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Antimicrobial stewardship in hospital settings

Marisa Holubar, MD, MS
Stan Deresinski, MD
Section Editor
David C Hooper, MD
Deputy Editor
Elinor L Baron, MD, DTMH


Antimicrobial stewardship consists of systematic measurement and coordinated interventions designed to promote the optimal use of antibiotic agents, including their choice, dosing, route, and duration of administration [1-3]. The primary goal of antibiotic stewardship is to optimize clinical outcomes while minimizing unintended consequences of antibiotic use. Additional benefits include improving susceptibility rates to targeted antibiotics and optimizing resource utilization [1].

The United States Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) promotes implementation of antibiotic stewardship programs that will impact antibiotic prescribers in United States health care facilities that receive CMS funding and/or Joint Commission accreditation [4-7]. The program is described in a "playbook" that is designed to help facilities implement the CDC Core Elements of Hospital Antibiotic Stewardship Programs [8]. The primary goal is to promote "smart use" of antibiotics in the face of data demonstrating substantial overuse. Measurement of outcomes will be performed by comparing health care facilities of similar size and patient populations. Interventions to achieve this goal are discussed in the following sections.

Effective in 2017, the Joint Commission requires that all hospitals and nursing care centers have antimicrobial stewardship programs [9,10]. As of 2017, however, only 48 percent of hospitals have such a program [11]. Implementation of antimicrobial stewardship programs in small hospitals (<200 beds) often requires confronting a number of barriers, such as a lack of dedicated staff trained in infectious diseases [12]. Potential solutions include pooling of resources among hospitals, utilizing the resources of a larger healthcare system if feasible, taking advantage of state health department resources, and use of telehealth activities.

Issues related to hospital-based stewardship are reviewed here. Issues related to outpatient antibiotic stewardship are discussed separately. (See "Antimicrobial stewardship in outpatient settings".)


Adverse effects of antibiotic use, which have been reported to occur in one-fifth of patients, include emergence of antibiotic resistance, selection of pathogenic organisms such as Clostridium difficile, and drug toxicity [13].

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Literature review current through: Nov 2017. | This topic last updated: Nov 03, 2017.
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  1. Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016; 62:e51.
  2. Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Pediatric Infectious Diseases Society. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol 2012; 33:322.
  3. European Commission. EU Guidelines for the prudent use of antimicrobials in human health. https://ec.europa.eu/health/amr/sites/amr/files/amr_guidelines_prudent_use_en.pdf (Accessed on July 24, 2017).
  4. Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs. http://www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html (Accessed on November 03, 2017).
  5. Centers for Disease Control and Prevention. The Core Elements of Hospital Antibiotic Stewardship Programs. http://www.cdc.gov/antibiotic-use/healthcare/pdfs/core-elements.pdf (Accessed on November 03, 2017).
  6. Centers for Disease Control and Prevention. The Core Elements of Hospital Antibiotic Stewardship Programs: Checklist. http://www.cdc.gov/antibiotic-use/healthcare/pdfs/checklist.pdf (Accessed on November 03, 2017).
  7. Centers for Diseaes Control and Prevention. Antibiotic Prescribing and Use. http://www.cdc.gov/antibiotic-use/ (Accessed on November 03, 2017).
  8. National Quality Forum. Antibiotic Stewardship in Acute Care: A Practical Playbook. NQF, Washington, DC 2016. http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=82501 (Accessed on July 12, 2016).
  9. The Joint Commission. Prepublication Standards – New Antimicrobial Stewardship Standard, June 22, 2016. https://www.jointcommission.org/prepublication_standards_antimicrobial_stewardship_standard/ (Accessed on August 08, 2016).
  10. Goff DA, Kullar R, Bauer KA, File TM Jr. Eight Habits of Highly Effective Antimicrobial Stewardship Programs to Meet the Joint Commission Standards for Hospitals. Clin Infect Dis 2017; 64:1134.
