Antimicrobial Stewardship: 30-Minute PowerPoint Presentation for DNB Students
Slide 1: Title Slide
Antimicrobial Stewardship: Preserving Our Most Critical Resource
- Your Name, Department
- Date
Slide 2: Opening Case - Interactive Poll
MCQ #1: A 45-year-old presents with 2 days of cough and rhinorrhea. Vitals normal. What do you do?
- A) Prescribe azithromycin immediately
- B) Order chest X-ray and prescribe antibiotics
- C) Watchful waiting with symptomatic treatment
- D) Prescribe broad-spectrum antibiotics "just in case"
Answer: C - Most upper respiratory infections are viral; antibiotics are unnecessary and harmful when bacterial infection is not confirmed 1, 2.
Slide 3: The Crisis We Face
Why Antimicrobial Stewardship Matters NOW
The primary goal of antimicrobial stewardship is to improve patient outcomes—specifically reducing morbidity and mortality—while minimizing adverse events, preventing antimicrobial resistance emergence, and optimizing resource utilization 1.
Key statistics:
- Up to 50% of antibiotic use in healthcare is unnecessary or inappropriate 3
- Antimicrobial resistance threatens our ability to treat common infections 4
- The pharmaceutical pipeline for new antibiotics has been severely curtailed—it may take ≥10 years before new antibiotics reach market 3
Slide 4: The 5 D's Framework - Your Daily Checklist
Every Prescription Must Answer These Questions:
- Right Diagnosis: Is this truly a bacterial infection? 1, 5
- Right Drug: Is this the narrowest-spectrum agent that will work? 6, 5
- Right Dose: Are you using optimal dosing to achieve cure? 7
- Right Duration: What is the shortest effective duration? 7, 5
- Right De-escalation: Can you narrow or stop based on cultures? 6, 5
Common Pitfall: Prescribing antibiotics when diagnosis is uncertain due to fear of missing infection or patient satisfaction concerns 7.
Slide 5: MCQ #2 - Test Your Knowledge
A urine culture grows 100,000 CFU/mL E. coli in an asymptomatic elderly patient with no pyuria. What do you do?
- A) Treat with ciprofloxacin for 7 days
- B) Treat with nitrofurantoin for 5 days
- C) No treatment - likely contamination
- D) Repeat culture and treat if positive again
Answer: C - Without pyuria or inflammatory changes, positive urine cultures likely represent contamination or asymptomatic bacteriuria, not infection requiring treatment 2.
Slide 6: WHO AWaRe Classification - Know Your Antibiotics
This Framework Guides Every Prescription Decision:
| Category | When to Use | Examples |
|---|---|---|
| ACCESS | First/second-line for common infections; wide availability, lower resistance potential [7] | Amoxicillin, doxycycline |
| WATCH | Higher resistance risk; critically important for humans; requires stewardship monitoring [7] | Fluoroquinolones, 3rd-gen cephalosporins |
| RESERVE | Last-resort only for confirmed MDR organisms; highly specific patients/settings [7] | Carbapenems, colistin |
Action Point: Watch and Reserve antibiotics should trigger automatic review in your institution 7.
Slide 7: Core Strategy #1 - Prospective Audit & Feedback
The Gold Standard Intervention
Prospective audit and feedback with real-time intervention to optimize antibiotic use represents the highest-quality evidence for stewardship effectiveness 6, 1.
How it works:
- Infectious disease-trained physicians or pharmacists review antimicrobial prescriptions within 24-48 hours 6
- Provide specific recommendations to prescribers in real-time 6, 5
- Focus on de-escalation, duration optimization, and stopping unnecessary therapy 6
Evidence: This strategy improves patient outcomes, reduces resistance, and decreases costs without compromising safety 4, 3.
Slide 8: Core Strategy #2 - Formulary Restriction
Controlling Access to High-Risk Agents
Formulary restriction and preauthorization form the foundation of effective antimicrobial stewardship programs alongside prospective audit 6, 5.
Implementation:
- Restrict Watch and Reserve category antibiotics to require approval 7
- Approval granted by infectious disease specialists or stewardship team 6
- Decisions made within 1-2 hours for urgent cases 7
Critical Warning: Never implement restrictive policies without educational support—this generates clinician resistance and dangerous workarounds 1.
Slide 9: MCQ #3 - Clinical Scenario
A patient with community-acquired pneumonia improves after 3 days of IV ceftriaxone. Cultures show penicillin-sensitive Streptococcus pneumoniae. What next?
- A) Continue IV ceftriaxone for 7 more days
- B) Switch to oral amoxicillin and discharge
- C) Switch to IV penicillin G
- D) Add azithromycin for atypical coverage
Answer: B - De-escalate to narrowest-spectrum oral agent (amoxicillin) once clinically stable with susceptibility data; this is a core stewardship principle 6, 5.
Slide 10: The Diagnosis Imperative
Document Before You Prescribe
You must document clinical evidence supporting bacterial infection before initiating antibiotics, measuring objective sepsis parameters 1.
Essential actions:
- Obtain appropriate cultures BEFORE antibiotic administration, especially in critically ill patients 1
- Use rapid diagnostic testing to distinguish viral from bacterial pathogens 1
- Employ watchful waiting for less severe infections where observation is safe 1
For respiratory infections: Obtain chest radiograph to support bacterial pneumonia diagnosis 2.
For urinary infections: Confirm pyuria or inflammatory changes before treating positive cultures 2.
Slide 11: Local Antibiograms - Your Most Important Tool
National Guidelines Are NOT Enough
Facility-specific clinical practice guidelines must be based on local resistance patterns and adapted to individual settings, rather than relying solely on national recommendations 1, 5.
Why this matters:
- Resistance patterns vary dramatically by region and institution 7, 5
- Empiric therapy should be restricted to therapies locally proven to be highly effective 7
- Treatment effectiveness must always be confirmed by test of cure 7
Action: Know your institution's antibiogram and update it annually 5.
Slide 12: MCQ #4 - Stewardship Strategy
Which intervention has the STRONGEST evidence for improving antimicrobial use?
- A) Educational seminars alone
- B) Antibiotic cycling programs
- C) Prospective audit with feedback
- D) Computerized alerts only
Answer: C - Prospective audit and feedback represents the highest-quality evidence for stewardship effectiveness, while education alone is insufficient for sustained practice change 7, 6, 1.
Slide 13: Monitoring & Measurement - What Gets Measured Gets Done
Essential Metrics for Your Institution
Track these continuously 1, 5:
- Antimicrobial utilization patterns (Days of Therapy per 1000 patient-days)
- Local and regional resistance trends (updated quarterly)
- Appropriateness of antibiotic therapy choices (guideline adherence)
- Clinical outcomes: Mortality, length of stay, rehospitalization rates 7, 5
- Microbiological outcomes: C. difficile infections, MDR organism rates 7
Process indicators reveal whether interventions actually changed prescribing behavior 7.
Slide 14: Special Considerations - Emergency Department
Unique Challenges Require Tailored Solutions
ED barriers to stewardship 7:
- Rapid decision-making without consultation time
- High patient turnover and overcrowding
- Medical liability concerns driving overuse
- Patient satisfaction pressures
Solutions that work 1:
- Provide 24/7 access to stewardship consultation
- Develop ED-specific treatment templates
- Implement clinical decision support tools at point of care
Remember: Broad-spectrum antibiotics are often appropriate for life-threatening infections in the ED; the focus is ensuring appropriate empiric treatment 7.
Slide 15: MCQ #5 - Duration of Therapy
A patient completes 5 days of antibiotics for uncomplicated cellulitis with complete resolution. They request the full 10-day course "to be safe." What do you do?
- A) Prescribe 5 more days as requested
- B) Stop antibiotics - treatment complete
- C) Prescribe 3 more days as compromise
- D) Switch to different antibiotic for 5 more days
Answer: B - Optimal duration is the shortest time required to reliably achieve cure; continuing antibiotics after clinical resolution increases resistance risk without benefit 7, 5.
Slide 16: Empiric vs. Definitive Therapy - Know the Difference
Two Distinct Phases of Treatment
- Initiated before culture results available
- Must cover likely pathogens based on clinical syndrome
- Should be based on local susceptibility patterns
- Requires culture collection FIRST
- Guided by culture and susceptibility results
- Narrowest-spectrum agent effective against identified pathogen
- Optimized dose and duration
- Requires active de-escalation decision
Critical principle: When culture and susceptibility information are available, they MUST be used to modify therapy 8, 9.
Slide 17: Building Your Stewardship Team
Multidisciplinary Collaboration is Essential
Leadership by infectious disease physicians with stewardship training, partnered with clinical pharmacists having infectious disease expertise, is essential for effective programs 6, 1.
Core team members 7:
- Infectious disease physician (leader)
- Clinical pharmacist with ID expertise
- Hospital epidemiologist
- Microbiologist
- Information technology specialist
- Representatives from each clinical department
Simplest first step: Have an ED/ward clinician volunteer to sit on the antimicrobial stewardship committee 7.
Slide 18: Education - Necessary But Not Sufficient
Active Learning Drives Engagement
Active educational programs including seminars and roundtable discussions promote clinician engagement, but education alone without complementary strategies is insufficient for sustained practice change 7, 5.
Effective educational approaches 7:
- Interactive case discussions (not passive lectures)
- Audit feedback with specific patient examples
- Real-time consultation at point of prescribing
- Integration with clinical decision support
Common pitfall: Relying solely on educational campaigns without implementing structural interventions like audit/feedback or formulary restrictions 7, 5.
Slide 19: MCQ #6 - Resistance Patterns
Your hospital antibiogram shows 40% fluoroquinolone resistance in E. coli urinary isolates. A patient presents with uncomplicated cystitis. What do you prescribe empirically?
- A) Ciprofloxacin - it's still first-line
- B) Nitrofurantoin or trimethoprim-sulfamethoxazole (if local resistance <20%)
- C) Ceftriaxone IV
- D) Fosfomycin
Answer: B or D - Empiric therapy must be restricted to agents with <10-15% local resistance; fluoroquinolones should be avoided when resistance exceeds 20% 7, 5.
