Antibiotic Stewardship Insights: Prepare. Plan. Implement.


Especially now, leaders need to assure that their organizations have followed all the required steps for the development and implementation of a comprehensive Antibiotic Stewardship policy in accordance with the new Requirements of Participation (RoP).

F881 §483.80(a) – Infection prevention and control program states that “The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

  • §483.80(a)(3) – An Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use.
  • §483.45(c), F756, Drug Regimen Review – In relation to pharmacy services, the assessment, monitoring and communication of antibiotic use shall occur by a licensed pharmacist.


The Core Elements of Antibiotic Stewardship, outlined by the Centers for Disease Control and Prevention to “optimize the treatment of infections while reducing the adverse events associated with antibiotic use” include:

•  Leadership Commitment
•  Accountability
•  Drug Expertise
•  Action
•  Tracking
•  Reporting
•  Education


As leaders, it is vital that your Antibiotic Stewardship Program is incorporated into the overall infection prevention and control program and reviewed on an annual basis and as needed. For continued success, the Infection Preventionist and clinical team should focus and incorporate the following into your clinical systems:

  • Ensure that documentation related to antibiotic selection and use is complete.
  • Track antibiotics used to review patterns of use and determine the impact of the antibiotic stewardship interventions.
  • Monitor for clinical outcomes such as rates of C.difficile infections, antibiotic-resistant organisms or adverse drug events.
  • Report of communicable disease per your specific state requirements.
  • Assist prescribing practitioners in choosing the right antibiotic using antibiograms (Recommend using AHRQ Toolkit).
  • Provide reports related to monitoring antibiotic usage and resistance data to the QAA committee.


Consider implementing the following to maintain compliance:

  • Review, revise and institute an Antibiotic Stewardship Program Policy and Procedure with elements for compliance with F88.
  • Update staff education materials for orientation, annual education and agency staff orientation, as needed.
  • Attend the Infection Preventionist Bootcamp to assure your staff is up-to-date on role, responsibilities, surveillance techniques, best practices and needed resources to be successful.
  • Provide a written education program for prescribing practitioners on the facility’s
    Antibiotic Stewardship Policy and Procedure.
  • Collaborate with your pharmacy consultant to assure the review of antibiotic use with the monthly medication regimen review, and as needed.
Are you ready for RoP requirements for the Antibiotic Stewardship Program? Pathway Health’s team of experts and trainers are ready to assist. Contact us today.

Susan LaGrange,
Director of Education,
Pathway Health