  11. Centers for Disease Control and Prevention. Antibiotic use in the United States: Progress and opportunities, 2017. https://www.cdc.gov/getsmart/pdf/stewardship-report.pdf (Accessed on August 25, 2017).
  12. Stenehjem E, Hyun DY, Septimus E, et al. Antibiotic Stewardship in Small Hospitals: Barriers and Potential Solutions. Clin Infect Dis 2017; 65:691.
  13. Tamma PD, Avdic E, Li DX, et al. Association of Adverse Events With Antibiotic Use in Hospitalized Patients. JAMA Intern Med 2017; 177:1308.
  14. Meek RW, Vyas H, Piddock LJ. Nonmedical Uses of Antibiotics: Time to Restrict Their Use? PLoS Biol 2015; 13:e1002266.
  15. Rashid MU, Zaura E, Buijs MJ, et al. Determining the Long-term Effect of Antibiotic Administration on the Human Normal Intestinal Microbiota Using Culture and Pyrosequencing Methods. Clin Infect Dis 2015; 60 Suppl 2:S77.
  16. Modi SR, Collins JJ, Relman DA. Antibiotics and the gut microbiota. J Clin Invest 2014; 124:4212.
  17. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2013. http://www.cdc.gov/drugresistance/threat-report-2013/ (Accessed on February 20, 2016).
  18. Goff DA, Bauer KA, Reed EE, et al. Is the "low-hanging fruit" worth picking for antimicrobial stewardship programs? Clin Infect Dis 2012; 55:587.
  19. Jones M, Huttner B, Madaras-Kelly K, et al. Parenteral to oral conversion of fluoroquinolones: low-hanging fruit for antimicrobial stewardship programs? Infect Control Hosp Epidemiol 2012; 33:362.
  20. Sevinç F, Prins JM, Koopmans RP, et al. Early switch from intravenous to oral antibiotics: guidelines and implementation in a large teaching hospital. J Antimicrob Chemother 1999; 43:601.
  21. Mertz D, Koller M, Haller P, et al. Outcomes of early switching from intravenous to oral antibiotics on medical wards. J Antimicrob Chemother 2009; 64:188.
  22. Omidvari K, de Boisblanc BP, Karam G, et al. Early transition to oral antibiotic therapy for community-acquired pneumonia: duration of therapy, clinical outcomes, and cost analysis. Respir Med 1998; 92:1032.
  23. Laing RB, Mackenzie AR, Shaw H, et al. The effect of intravenous-to-oral switch guidelines on the use of parenteral antimicrobials in medical wards. J Antimicrob Chemother 1998; 42:107.
  24. de Jong E, van Oers JA, Beishuizen A, et al. Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomised, controlled, open-label trial. Lancet Infect Dis 2016; 16:819.
  25. Bréchot N, Hékimian G, Chastre J, Luyt CE. Procalcitonin to guide antibiotic therapy in the ICU. Int J Antimicrob Agents 2015; 46 Suppl 1:S19.
  26. Rowland T, Hilliard H, Barlow G. Procalcitonin: potential role in diagnosis and management of sepsis. Adv Clin Chem 2015; 68:71.
  27. Kemme DJ, Daniel CI. Aminoglycoside dosing: a randomized prospective study. South Med J 1993; 86:46.
  28. Leehey DJ, Braun BI, Tholl DA, et al. Can pharmacokinetic dosing decrease nephrotoxicity associated with aminoglycoside therapy. J Am Soc Nephrol 1993; 4:81.
  29. Fernández de Gatta MD, Calvo MV, Hernández JM, et al. Cost-effectiveness analysis of serum vancomycin concentration monitoring in patients with hematologic malignancies. Clin Pharmacol Ther 1996; 60:332.
  30. Bartal C, Danon A, Schlaeffer F, et al. Pharmacokinetic dosing of aminoglycosides: a controlled trial. Am J Med 2003; 114:194.
  31. Bond CA, Raehl CL. Clinical and economic outcomes of pharmacist-managed aminoglycoside or vancomycin therapy. Am J Health Syst Pharm 2005; 62:1596.
