Antimicrobial Stewardship Rounds Template

Purpose

This template makes stewardship rounds systematic and repeatable so teams can improve antibiotic use, reduce harm, and measure impact. Use it as a starting kit: adapt selection criteria, decision thresholds, wording and metrics to local formulary, antibiogram, EHR workflows, and clinical governance.

Who should attend

• Stewardship lead (physician or pharmacist)
• Clinical pharmacist(s) assigned to the unit
• Infectious diseases consultant or on-call ID physician when available
• Bedside nurse or charge nurse representative (rotation)
• Microbiology laboratory contact (as needed)
• Clinical documentation specialist or EHR analyst (periodic)

Rounds frequency & duration

Typical cadence: daily weekdays or 3–5 times/week for high-acuity units; twice weekly for lower-risk wards. Keep rounds focused (15–45 minutes depending on caseload).

1) Patient selection criteria (examples)

Define precise automated or manual triggers to generate the daily patient list so rounds target highest-value cases. Examples:

• Active broad-spectrum antibiotics (e.g., carbapenems, piperacillin-tazobactam, vancomycin)
• IV antibiotics >48–72 hours without documented plan for duration or source control
• Positive blood cultures or other sterile-site cultures within prior 48–72 hours
• Therapy for suspected or confirmed multidrug-resistant organism
• High-risk patients: neutropenia, ICU, transplant, severe allergy history
• IV-to-oral opportunities (enteral tolerance, improving signs)
• Antimicrobials flagged by stewardship alerts (duplicate therapy, prolonged QT risk, C. difficile risk)

2) Pre-round preparation checklist

• Pull the daily patient list and sort by priority trigger.
• Attach key data to each patient: indication, start date/time, culture results, current vitals, lab trends, allergies, renal function.
• Link to local antibiogram and relevant local/national guideline for the suspected infection.
• Prepare suggested recommendation(s) for each patient (brief bullets).

3) Structured review fields (for each patient)

Use these fields consistently during review. They form the core of the documentation template below.

1. Patient identifier: name / MRN / location
2. Indication for antibiotic: suspected/confirmed diagnosis and source
3. Agent(s) & route: current drugs, doses, route, start date/time
4. Culture & microbiology: available results, Gram stain, susceptibilities, pending tests
5. Clinical status: trending fever, WBC, hemodynamics, organ dysfunction
6. Allergies / interactions / organ impairment: relevant constraints
7. Source control: any procedures planned or completed
8. IV to oral candidacy: enteral access intact, improving, absorption expected
9. Duration to date: calendar days of therapy
10. Risk factors for resistance or C. difficile:

4) Decision prompts and recommended actions

Use simple, actionable prompts to guide recommendations and conversations with the primary team.

• Stop: Is there evidence of infection? If not, recommend stopping antibiotics and monitoring. Script: “No active infection identified—recommend discontinue and observe for 24–48 hours; call if deterioration.”
• De-escalate / narrow spectrum: Can therapy be narrowed to targeted therapy based on cultures or clinical picture?
• IV to oral switch: Is patient clinically improving, tolerating enteral intake, and on an oral-equivalent agent?
• Change agent for susceptibility: Match therapy to culture susceptibilities to use narrower, safer, or more cost-effective agent.
• Optimize dose / renal adjustment: Adjust dosing for renal/hepatic function and therapeutic targets.
• Duration recommendation: Propose a stop or reassessment date (e.g., “total 5–7 days for uncomplicated [diagnosis]; reassess on day X”).
• Order set / consult: Recommend ID consult or diagnostic test when appropriate (e.g., persistent bacteremia, fungal suspicion).

5) Documentation template (use in EHR progress note or stewardship recommendation tool)

Keep notes brief, structured, and respectful of primary team autonomy. Include measurable follow-up items.

Stewardship Review (date/time):
Patient: [name / MRN / location]
Indication: [suspected/confirmed diagnosis]
Current therapy: [agent(s), dose, route, start date]
Key data: [culture results, clinical trend, allergies, renal function]
Recommendation(s):
 - Primary: [e.g., Narrow piperacillin-tazobactam to ceftriaxone 2 g IV q24h]
 - Duration / reassessment: [e.g., stop 5/10/2026 or reassess on day X]
Rationale: [brief—culture result, spectrum, toxicity risk, IV→PO opportunity]
Acceptance status: [Accepted / Modified / Declined] by [primary team name] at [time]
Follow-up: [planned reassessment or monitoring plan]
Reviewer: [stewardship clinician name and contact]

6) Tracking acceptance and outcomes

Capture acceptance at the time of recommendation and track outcomes over time. Suggested tracking fields:

• Recommendation ID (link to patient and date)
• Type of recommendation (stop, narrow, IV→PO, dose change, consult)
• Accepted? (Yes / No / Modified)
• If declined, brief reason (e.g., pending cultures, clinician preference, instability)
• Date/time of acceptance or action
• Outcome check (48–72 h): clinical improvement, readmission, C. difficile, mortality)

7) Suggested metrics to track

Balance process and outcome measures. Define denominators (patient days, eligible patients reviewed) and explicit calculation methods.

• Process measures:
  • % of eligible patients reviewed by stewardship per unit/week
  • % of recommendations accepted within 48 hours
  • % of IV→PO conversions where eligible
  • Median time from recommendation to action
• Outcome measures:
  • Days of therapy (DOT) per 1,000 patient-days for targeted agents
  • Proportion of broad-spectrum antibiotic use (e.g., carbapenems) over time
  • C. difficile infection rate (cases per 10,000 patient-days)
  • 30-day readmission for infection-related diagnosis
  • Antibiotic-associated adverse drug events

8) Implementation notes & practical tips

• Link each round packet to the local antibiogram and up-to-date local guidelines; state which guideline was used in the rationale.
• Keep recommendations short and specific; offer exact alternative agent, dose, route, and stop/reassess date.
• Document acceptance status in the chart and notify the primary team verbally for time-sensitive recommendations.
• When recommendations are declined, ask for the clinical rationale briefly and capture it for later review—this builds trust and identifies system gaps.
• Train rotating pharmacists and nurse champions on the rounds script to improve consistency and acceptance.

9) Example case (quick)

Patient: 72-year-old with pneumonia on piperacillin-tazobactam x 48 h; cultures negative; clinically improved; tolerating PO.

Recommendation: Narrow to amoxicillin-clavulanate PO (or cefuroxime PO) and convert to oral; total duration 5 days from start. Rationale: clinical improvement, negative cultures, oral tolerance. Acceptance: Accepted by primary team at 09:15; order changed in EHR.

10) Quality & governance reminders

• Adapt the template to match your formulary, stewardship policy and local regulation.
• Track recommendations and outcomes for ongoing quality improvement and reporting to governance committees.
• Do not use this template as a substitute for clinical judgment or local policies.

Quick implementation checklist (one-page)

1. Configure daily patient list triggers in your EHR or pull list manually.
2. Assign roles and scheduled attendees for rounds.
3. Adopt the structured review fields and documentation template into a note or stewardship form.
4. Decide a minimal metric set to track and define calculation methods.
5. Start with one unit or service and iterate weekly based on feedback and measured results.

References & links

Link here to your local antibiogram, institutional guidelines, IDSA guidance, and any internal order sets or EHR documentation templates.

Mal-Hungers / Cautions

This template is a practical starting kit, not a substitute for clinical judgment, local policy, or regulatory compliance. Avoid blaming individuals for system failures, relying on unchecked automation, or applying checklists without local adaptation (formulary, technology, staffing). Training, governance and local tailoring are required for safe and effective implementation.