Question 2

Regarding antibiotic stewardship in the ICU:
a) Outline the principles and practical aspects. (20% marks)
b) List the advantages and disadvantages. (80% marks)

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College answer

Not available.


Principles and practical aspects:

Antibiotic stewardship is a systematic approach to the responsible management of antibiotic prescribing, consisting of coordinated interventions intended to preserve the efficacy of available antibiotics. The main elements are:

  • Leadership support (adequate resources for the program)
  • Accountability (a physician leader taking responsibility for the program)
  • Pharmacy expertise (multidisciplinary involvement of pharmacy)
  • Action (implementation of auditable interventions, such as prospective approval of antibiotic prescriptions)
  • Tracking (monitoring prescribing and resistance patterns)
  • Reporting (feedback to prescribers)
  • Education (of clinicians, about appropriate antibiotic use)


  • Benefits would be maximal in the ICU:
    • Antibiotic use and infectious disease is prevalent in the ICU
    • Critically ill patients are the most vulnerable to adverse drug effects and resistant organisms
  • Safety improvement:
    • Reduced antibiotic toxicity
    • Reduced MRO colonisation
  • Reduced health care costs
    • Reduced use of expensive novel agents
    • Reduced length of ICU stay due to less MRO-induced infections
  • Increased patient exposure to infections disease specialist attention
  • Involvement of specialist pharmacists could improve the identification of adverse reactions and possible drug interactions, preventing morbidity
  • Use of computer-assisted decision support for antibiotic prescribing could simplify prescribing
  • Standardised order sets could improve empirical coverage, reducing missed infectious agents


  • There is the possibility that antibiotic stewardship, with its emphasis on stopping or not starting antibiotics, could lead to patient harm from missed sepsis
  • Delay imposed by the need to seek approval could lead to worse patient outcomes (as the timing of early antibiotics is thought to be important for reducing mortality)
  • Manpower-expensive: increased referrals increase the workload of ID specialists
  • Resource-expensive: pharmacists, physicians, administrators need to be recruited
  • Resistance will emerge to the classes of drugs favoured by the stewards
  • Antibiotic resistance will still develop in the community because of non-medical (eg. agricultural and veterinarian) antibiotic use
  • Antibiotic stewardship may be unacceptable culturally in the closed model of ICU care
  • May not improve clinical outcomes (eg. mortality) at the institution level
  • No evidence that it decreases the incidence of adverse drug reactions.