Slide 20: Test of Cure - Close the Loop
Surveillance Drives Continuous Improvement
Treatment effectiveness must always be confirmed by test of cure, and this data should be integrated into local antimicrobial stewardship programs 7.
- Collect test-of-cure data systematically
- Share antimicrobial susceptibility data with clinicians
- Integrate outcomes into regional stewardship programs
- Use treatment outcomes (not theoretical efficacy) to guide local recommendations
Goal: Optimized therapy should reliably achieve ≥95% cure rates in adherent patients with susceptible infections 7.
Slide 21: Common Pitfalls - Learn From Others' Mistakes
Avoid these critical errors:
- Treating asymptomatic bacteriuria - No pyuria = no treatment needed 2
- Ignoring local resistance patterns - National guidelines don't reflect your institution 1, 5
- Continuing antibiotics "to complete the course" after clinical cure 7, 5
- Prescribing antibiotics for patient satisfaction without documented bacterial infection 7
- Using broad-spectrum agents when narrow-spectrum would work based on cultures 6, 5
- Implementing restrictions without education - creates resistance and workarounds 1
Slide 22: MCQ #7 - Putting It All Together
A 65-year-old with fever and cough. CXR shows infiltrate. Started on ceftriaxone + azithromycin. Blood cultures at 48h grow MSSA. Patient afebrile, improving. Next step?
- A) Continue current regimen for 7 days
- B) Switch to IV nafcillin or cefazolin, stop azithromycin
- C) Add vancomycin for MRSA coverage
- D) Switch to oral levofloxacin
Answer: B - De-escalate to narrowest-spectrum agent (nafcillin/cefazolin) effective against MSSA; stop unnecessary azithromycin 6, 5.
Slide 23: Practical Implementation - Your Action Plan
Start tomorrow with these steps:
- Review every antibiotic prescription using the 5 D's framework 6, 5
- Obtain cultures before antibiotics in all hospitalized patients 1
- Check your local antibiogram before prescribing empirically 5
- Set calendar reminders at 48-72 hours to review cultures and de-escalate 6
- Document your reasoning for antibiotic choice, dose, and duration 1
- Join your institution's stewardship committee or start one 7
Slide 24: Measuring Success - Outcomes That Matter
Clinical outcomes (primary focus) 7:
- Mortality rates
- Clinical cure/failure rates
- Length of stay
- Readmission rates
Microbiological outcomes 7:
- C. difficile infection rates
- MDR organism colonization/infection
- Antimicrobial resistance trends
- Guideline adherence rates
- Time to appropriate therapy
- De-escalation rates
Slide 25: Final MCQ - Case Integration
Which scenario represents OPTIMAL antimicrobial stewardship?
- A) Prescribing 10 days of amoxicillin-clavulanate for viral URI "just in case"
- B) Using meropenem empirically for all febrile patients
- C) Obtaining blood cultures, starting ceftriaxone, then switching to oral amoxicillin after Strep pneumoniae identified
- D) Continuing antibiotics until all symptoms resolve completely
Answer: C - This demonstrates proper diagnosis (cultures first), appropriate empiric therapy, and de-escalation based on susceptibility data 6, 1, 5.
Slide 26: Key Takeaways - Commit These to Memory
The non-negotiables:
- Antimicrobial stewardship improves patient outcomes by reducing morbidity, mortality, and adverse events 1
- The 5 D's (Diagnosis, Drug, Dose, Duration, De-escalation) guide every prescription 6, 5
- Prospective audit with feedback has the strongest evidence for effectiveness 6, 1
- Local resistance patterns must drive empiric therapy choices 7, 5
- Culture before antibiotics, then de-escalate based on results 1
- Education alone fails—combine with structural interventions 7, 5
Slide 27: Your Role as Future Specialists
Every specialty contributes to stewardship:
- Surgeons: Optimize prophylaxis timing and duration 7
- Medicine: Lead de-escalation efforts on wards 6
- Emergency Medicine: Ensure appropriate empiric therapy 7, 1
- Pediatrics: Avoid antibiotics for viral infections 2
- Obstetrics: Optimize GBS prophylaxis 7
- Anesthesia: Support surgical prophylaxis protocols 7
Your prescribing decisions today determine whether antibiotics work tomorrow 4, 3.
Slide 28: Resources for Continued Learning
Essential references:
- IDSA/SHEA Antimicrobial Stewardship Guidelines 6, 1
- WHO AWaRe Classification 7
- Your institution's antibiogram and guidelines 5
- CDC Antibiotic Resistance Threats Report 6
Action: Bookmark your hospital's stewardship resources and antibiogram on your phone.
Slide 29: Questions & Discussion
Interactive discussion points:
- What are the biggest barriers to stewardship in your specialty?
- How can we implement audit and feedback in your department?
- What local resistance patterns concern you most?
Slide 30: Thank You - Now Go Practice Stewardship
Remember: Every prescription is an opportunity to practice stewardship.
Contact information for your institution's stewardship team: [Insert local contact details]
The future of antibiotics depends on decisions you make today 4, 3.