Antimicrobial Stewardship Guidelines for Judicious Use of An

Antimicrobial Stewardship Guidelines for Judicious Use of Antibiotics by ICMR

Indian Council of Medical Research (ICMR) has released Antimicrobial Stewardship Guidelines to advise hospitals in setting up Antimicrobial Stewardship Programmes (AMSP) to ensure judicious use of antibiotics in healthcare facilities. 

Since inappropriate use of antibiotics is rampant in India, there is an urgent need to improve antibiotic use in hospitals, which can be achieved through implementation of good AMS programmes, Director General of the Indian Council of Medical Research (ICMR) Dr Balram Bhargava said. Unfortunately, most of hospitals in India lack the structure and process of implementing AMSP, he continued.

What is AMSP? 

It is hospital-based programmes dedicated to improving antibiotic use. It is helpful in improving quality of patient care and safety through increased infection cure rates, reducing treatment failures and increasing the frequency of correct prescription for therapy and prophylaxis.

Need for AMSP 

Antimicrobial resistance (AMR) is a major public health challenge. Since inappropriate use of antibiotics is rampant in India, there is urgent need to improve antibiotic use in hospitals. The increasing consumption of antibiotics is one of key drivers of antimicrobial resistance seen in bugs. Some of the key factors driving antimicrobial resistance in our country are irrational prescription of broad-spectrum antibiotics, poor regulations around sale of antibiotics, self-medication, lack of education and awareness regarding responsible use of antibiotics. 

National Health Policy, 2017, terms antimicrobial resistance as one of key healthcare issues and prioritises development of guidelines regarding antibiotic use, limiting over-the-counter use of antibiotics and restricting use of antibiotics as growth promoters in livestock. It is important to use the existing drugs judiciously.

Purpose of antimicrobial stewardship program

AMS guidelines aims to provide guidance in setting up structure and processes of AMSP in healthcare institutions, discusses essential elements of antimicrobial stewardship and diagnostic stewardship and provide information on tools that can be used to measure progress.

Primary goal 

To optimize safe and appropriate use of antibiotics to improve clinical outcomes and minimize adverse effects of antibiotics.

Secondary goal
 • To reduce health care costs without adversely impacting quality of patient care
 • To reduce the incidence of antibiotic induced collateral damage

Components of antimicrobial stewardship

1. Active strategy
2. Supplemental strategy 
3. Other strategies

  • Information technology 
  • Role of Microbiology laboratory 
  • Monitoring of process and outcome measurement
  • Comprehensive multidisciplinary antimicrobial management program

Antibiotic cycling

“Antimicrobial cycling” refers to the scheduled removal and substitution of a specific antimicrobial or antimicrobial class to prevent or reverse the development of antimicrobial resistance. Cycling is an attempt at controlled heterogeneity of antimicrobial use to minimize antimicrobial selection pressures.

Duration optimization


All clinicians should perform a review of antibiotics 48 hours after prescription. 

The following key questions should be checked from the available clinical and laboratory data. 

• Has the patient with an infection responded to the given antibiotic? 
• If so, can the patient on right antibiotic choice, dose, route of administration change the therapy to targeted antibiotic choice (deescalate) to treat the infection 
• Calculate the duration of antibiotic therapy

Switch from parenteral to oral therapy

Antimicrobial therapy for patients with serious infections requiring hospitalization is generally initiated with parenteral therapy. Enhanced oral bioavailability among certain antimicrobials-such as fluoroquinolones, oxazolidinones, metronidazole, clindamycin, trimethoprim-sulfamethoxazole, fluconazole, and voriconazole—allows conversion to oral therapy once a patient meets defined clinical criteria. This can decrease length of hospital stay and health care costs.

A few suggested conversion regimen - antibiotic for dosing in specific indications

Antimicrobial stewardship team

1. Medical directors
2. Pharmacist
3. Microbiologist 
4. Infection prevention control committee

Expected threat if AMSP is not rigidly practiced

• Antibiotic resistance is the crisis that is precipitating the current push for AMSP. The impact of antimicrobial resistance is high. The Centers for Disease Control and Prevention (CDC) estimates that each year in the United States, at least 2 million people acquire serious infections with bacteria that are resistant to 1 or more of the antibiotics designed to treat those infections. At least 23 000 people die each year as a direct result of these antibiotic-resistant infections. Many more die from other conditions that were complicated by an antibiotic-resistant infection. 
• Antibiotic-resistant infections add considerable and avoidable costs to the already over-burdened healthcare system. In most cases, antibiotic-resistant infections require prolonged and/or costlier treatments, extend hospital stays, necessitate additional healthcare encounters, increased morbidity, and result in greater disability and death compared with infections that are easily treatable with antibiotics.
• The most awaiting threat of AMSP includes non-acceptance of physicians strictly restricting to institution specific guidelines or national antibiotic guidelines based on local antibiogram.
• Implementation of AMSP is time-consuming and extensively labour intensive. In addition, de-escalation, redundant therapy, source controlled based debridement could be challenging in the successful implementation of AMSP. 
• Non-compliance to AMS recommended antibiotic stop date among physicians would an additional challenge in implementing AMSP institutions.

Read in detail about the AMSP here:

About Author
Lakshay Chotiya
Lakshay Chotiya is an analyst at PlexusMD and is a part of the Editorial Team. He is a B.Tech graduate from Indian Institute of Information Technology, Vadodara. He likes learning new things and writing. When not working, he is either exploring new places, binge-watching, meeting new people or playing strategic games.
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Dr. A●●l A●●●a and 12 others like this18 shares
Dr. H●●●●h D●●●i
Dr. H●●●●h D●●●i Obstetrics and Gynaecology
Guidelines are good & very much required. But the issue is complex. Who will take chance with the patient ? Framing the guidelines will not solve the issue rather strong implementation is required.
Nov 28, 2018Like1
Dr. S●●●●m Pk
Dr. S●●●●m Pk Psychiatry
All Drs should get in service or in practice training for up-to-date rational use of antibiotics
Nov 30, 2018Like
Dr. S●●●●●●●●●●n K●●●●●●i
Dr. S●●●●●●●●●●n K●●●●●●i Family Medicine
Yes you are right
Dec 2, 2018Like