Indian Journal of Critical Care Medicine
Volume 25 | Issue 6 | Year 2021

Antibiotic Stewardship: Easy to Preach, Difficult to Practice

Ashit Hegdehttps://orcid.org/0000-0003-4342-122X

Department of Critical Care Medicine, PD Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India

Corresponding Author: Ashit Hegde, Department of Critical Care Medicine, PD Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India, Phone: +91-22-24462250, e-mail: ahegde1957@gmail.com

How to cite this article: Hegde A. Antibiotic Stewardship: Easy to Preach, Difficult to Practice. Indian J Crit Care Med 2021;25(6):608–609.

Source of support: Nil

Conflict of interest: None


The Merriam-Webster dictionary defines catchphrase as: “a word or expression that is used repeatedly and conveniently to represent or characterize a person, group, idea, or point of view.”1

The term “antimicrobial stewardship” (AMS) first used by McGowan and Gerding in 1996 from the USA has now become a catchphrase.2

While it is convenient to repeatedly talk and write about antibiotic stewardship, its actual implementation is a different proposition altogether.

According to the Centers for Disease Control and Prevention, there are seven core elements of an Antimicrobial Stewardship Program (AMSP):3

If a hospital wishes to implement an ideal AMSP incorporating all these core elements, an AMS committee needs to be constituted. This AMS committee should ideally comprise of representatives from (i) Administration, (ii) Infectious Diseases, (iii) Infection Control, (iv) Microbiology, (v) Intensive Care, (vi) Nursing, (vii) Surgery, (viii) Operation Theater, and (ix) Pharmacy.

Unfortunately, most Hospital Administrators in India are unwilling to spend too much (money and commitment) on an AMSP. In India, (at least in the private sector), the patient has to bear not only the health consequences of antimicrobial resistance but also bears the financial costs. The institution does not directly suffer any direct loss as a consequence of antimicrobial resistance. There is, therefore, no incentive for the Hospital Administration to promote appropriate antibiotic use and to decrease the incidence of antimicrobial resistance.

Agarwal et al.4 must, therefore, be complimented for trying to implement some of the elements of AMS in their hospital. The strategies they used for improving antibiotic use were:

Rapid identification of the organism using matrix-assisted laser desorption ionization time-of-flight or polymerase chain reaction-based techniques and rapid identification of resistance mechanisms using blood culture identification or Xpert Carba will go a long way in rapid optimization of therapy.7

Of course, rapid diagnostics will only work if clinicians are willing to de-escalate.

It is, however, chastening to note that in spite of all these measures, though there was a statistically significant increase in the sensitivity of most of the antibiotics, this increase did not translate into clinical significance—the sensitivity did not increase to a level where lower antibiotics could be safely prescribed as empiric therapy. It is, therefore, difficult to explain how the overall consumption of antibiotics still decreased in spite of an overall increase in the number of positive blood cultures. It would have been interesting to learn from the authors whether the overall decrease in antibiotic consumption was because of increased de-escalation or because of the decreased duration of use.

This study also underscores the point that to make a significant impact on the incidence of antibiotic resistance, a concerted effort is needed.

Execution of all the seven core elements of AMSP, however, involves a lot of hard work and takes up a lot of time. Unless the members of the AMSP are adequately compensated for their time and effort, their devotion to running a successful AMSP wanes over time.

In reality, it will be difficult to implement every step of an ideal AMSP. The few simple measures such has been practiced by Agarwal et al.—Restricting the number of antibiotic prescribers, greater dependence on microbiologists and microbiology labs, and good communication among clinicians will unfortunately be just one tiny weapon in our war against antimicrobial resistance.8 A war we are in danger of losing.


Ashit Hegde https://orcid.org/0000-0003-4342-122X


1. Merriam-Webster’s Online Dictionary. Available from: https://www.merriam-webster.com/dictionary/stewardship.

2. McGowan JE Jr, Gerding DN. Does antibiotic restriction prevent resistance? New Horiz. 1996 Aug;4(3):370-6. PMID: 8856755.

3. CDC. Core elements of hospital antibiotic stewardship programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2019.

4. Agarwal J, Singh V, Das A, et al. Reversing the Trend of Antimicrobial Resistance in ICU: Role of Antimicrobial and Diagnostic Stewardship. Indian J Crit Care Med 2021;25(6):635–641.

5. Pickens CI, Wunderink RG. Principles and practice of antibiotic stewardship in the ICU. Chest 2019;156(1):163–171. DOI: 10.1016/j.chest.2019.01.013.

6. Kollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest 1999;115(2):462–474. DOI: 10.1378/chest.115.2.462.

7. Giacobbe DR, Giani T, Bassetti M, Marchese A, Viscoli C, Rossolini GM. Rapid microbiological tests for bloodstream infections due to multidrug resistant Gram-negative bacteria: therapeutic implications. Clin Microbiol Infect 2020;26(6):713–722. DOI: 10.1016/j.cmi.2019.09.023.

8. Dryden M, Johnson AP, Ashiru-Oredope D, Sharland M. Using antibiotics responsibly: right drug, right time, right dose, right duration. J Antimicrob Chemother 2011;66(11):2441–2443. DOI: 10.1093/jac/dkr370.

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