Action 3.19 states

The antimicrobial stewardship program will:

  1. Review antimicrobial prescribing and use
  2. Use surveillance data on antimicrobial resistance and use to support appropriate prescribing
  3. Evaluate performance of the program, identify areas for improvement, and take action to improve the appropriateness of antimicrobial prescribing and use
  4. Report to clinicians and the governing body regarding
    • compliance with the antimicrobial stewardship policy and guidance
    • areas of action for antimicrobial resistance
    • areas of action to improve appropriateness of prescribing and compliance with current evidence-based Australian therapeutic guidelines or resources on antimicrobial prescribing
    • the health service organisation’s performance over time for use and appropriateness of use of antimicrobials


The health service organisation has systems for the safe and appropriate prescribing and use of antimicrobials as part of an antimicrobial stewardship program.

Reflective questions

  • What processes are in place to collect and evaluate data on antimicrobial use?
  • How does the health service use surveillance data on local antimicrobial resistance and use this to support appropriate prescribing?
  • What actions have been taken to improve the effectiveness of the AMS processes, for example, ensuring endorsed antibiotic treatment protocols are followed?
  • How are data on prescribing and use of antimicrobials reported to clinicians and the governing body?

Examples of evidence

  • Committee and meeting records in which compliance with the AMS policy, and antimicrobial prescribing and use were discussed, including reviews of surveillance data. This should include records of actions arising from meetings and progress on these actions
  • Results of analysis of surveillance data on antimicrobial resistance and action taken to improve AMS
  • Results of audits and surveys about appropriateness of prescribing, for example results from the Quality Improvement National Antimicrobial Prescribing Survey (QI NAPS) and actions taken to improve the AMS program
  • Examples of improvement activities for AMS that have been implemented and evaluated
  • Implement or review the process for reporting adverse events, incidents and near misses relating to antimicrobial use, including assessment and management of reported antibiotic–allergy mismatch
  • Communications with clinicians on antimicrobial use, resistance and stewardship
  • Memorandums, newsletters or other communication material provided to the workforce and consumers on appropriate use of antimicrobials, including feedback received from consumers
  • Record of prescribers completing antibiotic prescribing modules, such as those provided by NPS MedicineWise
  • Regular reports to the governing body on the effectiveness of the AMS program
  • Contributions to organisational annual reports on the performance of the AMS program

See also: