrobial stewardship (AMS) strategies can use different methods or techniques to support the adoption, implementation, and sustainability of a clinical program or practice.
The strategies include 'top down/bottom up, ' 'push/pull, ' and 'carrot/stick' tactics, and typically involve 'package' approaches. They also include methods for provider training and decision support; intervention-specific tool kits, checklists, and algorithms; formal practice protocols and guidelines; learning collaboratives, business strategies and organizational interventions (such as "plan-do-study-act" cycles) and economic, fiscal, and regulatory methods. In 2018, these core elements were adapted for a global audience and supplemented by a check list descri bing essential and minimum standards for AMS programs in hospitals worldwide ( Figure 15).
Although strategies depend on local needs and issues, and available expertise and other resources, there are a number of core elements that make up the basis of a good stewardship program.
Once these core elements have been identified, an 8-step process of implementation described on page 16 is one pragmatic way of implementing the stewardship program.
A program devised for hospitals in the Netherlands is also worthy of review This can be done for example by undertaking point prevalence surveys or audits, assessing appropriateness of infection management and antimicrobial prescription (e.g. indication, choice and duration of antibiotic therapy in pneumonia or surgical prophylaxis according to policy/guidance)

CORE ELEMENT 7 Reporting and feedback (on a continuous basis)
All these reports should also be shared with the hospital management leadership 16 17 HOW TO IMPLEMENT AN ANTIMICROBIAL STEWARDSHIP PROGRAM 1 Assess the motivations Analyze your situation and what problems you want to address. There are many international guidelines available, but you will need to adapt them to your local situation.
Define where you are and where you want to go, with quantitative figures.
One of the ways of obtaining these data is to measure the quantity and quality of antibiotic use, for example, using a Point Prevalence Survey, such as the Global-PPS (see Section 6.1.1).
What can be implemented will depend on local needs/issues, geography, available skills/expertise and other resources.
For example, easier or less costly approaches can include: • simple clinical algorithms, • prescribing guidance for treatment, surgical prophylaxis, • IV to oral conversion, • provision of microbiological support, • restricting availability of certain antibiotics (formulary restriction), • automatic therapeutic substitution, • IV antimicrobial batching, • promoting education.
[ Goff et al., 2012] 2 Ensure accountability and leadership To ensure a successful Antimicrobial Stewardship Program: the program should be supported by the senior hospital management, who are accountable for the outcomes, a team of people and resources should be allocated by the head of the organization to implement and evaluate the program, the ASP team members must possess power, expertise, credibility and leadership. These individuals need to convince managers and healthcare staff of the added value of the program. A key component of a stewardship program is leadership and culture. This can be set out as a driver diagram (see Table 1 on page 18 for more details). The key components of the structure and governance of the ASP are:

EIGHT KEY STEPS
Dedicated resources, including dedicated personnel time for stewardship activities, education, and measuring/monitoring antimicrobial use.
A multidisciplinary AS team with core membership of: • an infectious diseases physician (or lead doctor or physician champion), • a clinical microbiologist, • a clinical pharmacist with expertise in infection.
Other members could be specialist nurses, for example infection prevention or stewardship nurses, quality improvement /risk management/patient safety managers and clinicians with an interest in infection.
Governance within the hospital's quality improvement and patient safety governance structure Clear lines of accountability between the chief executive, clinical governance, drug and therapeutics committee, and infection prevention and control committees, and the AST. Figure 16 illustrates such an organization structure. This structure would need to be adapted to local context and available resources.

Identify clinical providers as champions to
be thought leaders about antibiotic stewardship. 2. Work with administrators to ensure that they understand the rationale and goals for stewardship programs and interventions and provide support (financial and non-financial). 3. Engage a physician champion and core team to enhance the focus of antimicrobial stewardship into the current process of care. 4. Bring disciplines together to improve communication and collaboration about improving antibiotic use, including: -Infection preventionists; -Hospitalists; -Intensivists; -Emergency department physicians; -Microbiologists; -Pharmacists; -Nurses; and -Infectious disease experts. 5. Consider having the multidisciplinary group perform a gap analysis of antimicrobial use at the facility to identify priority areas for improvement.

