What should be included in a 30-minute seminar on antibiotic stewardship for medical students?

Antibiotic Stewardship Seminar for Medical Students: 30-Minute Presentation Structure

Medical students require foundational education in antibiotic stewardship principles integrated into their clinical curriculum, as 90% of fourth-year students report wanting more education on appropriate antibiotic use and demonstrate low baseline knowledge scores on this topic. 1

Opening: Why Stewardship Matters (5 minutes)

The Crisis and Your Role

• Antibiotic resistance threatens patient mortality and morbidity due to widespread inappropriate use in up to 50% of cases in the United States, creating unnecessary selection pressure for resistant species 2
• Inappropriate antibiotic use directly increases Clostridium difficile infections, healthcare-associated infections with resistant organisms, and adverse drug events that harm patients 1, 3
• As future prescribers, you will be responsible for preventing these complications through judicious antimicrobial decision-making starting in your clinical rotations 1

Real Impact on Patient Outcomes

• Good stewardship reduces C. difficile infection rates, decreases nosocomial infections from resistant Enterobacteriaceae, and improves cure rates without negatively impacting mortality 1, 4
• Prospective audit and feedback programs have achieved 22% reductions in broad-spectrum antibiotic use over 7-year periods while improving patient outcomes 1, 4

Core Concept: The 5 D's of Stewardship (10 minutes)

Every antibiotic prescription must address five critical decisions: right Diagnosis, Drug, Dose, Duration, and De-escalation. 3, 4

1. Right Diagnosis

• Distinguish viral from bacterial infections before prescribing using appropriate diagnostic testing rather than empiric antibiotics for uncertain cases 5, 6
• Obtain cultures before antibiotic administration whenever possible, particularly blood cultures in suspected sepsis and respiratory cultures in pneumonia 4, 5
• Question positive urine cultures when pyuria or inflammatory changes are absent, as contamination is common 5
• Require chest radiograph confirmation before diagnosing bacterial pneumonia rather than treating presumptively 5

2. Right Drug

• Select the narrowest-spectrum antibiotic effective against the likely pathogen based on local antibiograms and resistance patterns 1, 3
• Know your institution's local epidemiology and resistance patterns to guide empiric choices 1, 7
• Avoid broad-spectrum agents (carbapenems, anti-pseudomonal cephalosporins) unless specifically indicated by severity or resistance risk 1

3. Right Dose

• Optimize pharmacokinetics and pharmacodynamics to achieve therapeutic levels that cure infection while minimizing toxicity 6, 2
• Inadequate dosing leads to clinical failures requiring subsequent antibiotic courses, increasing overall antibiotic exposure 5, 6

4. Right Duration

• Shorter durations are appropriate for most infections when source control is achieved 1, 3
• Uncomplicated intra-abdominal infections including acute cholecystitis and appendicitis require no post-operative antibiotics after source control 1
• Prolonging surgical prophylaxis beyond closure provides no clinical benefit and increases resistance risk 1

5. De-escalation

• Narrow or discontinue antibiotics based on culture results and clinical response rather than completing arbitrary courses 1, 3
• Stop unnecessary antibiotics immediately when infection is ruled out or alternative diagnosis established 1, 5

How Stewardship Programs Work (8 minutes)

Core Team Structure

• Antimicrobial stewardship programs require infectious disease physician leadership partnered with clinical pharmacists with infectious disease expertise 3, 4
• Multidisciplinary teams include microbiology laboratory support, infection control, nursing, and information technology 1, 3

Two Primary Intervention Strategies

Preauthorization (Formulary Restriction)

• Requires real-time approval before administering restricted broad-spectrum antibiotics 1, 4
• Advantages: Reduces inappropriate initiation, optimizes empiric choices, provides direct control, enables rapid response to shortages 1
• Disadvantages: Impacts only restricted agents, may delay therapy, requires 24-hour availability, reduces prescriber autonomy 1

Prospective Audit and Feedback (PAF)

• Reviews antibiotic prescriptions 24-48 hours after initiation with recommendations to optimize therapy 1, 4
• Advantages: Maintains prescriber autonomy, builds collegial relationships, provides educational benefit, allows flexibility in timing, can be done less than daily if resources limited 1
• Disadvantages: Compliance is voluntary, labor-intensive, success depends on delivery method, prescribers may resist changing therapy if patient improving 1
• PAF has demonstrated 22% reductions in broad-spectrum antibiotic use and decreased C. difficile infections without adversely affecting mortality 1, 4

Supporting Strategies

• Facility-specific clinical practice guidelines for common infections (pneumonia, cellulitis, intra-abdominal infections) based on local epidemiology 1
• Rapid diagnostic testing and biomarker utilization to distinguish bacterial from viral pathogens 4, 6
• Monitoring antibiotic consumption using Days of Therapy (DOTs) per 1,000 patient-days as the preferred metric 4, 8

What You Can Do Now as Students (5 minutes)

Immediate Actions in Clinical Rotations

• Question every antibiotic order you encounter: Is there confirmed bacterial infection? Is this the narrowest-spectrum option? What is the planned duration? 5, 7
• Advocate for obtaining cultures before antibiotics whenever clinically appropriate 4, 5
• Suggest clinical follow-up rather than antibiotics for patients who are not severely ill when diagnostic uncertainty exists 5

Building Your Knowledge Base

• Learn your institution's antibiogram and local resistance patterns during each rotation 1, 7
• Understand facility-specific guidelines for common infections rather than memorizing national guidelines that may not reflect local epidemiology 1
• Recognize that education alone produces non-sustainable improvements in prescribing—you must integrate stewardship principles into daily clinical decision-making 1

Patient Education Role

• Explain to patients why antibiotics are not indicated for viral infections to manage expectations and reduce demand for inappropriate prescriptions 5, 7
• Discuss the personal risks of antibiotic use including C. difficile infection, drug reactions, and promoting resistance in their own microbiome 3, 2

Critical Pitfalls to Avoid (2 minutes)

Common Prescribing Errors

• Never rely solely on didactic education or lectures to change prescribing behavior—stewardship requires active intervention strategies combined with education 1
• Avoid treating positive cultures without clinical correlation, particularly urine cultures without pyuria 5
• Do not continue antibiotics "to complete the course" when infection is ruled out or adequately treated 1, 3

System-Level Awareness

• Recognize that preauthorization systems can be manipulated by presenting requests in biased ways to gain approval 1
• Understand that prescribers may resist changing therapy even when inappropriate if the patient is clinically improving 1
• Antibiotic cycling and rotation strategies lack rigorous evidence and should not be primary stewardship interventions 2