  32. Whipple JK, Ausman RK, Franson T, Quebbeman EJ. Effect of individualized pharmacokinetic dosing on patient outcome. Crit Care Med 1991; 19:1480.
  33. Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs. http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html (Accessed on April 21, 2016).
  34. Spellberg B, Bartlett JG, Gilbert DN. How to Pitch an Antibiotic Stewardship Program to the Hospital C-Suite. Open Forum Infect Dis 2016; 3:ofw210.
  35. Centers for Disease Control and Prevention. Implementation Resources. http://www.cdc.gov/getsmart/healthcare/implementation.html (Accessed on February 20, 2016).
  36. Davey P, Marwick CA, Scott CL, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017; 2:CD003543.
  37. Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs. http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf (Accessed on February 20, 2016).
  38. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44:159.
  39. Tamma PD, Avdic E, Keenan JF, et al. What Is the More Effective Antibiotic Stewardship Intervention: Preprescription Authorization or Postprescription Review With Feedback? Clin Infect Dis 2017; 64:537.
  40. Mehta JM, Haynes K, Wileyto EP, et al. Comparison of prior authorization and prospective audit with feedback for antimicrobial stewardship. Infect Control Hosp Epidemiol 2014; 35:1092.
  41. Cosgrove SE, Patel A, Song X, et al. Impact of different methods of feedback to clinicians after postprescription antimicrobial review based on the Centers For Disease Control and Prevention's 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults. Infect Control Hosp Epidemiol 2007; 28:641.
  42. Chan S, Hossain J, Di Pentima MC. Implications and impact of prior authorization policy on vancomycin use at a tertiary pediatric teaching hospital. Pediatr Infect Dis J 2015; 34:506.
  43. Di Pentima MC, Chan S, Hossain J. Benefits of a pediatric antimicrobial stewardship program at a children's hospital. Pediatrics 2011; 128:1062.
  44. Di Pentima MC, Chan S. Impact of antimicrobial stewardship program on vancomycin use in a pediatric teaching hospital. Pediatr Infect Dis J 2010; 29:707.
  45. Newland JG, Stach LM, De Lurgio SA, et al. Impact of a Prospective-Audit-With-Feedback Antimicrobial Stewardship Program at a Children's Hospital. J Pediatric Infect Dis Soc 2012; 1:179.
  46. Meeker D, Linder JA, Fox CR, et al. Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial. JAMA 2016; 315:562.
  47. Cosgrove SE, Seo SK, Bolon MK, et al. Evaluation of postprescription review and feedback as a method of promoting rational antimicrobial use: a multicenter intervention. Infect Control Hosp Epidemiol 2012; 33:374.
  48. LaRocco A Jr. Concurrent antibiotic review programs--a role for infectious diseases specialists at small community hospitals. Clin Infect Dis 2003; 37:742.
  49. Vettese N, Hendershot J, Irvine M, et al. Outcomes associated with a thrice-weekly antimicrobial stewardship programme in a 253-bed community hospital. J Clin Pharm Ther 2013; 38:401.
  50. Doernberg SB, Dudas V, Trivedi KK. Implementation of an antimicrobial stewardship program targeting residents with urinary tract infections in three community long-term care facilities: a quasi-experimental study using time-series analysis. Antimicrob Resist Infect Control 2015; 4:54.
  51. White AC Jr, Atmar RL, Wilson J, et al. Effects of requiring prior authorization for selected antimicrobials: expenditures, susceptibilities, and clinical outcomes. Clin Infect Dis 1997; 25:230.
  52. Pakyz AL, Oinonen M, Polk RE. Relationship of carbapenem restriction in 22 university teaching hospitals to carbapenem use and carbapenem-resistant Pseudomonas aeruginosa. Antimicrob Agents Chemother 2009; 53:1983.