KEY CHANGE CONCEPTS
Engage administrative and clinical leadership to champion stewardship effort

SECONDARY DRIVER
Promote a culture of optimal antibiotic use within the facility Two core ASP strategies have evolved ( Figure 18):

FRONT-END STRATEGIES
Antimicrobials made available through an approval process (formulary restrictions and preauthorization)

BACK-END STRATEGIES
Antimicrobials reviewed after antimicrobial therapy has been initiated (prospective audit with intervention and feedback) One way of doing this is to produce a Driver Diagram (see Figure 17 as an example). A Driver Diagram is a logic chart with three or more levels, including: a goal or vision, the high-level factors needed to achieve this goal (called 'primary drivers'), specific projects and activities that would act upon these factors.
For more complex goals, each primary driver could have its own set of 'secondary drivers' (or lower level drivers).
Driver diagrams can help an ASP team to: explore the factors that need to be addressed to achieve a specific overall goal, show how the factors are connected, act as a communication tool for explaining a change strategy, provide the basis for a measurement framework.
The objectives of the ASP and how they are going to be achieved and measured need to be agreed by all the key stakeholders and communicated clearly. When establishing a new stewardship program, it is best to start with the core strategies and focus on achieving and maintaining them before adding some of the supplemental strategies (

HOW TO IMPLEMENT AN ANTIMICROBIAL STEWARDSHIP PROGRAM
Some of the advantages and disadvantages of these two strategies are given in Figure 19.
Although more labour-intensive, back-end strategies are: more widely practiced, more easily accepted by clinicians as they reflect the daily decision-making process, provide a higher opportunity for educational opportunities, ultimately provide a more sustained impact of improving the overall quality of antimicrobial prescribing. [Chung et al., 2013].
In the UK, this approach has been innovatively adapted to create a simple pragmatic approach that is aligned with the clinical teams' daily decision-making process ( Figure 20).

BACK-END STRATEGY
Day1: review dose and possibility of IV-to-oral switch

. Antimicrobial Prescribing Policy
Hospital ASPs should include an Antimicrobial Prescribing Policy that is regularly reviewed and updated.
The important messages that need to be incorporated into the policy (MINDME) from Australian Stewardship Guidelines [Duguid et al., 2010] are illustrated in Table 3. Clinical guidelines or care pathways should take into account local microbiology and antimicrobial susceptibility patterns, as well as local resources and priorities, clinician preference/views and potential risk or unintended consequences. For guidelines to be relevant to daily practice, it is important they are updated on a regular basis and that older or outdated recommendations are removed.

Formulary restrictions / approval systems
This involves determining the list of restricted antimicrobial agents (broad spectrum and later generation antimicrobials) and criteria for their use combined with an approval system which is subject to regular audit and feedback to the prescribers. It is essential that all aspects of prescribing are supported by expert advice 24 hours a day where possible.

Antimicrobial review methods
Antimicrobial review methods are employed post-prescription and outlined in Table 4. The most appropriate interventions for your institution should be chosen, according to local resources.
**The lack of diagnosis and delay in microbiology remains a significant hurdle to good stewardship and source of high cost.

Audit and direct feedback to prescribers
The audit and feedback process can be managed by either the medical infection specialist or specialist pharmacist. However, depending on the intervention, specialist nurses or clinical pharmacists can also be trained to support this process.
During clinical review, a range of point-of-care stewardship interventions are useful to provide direct and timely feedback to the prescriber at the time of prescription or laboratory diagnosis, and provide an opportunity to educate clinical staff on appropriate prescribing.
The types of interventions selected, how they are delivered and by whom, will be determined by local resources, need and available expertise.
Feedback on antimicrobial prescribing should be provided regularly to prescribers in the critical care setting, and areas of high and/or poor quality antimicrobial use.
One way of evaluating prescribing within a unit or hospital is through regular point prevalence surveys (PPS) [Ansari et al., 2009, Seaton et al., 2007.
These data can be used in an audit process to provide structured feedback to prescribing teams and to define areas for improvement. Such point prevalence surveys can be used to establish baseline prescribing information and identify priorities for quality improvement.

Role of Diagnostics in Stewardship
Diagnostic stewardship refers to the appropriate use of laboratory testing to guide patient management, including treatment, in order to optimize clinical outcomes and limit the spread of antimicrobial resistance. This requires a seamless partnership between clinical laboratories, pharmacists, and infectious diseases clinicians, so that appropriate tests are ordered and diagnostic information is translated into appropriate management in real time.
Laboratories play a key role in antimicrobial stewardship ( Figure 21). However, they are often not used optimally or, in many parts of the world, they do not exist or have poor capacity and capability to deal with the problem. An example of an antimicrobial stewardship program for the microbiology laboratory and how it could be achieved is described in Figure 22.

HOW TO IMPLEMENT AN ANTIMICROBIAL STEWARDSHIP PROGRAM
The role that rapid diagnostic tests can play in optimizing the prescription of the most appropriate antibiotic therapy is illustrated in Figure 23.
The case study in Figure 24 illustrates the real world impact of a rapid respiratory panel (RP) on antibiotic and resource use.  Integration of diagnostics with other AS interventions, to provide fast accurate identification and susceptibility testing, will achieve better clinical outcomes and timely streamlining/de-escalating of empiric broad-spectrum antibiotics in seriously ill patients.
Many studies have assessed algorithms based on procalcitonin (PCT) as a rapid-reacting biomarker of bacterial infection for antibiotic stewardship. Recent systematic reviews showed benefits of PCT among patients with respiratory tract infection and sepsis by significantly reducing antibiotic exposure as well as a trend towards reduced costs and reduced length of ICU stay [Schuetz et al., 2011, Agarwal et al., 2011, Heyland et al., 2011, Mann et al., 2011, Matthaiou et al., 2012.
Near-patient rapid tests, e.g. influenza, Strep A, can be useful to identify patients with bacterial versus viral infections.
Molecular diagnostics or screening tests providing a faster result play an important role in pathogen detection in critically ill patients which will improve antibiotic stewardship and clinical outcomes [Afshari et al., 2012].
Diagnostic tests are key components of Antimicrobial Stewardship Programs, enabling the adjustment of treatment from broad spectrum antibiotic therapy to targeted and personalized treatments (Figure 25).  Establishing what to measure, the frequency of measurement and how the data will be communicated and acted upon are also key.

Initial antibiotic therapy
In addition to the audit and feedback described in section 5.

Surveillance of antimicrobial use and resistance
Monitoring trends in antimicrobial use and resistance within a hospital over several years and also identifying small changes in a single ward over a one-month period are essential to: adapt empiric treatment according to local resistance trends, demonstrate changes in practice over time, identify wards with high antimicrobial usage or use of non-policy antimicrobials and define targeted interventions required.

Measure improvement after implemented interventions
Surveillance of antimicrobial use and resistance is important: at hospital, local, regional, national levels (i.

Prescription surveillance through Point Prevalence Surveys
Regular point prevalence surveys (PPS) can be used to evaluate prescribing within a unit or hospital [Ansari et al., 2009, Seaton et al., 2007. A new e-learning module is also now available to provide training for those undertaking these surveys [https: //www.futurelearn.com/courses/point-prevalence-surveys].
These data can be used in an audit process to provide structured feedback to prescribing teams and to define areas for improvement. At a national level, as illustrated in an example for Scotland (Table 5), such point prevalence surveys can be used to establish baseline prescribing information and identify priorities for quality improvement. This information has led to the development of national prescribing indicators [Malcolm et al., 2012].   The value of these metrics has recently been illustrated at a global level. The GLOBAL PPS mentioned previously (see Figure 3) can provide not only metrics in relation to the prescribing quality process, but the ability to compare variations in practice between classes of agents. For example, in Figure 26, the quality of antibacterial and antifungal prescribing is compared, the latter being an important and rapidly emerging area for stewardship.
6.1.2. How is antimicrobial use data collected and analyzed? Antimicrobial use at individual patient level, using an electronic prescribing system through the Hospital Information System.
Data from hospital pharmacy computer systems, showing antimicrobials delivered to each ward and used as a proxy measure for antimicrobials administered to patients.
The measure used is Defined Daily Dose (DDD) which represents the average daily maintenance dose of an antimicrobial for its main indication in adults (Figure 27). For instance, the DDD of oral amoxicillin is 1000 mg, so a patient receiving 500 mg every 8 hours for 5 days consumes 7.5 DDDs.
Usage data may then be divided by a measure of hospital activity such as number of admissions or in-patient bed days to provide more meaningful trend analysis. In-patient bed days is more commonly used as this data can usually be obtained earlier than admissions data.
Other denominators are also used and their strengths and limitations have been described [Monnet D et al., 2007;Berrington A, et al., 2010] Hospital level data may be transferred to a national database for further analysis. ABC Calc is a simple computer tool to measure antibiotic consumption in hospitals. It transforms aggregated data provided by hospital pharmacies into meaningful antibiotic utilisation rates.

[http://www.escmid.org/research_projects/study_groups/esgap/abc_calc/]
Pareto charts are another useful tool to provide an overview of antimicrobial usage at ward level and identify wards that have high total usage or high use of restricted antimicrobials. Resistance data is obtained from the Microbiology laboratory through computer systems. Hospital level data may then be transferred to national databases. This is illustrated by an example from England ( Figure 28).

Data collection for quality improvement
Antimicrobial stewardship is part of many patient safety programs. To measure the performance of these programs, data is primarily used for 3 purposes [Solberg et al., 1997]: accountability (e.g. targets), improvement, research.
A range of such measures for antimicrobial stewardship programs have been proposed. They can be summarized as four types (Table 6): structural, process, outcomes and balancing (are the changes causing new problems?) [www.abs-international.eu;Dumartin et al., 2011].
A focus on outcomes data must be the key to convincing leadership, budget holders and decision makers of the value of stewardship programs. Such measures are outlined in Table 7.

STRUCTURAL INDICATORS
Availability of multi-disciplinary antimicrobial stewardship team Availability of guidelines for empiric treatment and surgical prophylaxis Provision of education in the last 2 years

PROCESS MEASURES
Amount of antibiotic in DDD/100 bed days -Promoted antibiotics -Restricted antibiotics Compliance with acute empiric guidance (documented notes and policy compliance) % appropriate de-escalation; % appropriate switch from IV to oral Compliance with surgical prophylaxis (<60 min from incision, <24 hours and compliance with local policy Compliance with care "bundles" -all or nothing (3-day antibiotic review bundle, ventilator-associated pneumonia, community-acquired pneumonia, sepsis)   Checklists are increasingly used to measure quality of care. A study of the use of an antibiotic checklist implemented in nine Dutch hospitals showed that use of the checklist resulted in more appropriate antibiotic use (Table 8).

OUTCOME MEASURES
What changes can we make that will result in improvement?

HOW TO IMPLEMENT AN ANTIMICROBIAL STEWARDSHIP PROGRAM
36 37

Examples of measures for improvement
A common quality improvement methodology is the "Plan-Do-Study-Act" model.
Quality improvement programs often use annotated run charts to display data and show the effects of changes. Figure 29 shows an example of a run chart used to measure improvement of administration of surgical antibiotic prophylaxis on time. www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementHowtoImprove What are we trying to accomplish?
How will we know that a change is an improvement?
Plan Study Do Act

Example of measures used for accountability
Compliance with policy is a process measure ( Figure 30).

Analysis of hospital datasets
Linkage of hospital datasets such as hospital admissions, laboratory data and patient outcomes allows measurement of the impact of stewardship interventions on patient morbidity and mortality.
This provides information about effects of antimicrobial interventions on clinical outcome. Figure 31 shows how restriction of cephalosporins and fluoroquinolones has resulted in reduced Clostridium difficile rates by linking antimicrobial usage data and microbiology data [Talpaert et al., 2011, Vernaz et al., 2009, Mamoon et al., 2012.   Table 9 [ Ashiru-Oredope et al., 2014].
Educating patients and the general public about hygiene and antibiotic use is also important, and may indirectly support hospital education efforts. National and regional public health campaigns, including education aimed at parents and children, have had a variable level of success [Huttner et al., 2010].
Some examples of public awareness campaigns: www.e-bug.eu www.ecdc.europa.eu/en/eaad www.cdc.gov/getsmart This consists of five dimensions, each of which includes statements that describe the activity and outcomes that prescribers should be able to demonstrate: Infection prevention and control Antimicrobial resistance and antimicrobials The prescribing of antimicrobials Antimicrobial stewardship Monitoring and learning 7.2 How to design an education program?
Programs should take into account local recommendations for antimicrobial stewardship, if available. If not, they could be inspired by international policies (see section on "Additional Resources", page 48) but adapted as required. Table 10 shows educational measures to improve antibiotic use in hospitals. An evaluation process should be included in the education program to measure attendance, understanding and assimilation, using regular training assessment tools such as attendance forms, completion certificates, questionnaires, tests etc. Another key communication tool that improves the effectiveness of conveying key messages is data visualization. Using infographic or other visual aids can be a compelling means of communicating data ( Figure 33). Finally, it is important to keep messages for clinical practice simple. For example, the 10 point principles approach below is easy to assimilate into practice and is relevant to the whole team looking after a patient with infection on antibiotics (Table 11).

Communicate
Communication is a key component of the success of an ASP.
Communicating to prescribers what the program recommends them to do is one of the essential implementation steps to successful stewardship. This requires a simple messaging approach that has identified key processes where stewardship interventions are required to be considered and actioned, such as the "Start Smart-Then Focus" approach developed in the UK. Figure 32 identifies the process for delivering effective surgical prophylaxis.
Another approach is to identify and communicate to prescribers specific situations where antibiotics should be withheld (Table 12) and guidance in relation to the duration of antibiotic use, which is often an area of misuse (Table 13).
Communicating, sharing and learning from data is also important.
Face-to-face meetings with prescribers, where there is an opportunity for reflection about their prescribing practices, or attending multi-disciplinary team web-ex conferences, etc. are all important in promoting learning about prudent prescribing.
Clear, simple communication should show the vision and the benefits of the program, with core clinical messages. Clean contaminated surgery * A repeat dose dose of prophylaxis may be required for prolonged procedures or 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.
Clean surgery involving placement of a prosthesis or implant Contaminated surgery Table 11: Ten key points for the appropriate use of antibiotics in hospitalized patients Adapted from Levy et al. Int J Antimicrob Agents. 2016;48: 239-46 1 Get microbiological samples before antibiotic administration and carefully interpret results: if no clinical signs of infection, colonization rarely requires antimicrobial treatment.
2 Only treat significant bacterial infections.
3 When indicated, start empirical antibiotic treatment, according to site of infection, risk factors for MDR bacteria, and local microbiology/susceptibility patterns.
4 Prescribe drugs at optimal dose, administration mode and length of time.
5 Use antibiotic combinations only when current evidence suggests some benefit.
6 Avoid antibiotics with a higher likelihood of promoting drug resistance or hospital-acquired infections.
7 Remove all infected devices.
8 Always try to de-escalate antibiotic treatment according to clinical situation and microbiological results; switch to oral route as soon as possible.
9 Stop antibiotics as soon as a significant bacterial infection is unlikely.
10 Set up local teams with an infectious diseases specialist, clinical microbiologist, hospital pharmacist, infection control practitioner or hospital epidemiologist; comply with antibiotic policies/guidelines.

43
Recently, as shown in Table 13, the move towards safely and effectively reducing duration of treatment, an important antimicrobial stewardship goal, is gaining pace [Spellberg, 2016], as is the whole concept of completing courses of therapy [Llewelyn, 2017]. The use of diagnostic tests, including biomarkers, will further support the move towards a more precise approach to duration of antimicrobial therapy.

THE KEYS TO SUCCESS
Establish clear aims/vision that is shared by all the stakeholders and that conveys a sense of urgency. Stewardship should be a patient safety priority.
Seek management support, accountability and secure funding.
Assemble a strong coalition including a multi-professional antimicrobial stewardship team with a strong influential clinical leader.
Establish effective communication structures within your hospital.
Start with core evidence-based stewardship interventions depending on local needs, geography and resources and plan measurement to demonstrate their impact.
Ensure all healthcare staff are aware of the importance of stewardship. Empower them to act and support with education using a range of effective strategies.
Ensure early or short term wins and then consolidate success/gains while progressing with more change or innovation.
A number of interventions are key to the success of a hospital-based Antimicrobial Stewardship Program.  The information in this booklet is for educational purposes only and is not intended to be exhaustive. It is not intended to be a substitute for professional medical advice. Always consult a medical director, physician, or other qualified health provider regarding processes and/or protocols for diagnosis and treatment of a medical condition. bioMérieux assumes no responsibility or liability for any diagnosis established or treatment prescribed by the physician.

bioMérieux
In vitro diagnostics serving public health A major player in in vitro diagnostics for more than 50 years, bioMérieux has always been driven by a pioneering spirit and unrelenting commitment to improve public health worldwide.
Our diagnostic solutions bring high medical value to healthcare professionals, providing them with the most relevant and reliable information, as quickly as possible, to support treatment decisions and better patient care.
bioMérieux's mission entails a commitment to support medical education, by promoting access to diagnostic knowledge for as many people as possible. Focusing on the medical value of diagnostics, our collection of educational booklets aims to raise awareness of the essential role that diagnostic test results play in healthcare decisions.
Other educational booklets are available. Consult your local bioMérieux representative.