Second Edition 2022

MOH/S/FAR/69.
22(HB)-e
Second Edition 2022

Second Edition 2022
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Second Edition, 2022
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FOREWORD FROM
DIRECTOR-GENERAL OF HEALTH MALAYSIA
MESSAGE FROM
SENIOR DIRECTOR OF PHARMACEUTICAL SERVICES
MESSAGE FROM
HEAD OF CLINICAL SERVICES (INFECTIOUS DISEASES)
Foreword
TAN SRI DATO’ SERI DR. NOOR HISHAM ABDULLAH
Director-General of Health Malaysia
Antimicrobial resistance poses a significant threat to human health around the world.
It adversely impacts infectious diseases, deaths, hospital length of stay, and healthcare
costs. Containment of antimicrobial resistance is critical in ensuring the continuity
of successful treatment with antimicrobials and preventing the emergence of
infections of multidrug-resistant organisms. In the Global Action Plan on
Antimicrobial Resistance, the World Health Organization (WHO) Member States are
called to provide stewardship programmes that monitor and promote optimisation
of antimicrobial use at national and local levels in accordance with international
standards.
Antimicrobial stewardship is based on fundamental principles to guide the

implementation of efforts in promoting judicious antimicrobial use and, therefore,
advance patient safety and improve outcomes. It requires an integrated and
multidisciplinary approach that involves a physician, microbiologist, pharmacist, and
infection control practitioner. Judicious use of antimicrobials includes an appropriate
selection of antimicrobials for proper patients with proper duration and route to
minimise the risk of developing antimicrobial resistance.
The antimicrobial stewardship team provides feedback on prescribing practices,

antimicrobial use, medication safety incidents, local antimicrobial resistance
patterns, and antimicrobial resistance-related infections. They also advise prescribers
on necessary changes in antimicrobial policies and guidelines, therapeutic options,
and diagnostic interventions. This programme has been proven highly successful in
promoting the rational use of antimicrobials through evidence-based interventions.
To support the nationwide implementation of antimicrobial stewardship, the Ministry

of Health developed the “Protocol on Antimicrobial Stewardship Program in
Healthcare Facilities – First Edition” in 2014. This second edition of the protocol is
published given current development and references. The revised protocol provides
more detailed and comprehensive guides for all healthcare facilities to start or
strengthen the antimicrobial stewardship programme.
I want to congratulate all contributors, reviewers, Pharmaceutical Services Programme,

Medical Development Division, and Family Health Development Division for their
commendable efforts in reviewing and updating this protocol. I hope this updated
protocol will be implemented effectively at the healthcare facilities to ensure rational
use of antimicrobials, reducing antimicrobial resistance.
Thank you.
Second Edition 2022 | Protocol on Antimicrobial Stewardship (AMS) Programme in Healthcare Facilities 5
Message
NORHALIZA A HALIM
Senior Director of Pharmaceutical Services
The first edition of Protocol on Antimicrobial Stewardship Programme in

Healthcare Facilities was published by the Ministry of Health in 2014.
Since then, a lot of references have been made available and various
toolkits have been developed to guide the implementation of the
antimicrobial stewardship programme. Hence, it is high time to review
and update the protocol and keep up with the current development, with
the purpose that this protocol remains relevant.
Overuse and misuse of antimicrobials have been associated with more

rapid emergence of antimicrobial resistance. Therefore, promoting the
appropriate use of antimicrobials through a coordinated programme is
important to improve patient outcomes, reduce antimicrobial resistance
and decrease the spread of infections caused by multidrug-resistant
organisms.
As described in this protocol, pharmacists play prominent roles in
antimicrobial stewardship programme and must be able to work collectively
with other healthcare professionals in the multidisciplinary antimicrobial
stewardship team. To contribute effectively, pharmacists should equip
themselves with knowledge in antimicrobial pharmacotherapy, as well as soft
skills.
I believe this protocol will benefit all healthcare professionals in

implementing antimicrobial stewardship programme at their facilities and
subsequently improve the quality of antimicrobial utilisation.
Last but not least, I would like to thank the secretariat, contributors and
reviewers for their hard work in reviewing and updating this protocol.
Message
DATO’ DR. MAHIRAN MUSTAFA
Senior Consultant Infectious Diseases Physician
Head of Infectious Diseases Services
Ministry of Health, Malaysia
Antimicrobial stewardship programmes have shown to decrease inappropriate

antimicrobial use, improve healthcare outcomes and reduce adverse consequences
of antimicrobial use including antimicrobial resistance, toxicity and unnecessary
costs. This protocol serves as a guide for facilities and healthcare professionals in
implementing antimicrobial stewardship programme in a structured manner.
The first edition of this protocol marked an important step at the national level for
nationwide implementation of antimicrobial stewardship programme especially at
Ministry of Health facilities. Since then, antimicrobial stewardship has been given
more priority and implementation has expanded to include many other facilities
including the private hospitals. This revised edition has taken into consideration the
latest available guidelines, recommendations and toolkits from established sources
to ensure it remains relevant. It also incorporates more detailed guides on how to
initiate an antimicrobial stewardship programme and manage antimicrobial
stewardship interventions, as well as tips to run antimicrobial stewardship activities
for small hospitals and hospitals with limited resources.
Finally, I would like to take this opportunity to thank all contributors from
multidisciplinary healthcare professions, Pharmaceutical Services Programme as the
secretariat for this protocol, Medical Development Division and Family Health
Development Division for their joint effort in reviewing and updating this protocol.
Notably, I am looking forward positively for all practitioners from various levels to
make full use of this protocol to improve antimicrobial utilisation in the healthcare
facilities.
“Antimicrobial stewardship is a team game with the patient at the centre and it’s our
teamwork that makes the dream work.”
ADVISORS
YBhg. Datuk Dr. Noor Hisham Abdullah
Director General of Health
YBhg. Datuk Dr. Asmayani Khalib

Deputy Director General of Health (Medical)
YBhg. Datuk Dr. Norhayati Rusli

Deputy Director General of Health (Public Health)
YBhg. Mdm. Norhaliza A Halim

Senior Director of Pharmaceutical Services
YBhg. Dato’ Dr. Mahiran Mustafa

Senior Consultant Infectious Diseases Physician
Hospital Raja Perempuan Zainab II
EDITORIAL COMMITTEE & CONTRIBUTORS LIST

(HOSPITAL)
Mdm. Rohana Hassan Dr. Suraya Amir Husin

Deputy Director (Pharmaceutical Care) Senior Principal Assistant Director
Pharmacy Practice & Development Division, Medical Development Division,
MOH MOH
Mdm. Hazimah Hashim Dr. Nor Farah Bakhtiar

Senior Principal Assistant Director Senior Principal Assistant Director
MOH MOH
Ms. Nur Salima Shamsudin Dr. Noor Amelia Abd Rasid

