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An antimicrobial stewardship program (ASP) is a hospital’s coordinated, structured effort to optimize antibiotic use — the right drug, dose, duration, and route for a given infection — in order to improve patient outcomes, reduce adverse effects and Clostridioides difficile infection, and slow the emergence of antibiotic resistance. It is a distinct function from infection prevention: infection prevention stops pathogens from spreading between patients, while stewardship governs how antibiotics are used once a patient is being treated. The two programs share the same underlying goal — reducing resistant-organism harm — and in most hospitals they work closely together, often with overlapping committee membership.
CDC’s Core Elements of Hospital Antibiotic Stewardship Programs
CDC’s Core Elements framework, updated in 2019 (building on an original 2014 version), defines the structural components CDC associates with a functioning hospital stewardship program. The seven core elements are:
- Leadership commitment — dedicating necessary human, financial, and IT resources, and formal, visible support from hospital administration.
- Accountability — appointing a leader (often a physician) responsible for program outcomes.
- Pharmacy expertise — appointing a pharmacist leader (or equivalent expert) responsible for working to improve antibiotic use.
- Action — implementing at least one recommended intervention, such as prospective audit-and-feedback or facility-specific treatment guidance.
- Tracking — monitoring antibiotic prescribing, use, and resistance patterns.
- Reporting — regularly reporting information on antibiotic use and resistance to relevant staff (prescribers, nurses, leadership).
- Education — educating clinicians and other staff about antibiotic resistance and optimal prescribing.
These elements are structural, not prescriptive of a single implementation — CDC’s framework describes what a program needs to have in place, and hospitals build the specific interventions (audit-and-feedback, preauthorization, order sets, antibiograms, IV-to-oral conversion protocols, and so on) around that structure. Verify the current published Core Elements document (cdc.gov) before citing specific implementation strategies, since CDC periodically issues supplementary implementation guidance.
Regulatory and Accreditation Drivers
Hospital stewardship programs are not purely voluntary quality initiatives in the US; they are tied to accreditation and regulatory requirements built directly on the Core Elements framework:
- The Joint Commission’s Medication Management standard MM.09.01.01, effective since January 2017, requires accredited hospitals (and, in expanded form, several other Joint Commission-accredited settings) to maintain an antimicrobial stewardship program, and its elements of performance are explicitly built around the CDC Core Elements structure — leadership involvement, an accountable multidisciplinary team, drug-use tracking and reporting, and an education component.
- CMS Conditions of Participation — CMS finalized a hospital antibiotic stewardship program requirement (2019) as part of the hospital and critical access hospital Conditions of Participation, similarly grounded in the CDC Core Elements, making stewardship program infrastructure a condition of Medicare/Medicaid participation rather than an optional accreditation add-on.
- Other accrediting organizations that survey hospitals for CMS deemed status (e.g., DNV) have parallel stewardship standards built on the same Core Elements foundation.
Because these three drivers converge on the same seven-element structure, a hospital building a Joint Commission- and CMS-compliant program is, in practice, building to the CDC Core Elements — confirm the current text of MM.09.01.01 and the CMS Conditions of Participation directly before using either for a compliance determination, since accreditation standards are periodically revised.
How Stewardship and Infection Prevention Divide Responsibility
| Function | Antimicrobial Stewardship Program | Infection Prevention Program |
|---|---|---|
| Primary question | Is this patient on the right antibiotic, dose, route, and duration? | Is this pathogen being prevented from spreading to other patients? |
| Typical leadership | Physician + pharmacist co-leadership | Infection preventionist, often with hospital epidemiologist oversight |
| Core tools | Antibiograms, audit-and-feedback, preauthorization, treatment guidelines | Surveillance definitions (e.g., CLABSI, CAUTI), isolation precautions, hand hygiene |
| Shared goal | Reduce antimicrobial-resistant organism harm and healthcare-associated infection | |
Because a facility’s own antibiotic-resistance patterns and its device-associated infection rates directly inform each other’s priorities, most hospital infection preventionists sit on or coordinate closely with the antimicrobial stewardship committee, and stewardship pharmacists frequently review the same case-level data IPs use for NHSN surveillance adjudication.
Frequently Asked Questions
Is antimicrobial stewardship the same thing as infection prevention?
No. They are complementary but distinct programs: stewardship governs how antibiotics are prescribed and used for patients already being treated; infection prevention governs how pathogens are kept from spreading between patients in the first place. Many hospitals structure them as separate committees with overlapping membership.
Is a hospital antimicrobial stewardship program legally required?
In the US, yes for CMS-participating hospitals: CMS finalized a stewardship program requirement in the hospital and critical access hospital Conditions of Participation in 2019, and Joint Commission-accredited hospitals must additionally meet standard MM.09.01.01. Both are grounded in CDC’s Core Elements framework. Confirm current regulatory text directly, since requirements are periodically updated.
What are the seven CDC Core Elements?
Leadership commitment, accountability, pharmacy expertise, action, tracking, reporting, and education — see the breakdown above.
Who leads a hospital antimicrobial stewardship program?
CDC’s Core Elements call for both a physician (or other prescriber) leader accountable for program outcomes and a pharmacist leader with expertise in improving antibiotic use — co-leadership is the typical structure, not a single-owner model.
Related: the Patient Safety & Infection Prevention hub, the infection preventionist role guide, and the CLABSI and CAUTI guides for the surveillance definitions stewardship data often intersects with. When a programme needs to evaluate one specific agent against approved criteria and report the result to P&T, that work is a medication use evaluation, which follows its own criteria-and-sampling procedure.
See also: Defined Daily Dose.