  53. Lewis GJ, Fang X, Gooch M, Cook PP. Decreased resistance of Pseudomonas aeruginosa with restriction of ciprofloxacin in a large teaching hospital's intensive care and intermediate care units. Infect Control Hosp Epidemiol 2012; 33:368.
  54. Buising KL, Thursky KA, Robertson MB, et al. Electronic antibiotic stewardship--reduced consumption of broad-spectrum antibiotics using a computerized antimicrobial approval system in a hospital setting. J Antimicrob Chemother 2008; 62:608.
  55. Reed EE, Stevenson KB, West JE, et al. Impact of formulary restriction with prior authorization by an antimicrobial stewardship program. Virulence 2013; 4:158.
  56. Quale J, Landman D, Saurina G, et al. Manipulation of a hospital antimicrobial formulary to control an outbreak of vancomycin-resistant enterococci. Clin Infect Dis 1996; 23:1020.
  57. Lima AL, Oliveira PR, Paula AP, et al. Carbapenem stewardship: positive impact on hospital ecology. Braz J Infect Dis 2011; 15:1.
  58. Lautenbach E, LaRosa LA, Marr AM, et al. Changes in the prevalence of vancomycin-resistant enterococci in response to antimicrobial formulary interventions: impact of progressive restrictions on use of vancomycin and third-generation cephalosporins. Clin Infect Dis 2003; 36:440.
  59. Toltzis P, Yamashita T, Vilt L, et al. Antibiotic restriction does not alter endemic colonization with resistant gram-negative rods in a pediatric intensive care unit. Crit Care Med 1998; 26:1893.
  60. Seemungal IA, Bruno CJ. Attitudes of housestaff toward a prior-authorization-based antibiotic stewardship program. Infect Control Hosp Epidemiol 2012; 33:429.
  61. Linkin DR, Fishman NO, Landis JR, et al. Effect of communication errors during calls to an antimicrobial stewardship program. Infect Control Hosp Epidemiol 2007; 28:1374.
  62. LaRosa LA, Fishman NO, Lautenbach E, et al. Evaluation of antimicrobial therapy orders circumventing an antimicrobial stewardship program: investigating the strategy of "stealth dosing". Infect Control Hosp Epidemiol 2007; 28:551.
  63. Burke JP. Antibiotic resistance--squeezing the balloon? JAMA 1998; 280:1270.
  64. Rahal JJ, Urban C, Horn D, et al. Class restriction of cephalosporin use to control total cephalosporin resistance in nosocomial Klebsiella. JAMA 1998; 280:1233.
  65. Carratalà J, Garcia-Vidal C, Ortega L, et al. Effect of a 3-step critical pathway to reduce duration of intravenous antibiotic therapy and length of stay in community-acquired pneumonia: a randomized controlled trial. Arch Intern Med 2012; 172:922.
  66. Worrall CL, Anger BP, Simpson KN, Leon SM. Impact of a hospital-acquired/ventilator-associated/healthcare-associated pneumonia practice guideline on outcomes in surgical trauma patients. J Trauma 2010; 68:382.
  67. Hauck LD, Adler LM, Mulla ZD. Clinical pathway care improves outcomes among patients hospitalized for community-acquired pneumonia. Ann Epidemiol 2004; 14:669.
  68. Newman RE, Hedican EB, Herigon JC, et al. Impact of a guideline on management of children hospitalized with community-acquired pneumonia. Pediatrics 2012; 129:e597.
  69. Neuman MI, Hall M, Hersh AL, et al. Influence of hospital guidelines on management of children hospitalized with pneumonia. Pediatrics 2012; 130:e823.
  70. Jenkins TC, Irwin A, Coombs L, et al. Effects of clinical pathways for common outpatient infections on antibiotic prescribing. Am J Med 2013; 126:327.
  71. MacFadden DR, LaDelfa A, Leen J, et al. Impact of Reported Beta-Lactam Allergy on Inpatient Outcomes: A Multicenter Prospective Cohort Study. Clin Infect Dis 2016; 63:904.
  72. Charneski L, Deshpande G, Smith SW. Impact of an antimicrobial allergy label in the medical record on clinical outcomes in hospitalized patients. Pharmacotherapy 2011; 31:742.
  73. Leis JA, Palmay L, Ho G, et al. Point-of-care Beta-lactam Allergy Skin Testing by Antimicrobial Stewardship Programs: A Pragmatic Multicenter Prospective Evaluation. Clin Infect Dis 2017.
  74. Blumenthal KG, Shenoy ES, Wolfson AR, et al. Addressing Inpatient Beta-Lactam Allergies: A Multihospital Implementation. J Allergy Clin Immunol Pract 2017; 5:616.
  75. Ressner RA, Gada SM, Banks TA. Antimicrobial Stewardship and the Allergist: Reclaiming our Antibiotic Armamentarium. Clin Infect Dis 2016; 62:400.
  76. Blumenthal KG, Shenoy ES, Varughese CA, et al. Impact of a clinical guideline for prescribing antibiotics to inpatients reporting penicillin or cephalosporin allergy. Ann Allergy Asthma Immunol 2015; 115:294.
  77. Unger NR, Gauthier TP, Cheung LW. Penicillin skin testing: potential implications for antimicrobial stewardship. Pharmacotherapy 2013; 33:856.
  78. Forrest DM, Schellenberg RR, Thien VV, et al. Introduction of a practice guideline for penicillin skin testing improves the appropriateness of antibiotic therapy. Clin Infect Dis 2001; 32:1685.
  79. Arroliga ME, Radojicic C, Gordon SM, et al. A prospective observational study of the effect of penicillin skin testing on antibiotic use in the intensive care unit. Infect Control Hosp Epidemiol 2003; 24:347.
  80. del Real GA, Rose ME, Ramirez-Atamoros MT, et al. Penicillin skin testing in patients with a history of beta-lactam allergy. Ann Allergy Asthma Immunol 2007; 98:355.
  81. Raja AS, Lindsell CJ, Bernstein JA, et al. The use of penicillin skin testing to assess the prevalence of penicillin allergy in an emergency department setting. Ann Emerg Med 2009; 54:72.
  82. Trubiano JA, Thursky KA, Stewardson AJ, et al. Impact of an Integrated Antibiotic Allergy Testing Program on Antimicrobial Stewardship: A Multicenter Evaluation. Clin Infect Dis 2017; 65:166.
  83. Rimawi RH, Cook PP, Gooch M, et al. The impact of penicillin skin testing on clinical practice and antimicrobial stewardship. J Hosp Med 2013; 8:341.
  84. Rocha-Pereira N, Lafferty N, Nathwani D. Educating healthcare professionals in antimicrobial stewardship: can online-learning solutions help? J Antimicrob Chemother 2015; 70:3175.
  85. Standford Center for Continuing Medical Education. Optimizing Antimicrobial Therapy with Timeouts: Online CME/CPE Course. https://med.stanford.edu/cme/courses/online/optimizing-antimicrobial-therapy.html (Accessed on May 25, 2016).
  86. Future Learn. Antimicrobial Stewardship: Managing Antibiotic Resistance - Free Online Course. https://www.futurelearn.com/courses/antimicrobial-stewardship (Accessed on May 25, 2016).
  87. Lee CR, Lee JH, Kang LW, et al. Educational effectiveness, target, and content for prudent antibiotic use. Biomed Res Int 2015; 2015:214021.
  88. Landgren FT, Harvey KJ, Mashford ML, et al. Changing antibiotic prescribing by educational marketing. Med J Aust 1988; 149:595.
  89. Baur D, Gladstone BP, Burkert F, et al. Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis. Lancet Infect Dis 2017; 17:990.
  90. Hung YP, Lee JC, Lin HJ, et al. Doxycycline and Tigecycline: Two Friendly Drugs with a Low Association with Clostridium Difficile Infection. Antibiotics (Basel) 2015; 4:216.