Senior Principal Assistant Director Principal Assistant Director
MOH MOH
Mdm. Mardhiyah Kamal Prof. Dr. Sasheela Sri La Sri

Senior Principal Assistant Director Ponnampalavanar
Pharmacy Practice & Development Division, Consultant Infectious Diseases Physician
MOH University of Malaya Medical Centre
10 Protocol on Antimicrobial Stewardship (AMS) Programme in Healthcare Facilities | Second Edition 2022
Dr. Benedict Sim Lim Heng Dr. Tuan Suhaila Tuan Soh
Consultant Infectious Diseases Physician Microbiologist
Hospital Sungai Buloh Hospital Sungai Buloh
Dr. Suraya Hanim Abdullah Hashim Dr. Cheng Joo Thye

Infectious Diseases Physician Infectious Diseases Physician
Hospital Ampang Hospital Seberang Jaya
Dr. Rahela Ambaras Khan Mdm. Siti Hir Huraizah Md Tahir

Senior Pharmacist Senior Pharmacist
Hospital Kuala Lumpur Hospital Melaka
Dr. Janattul Ain Jamal Ms. Izyana Munirah Idham

Senior Pharmacist Pharmacist
Hospital Pulau Pinang Hospital Sungai Buloh
Dr. Syamhanin Adnan Ms. Thong Kah Shuen

Senior Pharmacist Senior Pharmacist
Hospital Sungai Buloh Hospital Raja Permaisuri Bainun
Mr. Tan Chee Chin Ms. Hannah Md Mahir

Senior Pharmacist Pharmacist
Hospital Sultanah Aminah Hospital Sungai Buloh
EDITORIAL COMMITTEE & CONTRIBUTORS LIST

(PRIMARY CARE)
Dr. Nazrila Hairizan Nasir Dr. Ho Bee Kiau

Deputy Director (Primary Care) Consultant Family Medicine Specialist
Family Health Development Division Bandar Botanic Health Clinic, Klang
Dr. Noraini Mohd Yusof Dr. Salmiah Md Sharif

Senior Principal Assistant Director Consultant Family Medicine Specialist
Family Health Development Division Seremban Health Clinic, Seremban
Dr. Husni Hussain Dr. Vickneswari a/p Ayadurai

Consultant Family Medicine Specialist Consultant Family Medicine Specialist
Salak Health Clinic, Sepang Taman Medan Health Clinic, Petaling
Dr. Jemah Sajari Mdm. Nur Syellawaty Ahmad
Consultant Family Medicine Specialist Pharmacist
Serendah Health Clinic, Hulu Selangor Klang District Health Office, Klang
Dr. Izan Hairani Ishak Dr. Norhazirah Mohd Noor

Family Medicine Specialist Senior Principal Assistant Director
Bukit Kuda Health Clinic, Klang Family Health Development Division
Dr. Wan Noor Azlin Wan Idris Mdm. Kueh Mei Yen
Family Medicine Specialist Principal Assistant Director (Pharmacy)
Precint 9 Health Clinic, Putrajaya Family Health Development Division
Dr. Izwan Effendy Ismail Mdm. Mardhiyah Kamal

Family Medicine Specialist Principal Assistant Director
Puchong Health Clinic, Petaling Pharmacy Practice & Development Division
Dr. Hazaimah Shafii Ahmad Sufardy Mohamad

Senior Principal Assistant Director Assistant Medical Officer Supervisor
Family Health Development Division Family Health Development Division
EXTERNAL REVIEWERS
Prof. Madya Dr. Petrick @ Dr. Mohd Fozi Kamaruddin

Ramesh K. Periyasamy Family Medicine Specialist
Consultant Infectious Diseases Physician Klinik Kesihatan Beseri, Kangar,
Hospital Canselor Tuanku Muhriz UKM Perlis
Dato’ Dr. Chow Ting Soo Mdm. Lau Chee Lan

Consultant Infectious Diseases Physician Pharmacist
Hospital Pulau Pinang Hospital Canselor Tuanku Muhriz UKM
Dr. Sahlawati Mustakim

Clinical Microbiologist
Hospital Sungai Buloh
SECRETARIAT
Pharmaceutical Services Programme, MOH
“The Secretariat would like to thank all parties who have directly or indirectly
involved in reviewing and updating this protocol”
CONTENTS
ADVISORS 10
EDITORIAL COMMITTEE & CONTRIBUTORS LIST (HOSPITAL) 10
EDITORIAL COMMITTEE & CONTRIBUTORS LIST (PRIMARY CARE) 11
EXTERNAL REVIEWERS 12
INTRODUCTION 15
OBJECTIVES 16
Antimicrobial Stewardship Implementation 16
Governance 16
General Policies 18
Specific Policies 19
SECTION A: ANTIMICROBIAL STEWARDSHIP PROGRAMME IN HOSPITAL 21
A.1 ANTIMICROBIAL STEWARDSHIP TEAM 21

General Role of Antimicrobial Stewardship Team 21
Antimicrobial Stewardship Team Members 22
Roles and Responsibilities 23
A.2 ANTIMICROBIAL STEWARDSHIP ACTIVITIES 26

i. General Overview 26
ii. Getting Started 27
iii. AMS Action / Intervention 28
Step 1 - Identify areas for improvement based on available data 29
1.1 Surveillance data 29
1.2 Audit 30
Step 2 - Develop and implement targeted AMS interventions 32
based on the identified areas of concern in Step 1
Step 3 - Assess the effectiveness of interventions 38
A.3 ANTIMICROBIAL STEWARDSHIP PROGRAMME MEASUREMENT 40

Structural Measures 40
Process Measures 41
Outcome Measures (after AMS interventions) 42
SECTION B: ANTIMICROBIAL STEWARDSHIP PROGRAMME IN PRIMARY CARE 43
B.1 ANTIMICROBIAL STEWARDSHIP TEAM 43

Strategies and activities of Antimicrobial Stewardship Programme 43
Antimicrobial Stewardship Team Members 44
Roles and responsibilities 44
B.2 ANTIMICROBIAL STEWARDSHIP PROGRAMME ACTIVITIES 45

1. Implementation of Treatment Guidelines and Clinical Pathways 45
2. Surveillance and Feedback 45
3. Audit and Feedback 46
4. Formulary Restriction 48
5. Antibiotic Selection and Dose Optimization 48
6. Education 48
B.3 ANTIMICROBIAL STEWARDSHIP PROGRAMME MEASUREMENT 49

A. Process indicators 49
B. Outcome indicators 49
REFERENCES 50
APPENDICES 53
INTRODUCTION
The introduction of antimicrobial agents has contributed to the reduction of infectious diseases
as the major cause of premature death. Treatment with antimicrobial agents seems so effective
and safe that they are sometimes prescribed for dubious indications and for longer than
necessary, with little concern for adverse effects and the development of resistance.
In the last 40 years, the prevalence of multidrug-resistant microorganisms (e.g. extended

spectrum beta-lactamase-producing Enterobacterales) have risen alarmingly. Antimicrobial
resistance (AMR) occurs when microorganisms change in ways that render the medications
used to cure the infections they cause ineffective. There is evidence that overall rates of
antimicrobial resistance correlate with the use of antimicrobials. Certain antimicrobials like
quinolones promote the emergence of resistance more than others. Quinolone usage has been
linked to an increase in methicillin-resistant Staphylococcus aureus and with increased
quinolones resistance in Gram-negative bacilli.
The emergence of AMR can cause the resistance to first-line medicines and leads to the use
of second or third-line drugs which is less effective, more toxic and costlier. As more resistance
is acquired, we are eventually left without any effective antimicrobial therapies. Hence, AMR
can negatively impact patient outcomes, become a major threat to patient safety, increase
healthcare expenditure, and limit treatment options for common infections.
Antimicrobial management or stewardship programme has been developed as a response to

these issues. Antimicrobial Stewardship (AMS) is a coordinated systematic approach to improve
the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial
drug regimen; right choice of antimicrobial, right route of administration, right dose, right time,
right duration and minimize harm to the patient and future patients.
The development of antimicrobial resistance strains in hospitals is intensified because of a

high level of antimicrobial use and concentration of patients with multiple pathogens. Ongoing
monitoring and prospective audits have shown to improve patient care, decrease unnecessary
antimicrobial use and antimicrobial resistance and reduce healthcare expenditures.
OBJECTIVES
1. To optimize antimicrobial therapy in order to maximize clinical cure or prevent

infections by optimizing selection, dosing, route, and duration of antimicrobial therapy.
2. To minimize the unintended consequences such as the emergence of antimicrobial

resistance and adverse drug events.
3. To improve patient outcomes (e.g. reduce morbidity and mortality from infection).
4. To reduce healthcare costs without adversely impacting the quality of care.
Antimicrobial Stewardship Implementation
Introduction
At the healthcare facility level, different contexts and types of facilities will face different
challenges. The essential healthcare facility core elements in the WHO toolkit: Antimicrobial
Stewardship Programmes in Healthcare Facilities in Low- and Middle-income Countries
(Appendix 2) have been stratified into basic core elements requiring fewer resources and more
advanced core elements requiring more resources. However, this differentiation may vary from
facility to facility based on size, needs, priorities, resources and context. (Refer Table 2).
Governance
Hospital
The Antimicrobial Stewardship Programme in hospitals is under the purview of the Hospital
Infection and Antibiotic Control Committee and is supported by the:
a. Hospital Director
b. Head of various clinical departments
c. Head of Pharmacy Department
d. Head of Medical Microbiology
Implementing and maintaining an effective AMS requires a dedicated multidisciplinary team
and involves ongoing communication and collaboration among multiple disciplines and
departments. The AMS team should be appointed by the Hospital Director.
The role of the Hospital Director is critical in ensuring the success of the Antimicrobial
Stewardship Program initiatives by:
• ensuring AMS becomes strategic goal of the organisation
• communicating on why change is needed to staff and other leaders of
Departments
• allocating adequate resources in terms of manpower and time for dedicated
AMS team activities
• reviewing progress by the team, identifying barriers and providing advice
• assigning high-performing staff to the team and resourcing them adequately
• endorsing the AMS team and the activities
Primary Care
The Antimicrobial Stewardship Programme (AMS) in Primary Care shall be implemented at
both District and Health Clinic levels and is within the purview of the District Infection and
Antibiotic Control Committee (DIACC). The committee at the district level should be appointed
by the District Health Officer.
All Health Clinics with Family Medicine Specialists (FMS) or Medical Officers In Charge
(MOIC) and pharmacists shall have an AMS team at the clinic level. Members of the AMS
team at the clinic level shall be appointed by FMS/ MOIC. Implementing and maintaining an
effective AMS requires a dedicated multidisciplinary team and involves ongoing
communication and collaboration among team members.
Functional structure of AMS at districts and health clinics
District Infection and Antibiotic Control Districts

Committee (DIACC)* APPENDIX 1
Health Clinic Infection and Antibiotic Health

Control Team* Clinics
Antimicrobial Infection Control

Stewardship Team Team
* Responsible in Infection Control and the implementation of AMS
General Policies
1. Formulation of AMS team in each hospital, Health District Office and Health Clinics
The core members of AMS team should be multidisciplinary and appointed by Hospital
Director/ District Health Officer/ FMS/ Medical Officer In Charge.
2. Development and documentation of local antimicrobial policy
Every healthcare facility shall develop and document their local antimicrobial policy.
The policy should be endorsed by the Drugs and Therapeutics Committee (JKUT) and
ultimately the Hospital Director/ District Health Officer/ FMS/ Medical Officer In Charge
and publicized to the whole health care facility.
The antimicrobial policy shall include as below:
• Indications for antimicrobials are to be explicitly spelt out at the time of

prescribing to assist with audit efforts.
• Appropriate microbiology investigations (culture or serology) prior to
antimicrobial commencement. **
• Clinicians to prescribe antimicrobials guided by the National
Antimicrobial Guidelines or local antimicrobial guideline where
applicable.
• A list of restricted antimicrobials and the procedures for obtaining
approval.
• To limit the use of broad-spectrum antimicrobials unless necessary.
• To review patient’s antimicrobial therapy on a regular basis based on
microbiology result and the patient’s progress.
**according to availability in primary care setting
3. Educational programme on AMS via continuous medical education (CME) and

antibiotic awareness campaign
Provide regular updates on antimicrobial prescribing, practice and usage for healthcare
professionals.
Specific Policies
Implementation of AMS activities according to category & type of facilities.
State and Major Specialist Hospitals Minor and Non-Specialist Hospitals
i. Surveillance and feedback mechanism i. Surveillance and feedback mechanism

on specific antimicrobial consumption. on specific antimicrobial consumption.
(Core Strategy) (Core Strategy)
ii. Implementation of prospective audit ii. Implementation of prospective audit
and feedback according to local needs. and feedback according to local needs.
(Core Strategy) (Core Strategy)
iii. Formalize regular antimicrobial rounds iii. Establishment of formulary restriction
by AMS team especially in State and and preauthorization/ approval system.
Specialist Hospital. (Core Strategy) (Core Strategy)
iv. Establishment of formulary restriction iv. Establishment of antimicrobial order
and preauthorization/ approval system. tools for restricted antimicrobials.
(Core Strategy) v. De-escalation/ streamlining the
v. Establishment of antimicrobial order antibiotic usage.
tools for restricted antimicrobials. vi. Antimicrobial selection and dose
vi. De-escalation/ streamlining the optimization of the antimicrobial.
antibiotic usage. vii. Initiation of intravenous (IV) to oral
vii. Antimicrobial selection and dose (PO) switch programme.
optimization of the antimicrobial.
viii.Establishment of intravenous (IV) to
oral (PO) switch programme.
Primary care*** with Family Medicine Specialist (FMS)
i. Surveillance and feedback mechanism on specific antimicrobial consumption (DDD).

(Core Strategy)
ii. Implementation of process audit (clinical audit, structure audit, and Point Prevalence
Survey) and feedback according to local needs. (Core Strategy)
iii. Establishment of formulary restriction and preauthorization/ approval system.
(Core Strategy)
***for primary care without FMS, AMS team from the main clinic shall conduct a
minimal AMS activity such as clinical audit
SECTION A:
ANTIMICROBIAL
STEWARDSHIP
PROGRAMME
IN HOSPITAL
The judicious use of antibiotics is an important strategy to preserving
efficacy in the treatment of infectious diseases. Thus, this protocol was
developed to provide practical recommendations to healthcare
professionals in the hospitals in implementing antimicrobial
stewardship programme to improve the quality of antibiotic usage and
prescribing as well as improve patient clinical outcomes. The
recommendations in this protocol are based on reviews of several
published guidelines such as IDSA Guidelines, CDC – Core Elements
Antimicrobial Stewardship in Hospitals, WHO Practical Guide to
Antimicrobial Stewardship in Hospital and other guidelines from other
countries where appropriate.
A.1 ANTIMICROBIAL STEWARDSHIP TEAM
Antimicrobial stewardship team in-charge of rational and responsible use of antimicrobials in

healthcare facilities.
General Role of Antimicrobial Stewardship Team

1. Strengthens formulary restriction and approval systems.
2. Regularly reviews antimicrobial prescribing with intervention and direct feedback to
the prescribers.
3. Educates prescribers, pharmacists and nurses about good antimicrobial prescribing
practice and antimicrobial resistance.
4. Evaluates compliance to clinical guidelines and reports on process measures, outcomes
measures (e.g. clinical and financial) and antimicrobial resistance patterns to Hospital
Infection and Antibiotic Control Committee (HIACC) and Hospital Director.
Antimicrobial Stewardship Team Members
3.1 AMS team members in hospital include:
Head of AMS Team
Infectious Disease(ID)
Other Members Physician / Senior Physician
or Clinician
Infection Prevention &

Pharmacists
Control Practitioner
Clinical Microbiologist or
Microbiologist
Optional:
• Information Technology
Officer
• Hospital Epidemiologist
• Interested Clinicians
• Quality Officer
Every AMS team member shall meet regularly to discuss about any plan for AMS activities, to
review current activities, to measure the outcome of intervention that has been done and to
deliberate any problem that arise.
Roles and Responsibilities
Head of AMS team
Is either an Infectious Disease Physician/ Paediatrician, senior physician

or clinician deemed to be suitable by the Hospital Director.
Represents the AMS team in the Hospital Infection and Antibiotic Control
Committee (HIACC) and gives feedback on AMS programme.
Co-opted in the Drugs and Therapeutics Committee (JKUT) when

considering changes of antimicrobials in the hospital formulary.
Prepares surveillance and audit reports for submission to state and

national level.
Proposes annual AMS activities with the Hospital Director and various
departments.
Infectious Disease Physician / Senior

Physician or Clinician
Leads the technical component of Antimicrobial Stewardship team.
Advises on specific stewardship related cases and issues.
Pharmacist
A dedicated pharmacist trained in AMS for pharmacy under the

Ministry of Health (MOH).
Clinical role in conjunction with other members of the AMS Team:

• Gives technical input on finer aspects of antimicrobials.
• Identifies potential patients for stewardship interventions
(e.g. de-escalation etc.)
• Ensures dose optimization is carried out especially for complex
antimicrobials and complex clinical scenarios.
• Enforces the approval system of restricted antimicrobials.
Ensures safe and effective use of medication to reduce risk for

errors and adverse events.
Surveillance of antimicrobial use

• Collection and analysis of local consumption and expenditure.
• Provision of data to regional/ national surveillance programmes.
• Carries out and analyses point prevalence studies on
antimicrobial usage.
Audit and feedback

• Leads and conducts appropriate antimicrobial audits
• Provides timely feedback for future improvement
Clinical Microbiologist
Provision of guidance on appropriate diagnostic tests in microbiology, as

part of ‘diagnostic stewardship’.
Ensures the appropriateness of microbiology request, sample collection

(types, time, date taken and documentation) and sample quality.
Provision of timely and accurate reporting of culture and antimicrobial

susceptibility data.
Ensures selective reporting of antimicrobial susceptibilities and
interpretative reporting of microbiology results.
Provision of yearly data on antimicrobial resistance patterns in hospital.
Information Technology Officer
Hospitals with existing IT systems may consider including an IT

specialist/ personnel in the AMS team to assist with:
•Creating localized electronic decision-making systems that can be
available through the hospital network system.
•Providing AMS team access to microbiological data and antibiotic
utilisation data.
•Producing automated antimicrobial utilisation data and other
programmed clinical data.
Infection Control Practitioner
AMS teams frequently chance upon opportunities to tighten infection

control practices during their course of the work. Having an Infection
Control Practitioner within the team complements the efforts of the AMS
team in bringing down resistance rates.
A.2 ANTIMICROBIAL STEWARDSHIP ACTIVITIES
i. General Overview
The core elements below need to be in place prior to start antimicrobial stewardship activities:
CORE ELEMENTS
1 Governance structure
2 Formulation of hospital antimicrobial policy

(Refer to General Policies - Development and documentation of local antimicrobial
policy)
3 Establishment of AMS team
4 Hospital-endorsed guideline (preferably based on local antimicrobial guideline e.g.

National Antimicrobial Guideline (NAG)
5 Assessment of current practice and available resources

• Antimicrobial utilisation data (e.g. defined-daily dose (DDD), Days of
therapy (DOT) of selected antimicrobial, trending antimicrobial use)
• Rates of resistance among common pathogens
6 Identify areas of intervention

• Specific location (e.g. medical wards or ICU)
• Specific disease conditions (e.g. Pneumonia, UTI)
• Specific antimicrobial ( e.g. Broad-spectrum antimicrobial (carbapenem),
High usage of specific antimicrobial (vancomycin))
7 Development and implementation of effective strategies to address any

inappropriate antimicrobial usage
8 Regular educational and awareness programme related to AMR & AMS
ii. Getting Started
Before starting the AMS initiatives, a facility should analyse its local current situation and
identify areas of concern. The AMS programme must be individualized to the facility’s financial,
structural, organizational and human resources and to the patient mix case. A large tertiary
facility with various specialties will need more comprehensive AMS plans and actions
compared to a district hospital. Therefore, it is important for the AMS team to analyse, discuss
and decide what are the antimicrobial issues that require intervention and the best strategies
to implement.
The checklist below can be used to analyse the facility current situation and navigate the AMS
activities:
Healthcare facility elements Yes No
1. Governance
Conduct regular (yearly) situational analysis of the AMS programme
requirement to identify gaps to implementation of an AMS
programme (e.g. surveillance programme, human & financial
resources etc.)
2. Antimicrobial policy
The healthcare facility has a written policy that requires prescribers
to clearly document the antibiotics prescribed and its indication in
the prescription chart and medical record.
3. Hospital-endorsed guideline
4. Formation of AMS team
5. AMS team discussion

• Discussion should be done periodically to review antimicrobial
utilisation data, multidrug-resistance organism rates and identify
antibiotic/ clinical conditions that require interventions.
• Strategic discussion with infection control team regarding usage
of antimicrobial during the time of nosocomial outbreak.
6. Audit and feedback

Periodic audit and feedback to hospital management and prescribers
on antimicrobial utilisation.
7. Healthcare facility drug formulary with a list of

• Approved antibiotics
• Restricted antibiotics*
*Require approval by the hospital director or appointed physician.
Note: Strategies to achieve the missing elements needs to be documented for future AMS planning.
iii. AMS Actions/ Interventions
Introduction
AMS interventions should begin in a stepwise build on existing systems and available data
and encourage participation of clinical staff and prescribers. Start with a simple intervention
on a small scale and keep it doable.
Below are the steps for AMS actions. It involves monitoring, surveillance and audit of antibiotic
utilisation.
Step 1 Identify areas for improvement based on available data such as

• Antimicrobial utilisation data.
• Rates of resistance among common pathogens.
• Assessing current prescribing practices (e.g. from point prevalence
survey, audits etc.) (Refer Table 1.)
Step 2 Develop and implement targeted AMS interventions based on the identified
areas of concern in step 1. Choose specific location (e.g. wards or unit) or
disease condition or specific antibiotic where it is feasible to intervene.
Involve stakeholders (prescribers) in the development of intervention

programme to enhance sustainability.
Determine the outcome and process measures that will be used to monitor
effectiveness of the intervention.
(Refer to section A.3)
Step 3 Assess the effectiveness of interventions and decide if further action needs
to be taken based on the target set.
Step 1 - Identify areas for improvement based on available data
1.1 Surveillance data
Surveillance of antimicrobial use can show us how and why antimicrobials are being used by
healthcare providers. Situation analysis via monitoring of antimicrobial prescription and
consumption with comparison to national data provides insights and helps determine the area
(ward/service/discipline) or antibiotic to be targeted for intervention. Access to information on
antimicrobial consumption is an important source for healthcare professionals and policy
makers and is the first step in increasing awareness of the importance of careful antibiotic use.
Routine measurement and display of consumption information to healthcare professionals and
policy makers can help monitor progress in our effort towards a more prudent use of
antimicrobials. Prescribers should be made aware of their own prescribing practices. Thus,
feedback to prescribers is one potential form of intervention.
Collection and analysis of local antimicrobial consumption

• Data collection and analysis of antimicrobial use should be done periodically (at
least three monthly). The report of antimicrobial use should be disseminated to
clinician and discuss the results in relevant meeting.
Indicators for reporting antimicrobial consumption

• Daily Defined Dose (DDD) per 1000 Patient Days is used to determine the
antimicrobial utilisation in adult patients.
• Days of Therapy (DOT) per 1000 Patients days is used to determine the antimicrobial
utilisation in paediatric patients.
• ABC VEN analysis is used to justify the selection of antibiotic in a facility.
• Identify marked increase in antimicrobial utilisation.
Provision of data to regional/ national surveillance programmes

• The data should be reported and presented at local and state levels. It also has to be
submitted to Pharmacy Practice and Development Division, MOH for National
Surveillance on Antibiotic Utilisation (NSAU).
• Comparisons between similar services in different institutions with similar capacity
and case-mix may yield useful information.
• Identify hospital/ ICU with high usage of antimicrobial at the state or national level.
1.2 Audit
AMS intervention is done by identifying areas of concerns with regards to antimicrobial

prescribing patterns. This can be achieved by conducting an audit. Audit activities involves
multidisciplinary team efforts and can be done in a prospective or retrospective manner.
1.2.1 Audit on Antibiotic Usage

A quick audit of prescribing patterns (e.g. 10-30 patients) can be done
prospectively or retrospectively with real-time feedback to the prescribers. Audit
is conducted in response to incidences e.g. when there is significant increase of
a specific antibiotic usage or if a particular antibiotic in the facility is an outlier
at the hospital, state or national level. The evaluation of antimicrobial usage is
determined by using standardized methods like antibiotic utilisation DDD or
DOT data.
The audit measures utilisation patterns such as the choice of antibiotic, dose,
frequency and duration, against local or national antimicrobial guidelines.
Additional criteria such as empirical or definitive therapy (with cultures and
antimicrobial susceptibility results) can also be included. Deviations from
accepted standards will be documented.
Certain antimicrobials should be prioritized for audits and monitored. These

antibiotics include antimicrobials under a restricted list and those that are
monitored for usage at regional or national level (e.g. carbapenem, colistin,
cephalosporin, vancomycin, piperacillin/ tazobactam).
To ensure the success of the audit, a two-way system for communication or

feedback should be established. Mode of feedback includes email/ letter to head
of units/ individual prescribers, presentation at ward or unit meetings, presentation
at Drugs and Therapeutics Committee (JKUT) meeting and Hospital Infection and
Antibiotic Control Committee (HIACC) meeting.
Example of Antibiotic Audit Format & Work Process (Appendix 3).
1.2.2 Antibiotic Point Prevalence Survey (PPS)

PPS is a cross-sectional survey that analyzes compliance against antibiotic
guidelines. The auditing team comprises of physicians, pharmacists and the
infection control team. PPS provides an insight of antibiotic prescribing pattern
to identify target for quality improvement in antibiotic prescribing. Sequential
PPS audit allows the hospital to measure changes in practice and determine the
impact of interventions.
Example of Point Prevalence Survey Forms & Work Process (Appendix 4).
Example of Point Prevalence Survey User Manual & Assessment Tool – Google
Drive link:
https://drive.google.com/drive/folders/1rRhsRQKW8XHNATDKrispuxekWwCUaLo9?usp=sharing
1.2.3 Surgical Antibiotic Prophylaxis (SAP) Audit

Surgical antibiotic prophylaxis is the use of antibiotic before a surgical procedure
to reduce the risk of post-operative surgical site infections (SSI). However, if
administered inappropriately, antibiotic prophylaxis will not be effective and may
be harmful. An audit can be done to monitor and measure inappropriate use of
antibiotics (antibiotic necessity, antibiotic selection, time of administration and
duration) for surgical prophylaxis.
Table 1. Common concerns of antimicrobial prescribing practice that can be targeted
Areas of Concern Description
Overprescribing Antibiotics are prescribed when not needed, e.g. fever without
evidence of infection, asymptomatic urinary tract
colonization, viral infections, malaria, and inflammatory
conditions.
Broad-spectrum More broad-spectrum antibiotics are prescribed than are

necessary (e.g. surgical prophylaxis).
Unnecessary Multiple antibiotics are used, particularly with overlapping

combination therapy, spectra and in combinations that have not been shown to
including certain fixed improve clinical outcomes.
dose combinations
Wrong antibiotic Wrong antibiotic(s) are prescribed for particular indications/

choice infections.
Wrong dose Antibiotics are prescribed with the wrong dose (overdosing or
underdosing).
Wrong dose interval Antibiotics are prescribed with the wrong dose interval (too
much time between doses).
Wrong route Antibiotics are prescribed by the wrong route (e.g. IV instead
of oral).
Wrong duration Duration of antibiotic treatment is not at optimized period

(e.g. antibiotics prescribed for too long a period, prolonged
surgical prophylaxis).
Delayed Administration of the antibiotic(s) is delayed from the time of

administration prescription. Repeat doses are not administered in a timely
way, which is critical in the case of septic shock and other
serious infections.
Example of Surgical Antibiotic Prophylaxis Forms & Work Process (Appendix 5).
Example of Surgical Antibiotic Prophylaxis Audit Data Collection Protocol – Google Drive
link: https://drive.google.com/drive/folders/1rRhsRQKW8XHNATDKrispuxekWwCUaLo9?usp=sharing
Step 2 - Develop and implement targeted AMS interventions based on the

identified areas of concern in Step 1
After areas of intervention has been identified through audits (i.e. specific location, e.g. ward
or unit or disease condition or antibiotic with high usage), the AMS team should discuss on
the interventions that can be applied. If the intervention involves a unit/discipline, the AMS
team should meet up with the respective unit/ discipline, select a champion from the
unit/discipline that can give commitment to make changes, set goals of what to achieve in
changing the antimicrobial practice and discuss on possible strategies and interventions that
can be implemented tailored to the local settings.
AMS interventions should be implemented in a stepwise approach. Start with strategies that
are simple and doable, building on the existing structures, maximizing teamwork and
encouraging champions among clinical staff including prescribers in developing the
intervention. AMS interventions should align with local needs.
Determine the outcome and process measures that will be used to monitor the effectiveness
of the intervention. Outcomes of the interventions must be measurable. (Refer to section A.3)
Below is the example of AMS activities or interventions for improving antimicrobial prescribing
practice:
a) Antimicrobial treatment guideline and SAP guideline

Antimicrobial treatment guideline and SAP guideline can be adapted from the NAG
and endorsed at hospital level. These guidelines should be made accessible and
promoted to all healthcare professionals. Automatic stop orders might be applied
if the prescriptions do not adhere to these guidelines.
b) Antimicrobial Selection
Empirical antimicrobial selection is determined by the indication, suspected
causative organism and site of infection as per antimicrobial guidelines. A review of
a patient’s antimicrobial therapy after microbiology results are available is important
to avoid polypharmacy e.g. duplication of treatment, overlapping bacterial coverage
(e.g. metronidazole added on top of another antibiotic with anaerobic cover). Co-
administered medications should also be reviewed to prevent interactions with other
medicines.
c) Formulary Restriction and Pre-authorization

Formulary restriction is one of the pillars of AMS Programme. A list of restricted
antimicrobials shall be mentioned in the hospital antimicrobial policy (Appendix 6).
Restriction can be implemented in a number of ways:

• pre-approval (can only be started after getting a specific approval)
• temporary approval (can be started but would need approval for continued usage
and this can be done via antimicrobial order tools)
Methods to acquire approval:

• antimicrobial order tools
• telephone
d) Antimicrobial Order Tools

The order tools are designed to encourage the clinician to review basic clinical and
laboratory information and to categorize antimicrobial use as prophylactic, empirical
and therapeutic. An antimicrobial order tool may improve the quality of prescriptions
by increasing the awareness of clinicians of desired antimicrobial spectrum.
Antimicrobial order tools can be an effective measure to decrease antimicrobial
consumption by implementing automatic stop orders and/or requiring clinicians to
justify antimicrobial use.
Example of Antibiotic Order Form (Appendix 7).
e) Dose Optimization
Dose optimization will tailor therapy to the patient’s clinical characteristics, causative
organism, site of infection, and pharmacokinetic and pharmacodynamic
characteristics of the antimicrobial agent.
Strategies that may be considered for dose optimization include:

• extended or continuous infusion of beta-lactams (cefepime, piperacillin/
tazobactam)
• once-daily dosing of aminoglycosides (gentamicin)
• appropriate dosing of antimicrobials with narrow therapeutic range (vancomycin)
• dosing of certain antimicrobials in special populations (obesity, pregnancy)
• dose adjustments for patients with renal or liver dysfunction (polymyxins)
• dose adjustments for patients with hypoalbuminemia (ertapenem)
• dose adjustments for patients on renal replacement therapy
f) De-escalation/ Streamlining
Antimicrobial streamlining or de-escalation is a process which converts broad-
spectrum antimicrobial therapy to a narrower-spectrum antimicrobial treatment that
targets a more specific organism once culture reports are available. Unnecessary
exposure to a broad-spectrum empirical antimicrobial treatment will increase the
risk of developing subsequent antimicrobial resistance.
Occasionally, patients may be treated with one or more antimicrobials before

causative organism is identified, where this approach is referred to as empiric
therapy. Empiric therapy takes into account the type of infection suspected, and the
patient’s clinical status. Once test and culture results are available, the antimicrobial
choice should be streamlined to definitive therapy based on the results.
De-escalation/ streamlining can be typically conducted in several ways:

• Review by prescribers whether empirical treatment is according to the guidelines
(diagnosis, drug, dose, interval, administration route, duration). Discontinue dual
antimicrobial therapy if there is overlapping in the spectrum of activity.
• When cultures and sensitivity results become available, antibiotic treatment
should be streamlined accordingly; choose susceptible antibiotic with the least
toxicity, narrowest spectrum and lowest cost.
• Discontinue empiric antimicrobial therapy if sensitivity testing or clinical
correlation subsequently does not support the presence of infection.
Example of 72-hour Antimicrobial Review Form (Appendix 6).
g) Intravenous (IV) to Oral (PO) Antimicrobials Conversion

This describes the practice of converting intravenous antimicrobials therapy to an
effective oral formulation. Evidences have demonstrated the efficacy, safety and
economic impact of IV to PO antimicrobials conversion.
IV to PO antimicrobials conversion also benefits the patient by eliminating adverse

events associated with IV therapy, increasing patient comfort and mobility as well
as enabling early hospital discharge.
The optimal time to consider switching a patient to oral therapy is after 48 to 96

hours of intravenous therapy. This period of time allows the clinician to evaluate the
patient’s microbiology results and assess their response to treatment. Before
switching to oral antimicrobial, patient must meet a number of criteria:
A. Display signs of clinical improvement AND
B. Able to tolerate oral therapy AND
C. Good compliance to oral therapy.
D. Not having a condition in which higher concentrations of antibiotic are required

in the tissue or a prolonged course of IV therapy is essential.
Conditions to consider for IV to PO Conversion:

i. Pneumonia
ii. Skin and soft tissue infections
iii. Urinary tract infections
iv. Uncomplicated Gram-negative bacteremia
v. Intra-abdominal infection without deep-seated collections
Conditions require adequate parenteral therapy with approval from ID

physicians or AMS-led physicians prior to IV to PO conversion:
i. Osteomyelitis
ii. Septic arthritis
iii. Infected implant or prostheses
iv. Necrotising soft tissue infection
v. Melioidosis (at least 10 to 14 days of IV therapy)
vi. Deep-seated infection e.g. abscesses/empyema
vii. Complicated orbital cellulitis (abscess or other complication)
Conditions not recommended for IV to PO conversion:

i. Endocarditis
ii. Central nervous system infections (e.g. meningitis, brain abscess, etc.)
iii. Staphylococcus aureus bacteremia
If patient deteriorates clinically after the conversion from IV to PO antibiotic

(which indicates failure of oral therapy), IV therapy should be reinitiated.
Example of Antimicrobials That Can Be Included in IV to PO Therapy Conversion

and Bioavailability of Selected Antimicrobials Available in Both IV and PO
Formulations (Appendix 8).
h) AMS Round
Audit and feedback can also be done in a real-time manner during AMS rounds or
normal everyday ward rounds. Appropriateness of a prescribed antimicrobial can
be assessed during the round and immediate oral or written feedback can be
delivered. Issues that can be assessed include compliance to guidelines, streamlining
after microbiology test results are released, dose optimization, IV to oral switch,
duration of the treatment and any further investigation required.
The frequency of the AMS round shall depend on the facility’s resources and the
urgency of interventions. For example:
• Patients on one or more restricted antimicrobials (Appendix 9)
• Patients on prolonged antimicrobials i.e. more than 2 weeks
• Patients on 2 antibiotics without overlapping spectrum (excluding patients on

HIV-opportunistic infections, anti-tuberculosis and H. pylori treatment)
• Other cases as deemed necessary by ward pharmacists (e.g. antibiotic indication

not clear or not in keeping with antimicrobial guideline)
i) Education
AMS team should prepare a formal or informal teaching and training to engage
prescribers and other healthcare workers i.e. pharmacists and nurses in improving
antibiotic prescribing, dispensing and administration practices. By engaging them,
it will help to enhance and increase the acceptance of AMS strategies. This program
shall be included in the induction training for all newly reporting medical, nursing
and pharmacy staff.
Example of educational key points (Appendix 10).
Recommended Educational Programs

• Educational meetings (e.g. basics on antibiotic use, case-based discussions,
morbidity and mortality, significant event analysis, lectures on specific topics)
Continuous Nursing Education (CNE)/ Continuous Medical Education.
• Antimicrobial Newsletter/including a sub-topic on antimicrobials in any hospital

publications
• Using local key opinion leaders (champions) to advocate for key messages
• Reminders provided verbally, on paper or electronically
• AMS e-learning resources made available to all healthcare personnel
• Prescribing aids
Educational aids to guide prescribers at the point of prescribing. These may

include clinical algorithms for the diagnosis of infection, or methods to
standardize documentation of treatment decisions, such as infection stamps
or stickers to be included in the clinical notes.
Surgical prophylaxis guideline may be disseminated through poster in the

operating theatre, leaflet, smartphone applications or other electronic
platforms.
Where possible, information technology support for prudent antimicrobial

use should be introduced. This includes electronic patient records,
computerized prescribing and clinical decision support software.
Step 3 - Assess the effectiveness of interventions
Once AMS interventions have been implemented or performed, analyse and present changes
made (with the respective unit, if applicable). Discuss whether the interventions should be
continued or changed and follow up with a continuous improvement cycle i.e. Plan-Do-Study-
Act.
Tips to run AMS activities for small hospital and limited resources
Studies have demonstrated a number of interventions to improve antibiotic use for each of
these three disease conditions; community- acquired pneumonia (CAP), urinary tract infection
(UTI) and skin and soft tissue infection (SSTI). Hence, these are often high-yield targets for
improvement.
Key opportunities to improve antimicrobial usage:
Assess duration of
Diagnostic Guide empiric
therapy including
considerations therapy
discharge prescription
CAP Review cases at 48 Avoid empiric use of Uncomplicated

hours to confirm antipseudomonal beta- pneumonia can be
pneumonia diagnosis lactams and/or treated for 5-7 days in
versus non-infectious methicillin-resistant the setting of timely
etiology. Staphylococcus aureus appropriate clinical
(MRSA) agents unless response.
clinically indicated.
UTI Implement criteria to Establish Use the shortest

ensure urine culture checklist/criteria to duration for antibiotic
sent for those clinically distinguish therapy where
indicated. asymptomatic/ clinically appropriate.
symptomatic bacteriuria.
Avoid antibiotic therapy
for asymptomatic
bacteriuria except for
certain clinical
conditions.
SSTI Develop diagnostic Avoid empiric use of Uncomplicated
criteria to distinguish antipseudomonal beta- bacterial cellulitis can
purulent and non- lactams and/or anti- be treated for 5 days if
purulent infections and anaerobic agents unless there is a timely clinical
severity of illness (i.e., clinically indicated. response.
mild, moderate and
severe) to ensure
infections can be
treated appropriately
according to guidelines.
AMS also can be done by focusing on certain broad-spectrum antibiotic, especially reviewing
when it was started as empirical therapy. Three important questions can be used when
reviewing are:
• Is the antibiotic still needed?
• If so, is the antibiotic tailored to the culture results (e.g. is the narrowest spectrum agent
being used?)
• How long the antibiotic should be used?
Daily activities done by pharmacists are also a part of AMS, such as:
• Monitor response to antibiotic therapy with feedback to the treating clinician.
• Review unnecessary polypharmacy of the same antimicrobial coverage.
• Opportunities for IV to PO switch.
• Monitor safety of antimicrobial therapy (e.g. renal dose adjustment and drug-drug
interaction).
Any AMS activities can be incorporated appropriately where applicable.
A.3 ANTIMICROBIAL STEWARDSHIP PROGRAMME MEASUREMENT
Successful AMS programme includes all the elements of successful quality improvement
programmes and measuring the effectiveness of their activities is a key component. Monitoring
and analysis of antimicrobial usage is critical to measure the effects of stewardship
interventions in order to reduce antimicrobial resistance and to support appropriate
antimicrobial prescribing. Structural, process and outcome measures should be incorporated
into the AMS plan. All the program measurement should be reported to the local, state and
national level.
Structural Measures
It is an overview of the AMS programme in an organization at a point in time. The criteria to

measure is stated in the table below.
Table 2. Criteria to measure for an AMS programme
CRITERIA TO MEASURE INDICATOR
1. AMS team members a. Does your hospital have a dedicated AMS team?
b. Number of AMS Doctors/ number of beds in your
hospital?
c. Number of AMS Pharmacists/ number of beds in your
hospital?
2. AMS committee meeting a. Does your hospital have regular AMS committee
meeting?
b. How frequent is the meeting?
3. Antimicrobial policy a. Does your hospital have an antimicrobial policy?
4. Formulary Restriction & a. Do you practice formulary restriction &

Preauthorization preauthorization in your hospital?
b. What type of antimicrobial is being restricted?
5. Antimicrobial guidelines a. Do you have a local antimicrobial guideline in your

or clinical pathway hospital?
b. Do you have a clinical pathway in your hospital?
c. When is the latest updated version?
6. Education a. How many trained personnel in your AMS team?
• Number of AMS personnel trained under MOH AMS
training module.
• Number of AMS personnel trained under other
certified organization besides MOH. Please specify
the name of organization and date.
• Number of AMS personnel attended any AMS short
courses. Please specify the name of the course and
date.
7. Antibiogram a. Does your hospital have a local antibiogram?

b. Does your hospital distribute the current antibiogram
to the prescribers?
Note: Not all of the examples listed may be necessary and/or feasible in all hospitals.
Process Measures
INDICATOR INDICATOR CONSTRUCTION
Documented indication for Number of patients with a written indication for antibiotic
antibiotic use treatment/ Total number of patients treated with
antibiotic(s).
Stop/review date Number of patients with a written stop/review date for

antibiotic treatment/ Total number of patients treated with
antibiotic(s).
Compliance with current Number of patients with an indication receiving empirical

clinical treatment guidelines treatment with antibiotic(s) according to clinical
guidelines/ Total number of patients with this indication.
Length of therapy by Total number of days of antibiotic treatment for a specific

indication indication/ Total number of patients treated with
antibiotic(s) for that indication.
48-hour review Number of patients where a 48-hour review is performed/

Total number of patients treated with antibiotic(s)
hospitalized >48 hours.
De-escalation Number of patients where a de-escalation from the initial
therapy is performed/ Total number of indicated empirical
treatments.
IV-to-oral switch Number of regimens switched to oral route/ Total number

of regimens that can be switched to oral route based on
predefined criteria.
Compliance with current Number of patients receiving surgical antibiotic

guidelines for surgical prophylaxis according to guidelines/ Total number of
prophylaxis (antibiotics) surgical patients receiving antibiotic prophylaxis.
Surgical prophylaxis within Surgeries with prophylaxis administered within 60

the previous 60 minutes minutes prior to surgery/ Total number of surgeries that
require prophylaxis.
Surgical prophylaxis stopped Surgeries with prophylaxis stopped within 24 hours after
within 24 hours after surgery surgery/ Total number of surgeries that require
prophylaxis.
(Adapted from WHO toolkit: Antimicrobial Stewardship Programmes in Healthcare Facilities

in Low- and Middle-income Countries)
Outcome Measures (After AMS Interventions)
i. Outcomes related to antimicrobial use:

• DDD per 1000 patient-days
• DDD per 100 admissions
• DOTs per 1000 patient-days
• Proportion of DDDs in AWaRe and OTHER groups
ii. Outcomes related to patients and microbiology:

• Patient outcomes
In-hospital mortality, length of stay, readmission within 30 days after discharge.
• Microbiology outcomes
Clostridium difficile / MDR organisms:
Number of healthcare-associated infections in a period of time/ Total number
of patient days within that period x 100 000.
SECTION B:
ANTIMICROBIAL
STEWARDSHIP
PROGRAMME IN
PRIMARY CARE
Inappropriate use of antimicrobials, primarily involving therapeutic
agents used to treat infections, is considered one of the world’s most
significant public health problems. In addition to diminishing the
therapeutic benefit of essential medications, inappropriate use of
antimicrobials also facilitates the development and spread of
multidrug-resistant organisms.
The National Infection Control and Antibiotic Committee introduced

AMS in primary care in 2014 as a strategy to combat antibiotic
resistance.
Successful implementation of AMS requires a continuous commitment

from all levels of management in MOH primary care and therefore
shall be incorporated in existing meetings such as Drugs &
Therapeutics Committee Meetings, Infection and Antibiotic Control
Committee Meetings and Management Meetings at all levels.
B.1 ANTIMICROBIAL STEWARDSHIP TEAM
Strategies and activities of Antimicrobial Stewardship Programme

AMS strategies and activities shall be carried out as follows:
1. Implement the National Antimicrobial Guideline, clinical guidelines and pathways for
common infections.
2. Report the surveillance and clinical audit findings and ensure the necessary actions are
taken.
3. Establish formulary restrictions and approval systems, especially for broad-spectrum
antimicrobials.
4. Select and optimize the antimicrobial dose tailored to patient characteristics.
5. Educate prescribers, pharmacists, and paramedics on good antimicrobial prescribing
practices and antimicrobial resistance.
Antimicrobial Stewardship Team Members

AMS team members in health facility include:
a. Family Medicine Specialist/ Medical Officer In Charge/ Medical Officer in charge of

the program (Leader)
b. Pharmacist (Secretariat)
c. Assistant Medical Officer
d. Infection Control/ Link Nurse (Optional)
e. Medical Lab Technician (Optional)
f. Information Technology Officer (Optional)
Roles and responsibilities

1. Family Medicine Specialist/ Medical Officer In Charge/ Medical Officer in charge of
the programme
• Head of AMS Team.

• Leads the technical components of Antimicrobial Stewardship team.
• Plans and ensures the implementation of AMS activities.
• Consults relevant specialists on antimicrobial stewardship related issues.
• Advises on antimicrobial stewardship related issues.
• Represents the AMS Health Clinic team in the district AMS meeting and gives
feedback on AMS program.
• Collaborates with the District Drugs and Therapeutics Committee (JKUT) to
determine the availability of antimicrobials in the District Drug Formulary.
• Plans and conducts AMS Process and Structure Audits and provides timely feedback
for improvement.
• Prepares reports on AMS activities for submission to district level.
2. Pharmacist
• Ensures the implementation of AMS activities.

• Plans, conducts and analyses data of the antimicrobial surveillance and survey.
• Provides timely feedback on antimicrobial utilisation.
• Ensures dose optimization for antibiotics is carried out.
• Enforces the approval system of restricted antimicrobials prescriptions.
3. