Summary

IDSA/SHEA 2016 guideline on implementing antibiotic stewardship programs (ASPs) in acute inpatient, long-term care, and ED settings. Provides 28 GRADE-rated recommendations across interventions, optimization, microbiology/diagnostics, measurement, and special populations. Emphasizes preauthorization and/or prospective audit and feedback as core ASP activities led by ID physicians with pharmacist partners.

Key Recommendations

Implement preauthorization and/or prospective audit and feedback (PAF) as the foundational ASP intervention (strong, moderate).
Do not rely solely on didactic education; use it only to complement active stewardship interventions (weak, low).
Develop facility-specific clinical practice guidelines for common infectious syndromes (eg, CAP, SSTI, UTI) with active dissemination (weak, low).
Implement interventions specifically designed to reduce use of antibiotics with high CDI risk—clindamycin, broad-spectrum cephalosporins, fluoroquinolones (strong, moderate).
Use antibiotic time-outs or stop orders with prompting to encourage prescriber-led review (weak, low); do NOT use antibiotic cycling (weak, low).
Incorporate computerized clinical decision support at time of prescribing when IT resources allow (weak, moderate).
Implement pharmacokinetic monitoring/adjustment programs for aminoglycosides (strong, moderate) and for vancomycin (weak, low).
Use alternative (extended/continuous-infusion) dosing strategies for broad-spectrum β-lactams to reduce costs (weak, low).
Promote appropriate use of oral antibiotics and timely IV-to-PO conversion (strong, moderate).
Promote β-lactam allergy assessment and penicillin skin testing to enable first-line β-lactam use (weak, low).
Implement strategies to reduce antibiotic therapy to the shortest effective duration based on syndrome-specific evidence (strong, moderate).
Use stratified antibiograms, selective/cascade susceptibility reporting, rapid viral testing, and rapid blood culture diagnostics coupled with ASP interpretation (all weak).
Use serial procalcitonin measurements in adult ICU patients with suspected infection to guide antibiotic discontinuation (weak, moderate); do not use PCT to withhold initiation.
Monitor antibiotic use using days of therapy (DOT) preferentially over defined daily dose (DDD) (weak, low); measure antibiotic costs from prescriptions/administrations, not purchasing data.
Implement antibiotic stewardship in nursing homes/SNFs, NICUs, and in terminally ill patients (good practice recommendations).

Thresholds & Doses

Antibiogram stratification requires ≥30 isolates per organism per stratum (CLSI M39).
Penicillin skin testing negative predictive value 97–99%; positive predictive value ~50%.
PCN allergy reported in 10–15% of admitted patients and 15–24% of those requiring antibiotics.
Short-course evidence-based durations: CAP 3–5 days; VAP 7–8 days; uncomplicated cellulitis 5 days; acute pyelonephritis 7 days; spontaneous bacterial peritonitis 5 days; intra-abdominal infection 4 days post-source control; vertebral osteomyelitis 6 weeks.
Procalcitonin-guided algorithms reduce antibiotic duration by ~2–4 days in ICU sepsis without increased mortality.
Vancomycin 3-day stop orders reduced inappropriate continuation from 25% to 11%.

Citations

Section I, Recommendation 1 — preauthorization and/or PAF as core ASP intervention
Section V, Recommendation 5 — interventions to reduce high-CDI-risk antibiotics
Section IX–X, Recommendations 9–11 — PK monitoring for aminoglycosides/vancomycin and alternative β-lactam dosing
Section XI, Recommendation 12 — IV-to-oral conversion programs
Section XII, Recommendation 13 — β-lactam allergy assessment and PCN skin testing
Section XIII, Recommendation 14 and Table 2 — shortest effective duration of therapy with syndrome-specific RCT data
Section XVIII, Recommendation 19 — procalcitonin use in ICU
Section XX, Recommendation 21 — DOT preferred over DDD for measurement