  91. Turner RB, Smith CB, Martello JL, Slain D. Role of doxycycline in Clostridium difficile infection acquisition. Ann Pharmacother 2014; 48:772.
  92. Doernberg SB, Winston LG, Deck DH, Chambers HF. Does doxycycline protect against development of Clostridium difficile infection? Clin Infect Dis 2012; 55:615.
  93. Valiquette L, Cossette B, Garant MP, et al. Impact of a reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile-associated disease caused by the hypervirulent NAP1/027 strain. Clin Infect Dis 2007; 45 Suppl 2:S112.
  94. Avdic E, Carroll KC. The role of the microbiology laboratory in antimicrobial stewardship programs. Infect Dis Clin North Am 2014; 28:215.
  95. Langford BJ, Seah J, Chan A, et al. Antimicrobial Stewardship in the Microbiology Laboratory: Impact of Selective Susceptibility Reporting on Ciprofloxacin Utilization and Susceptibility of Gram-Negative Isolates to Ciprofloxacin in a Hospital Setting. J Clin Microbiol 2016; 54:2343.
  96. Clinical and Laboratory Standards Institute. M100-S23: Performance Standards for Antimicrobial Susceptibility Testing, Twenty-Third Informational Supplement, January 2013. http://reflab.yums.ac.ir/uploads/clsi_m100-s23-2013.pdf (Accessed on February 20, 2016).
  97. Liang B, Wheeler JS, Blanchette LM. Impact of Combination Antibiogram and Related Education on Inpatient Fluoroquinolone Prescribing Patterns for Patients With Health Care-Associated Pneumonia. Ann Pharmacother 2016; 50:172.
  98. Hebert C, Ridgway J, Vekhter B, et al. Demonstration of the weighted-incidence syndromic combination antibiogram: an empiric prescribing decision aid. Infect Control Hosp Epidemiol 2012; 33:381.
  99. Randhawa V, Sarwar S, Walker S, et al. Weighted-incidence syndromic combination antibiograms to guide empiric treatment of critical care infections: a retrospective cohort study. Crit Care 2014; 18:R112.
  100. Smith ZR, Tajchman SK, Dee BM, et al. Development of a combination antibiogram for Pseudomonas aeruginosa bacteremia in an oncology population. J Oncol Pharm Pract 2016; 22:409.
  101. Hsu AJ, Carroll KC, Milstone AM, et al. The Use of a Combination Antibiogram to Assist with the Selection of Appropriate Antimicrobial Therapy for Carbapenemase-Producing Enterobacteriaceae Infections. Infect Control Hosp Epidemiol 2015; 36:1458.
  102. Rabs N, Wieczorkiewicz SM, Costello M, Zamfirova I. Development of a urinary-specific antibiogram for gram-negative isolates: impact of patient risk factors on susceptibility. Am J Infect Control 2014; 42:393.
  103. Bauer KA, Perez KK, Forrest GN, Goff DA. Review of rapid diagnostic tests used by antimicrobial stewardship programs. Clin Infect Dis 2014; 59 Suppl 3:S134.
  104. Buehler SS, Madison B, Snyder SR, et al. Effectiveness of Practices To Increase Timeliness of Providing Targeted Therapy for Inpatients with Bloodstream Infections: a Laboratory Medicine Best Practices Systematic Review and Meta-analysis. Clin Microbiol Rev 2016; 29:59.
  105. Luther VP. The Essential Role of Clinical Microbiology Laboratories in Antimicrobial Stewardship. Clin Lab News 2014. https://www.aacc.org/publications/cln/articles/2015/august/stewardship (Accessed on February 20, 2016).
  106. Morris AM, Brener S, Dresser L, et al. Use of a structured panel process to define quality metrics for antimicrobial stewardship programs. Infect Control Hosp Epidemiol 2012; 33:500.
  107. Morris AM. Antimicrobial Stewardship Programs: Appropriate Measures and Metrics to Study their Impact. Curr Treat Options Infect Dis 2014; 6:101.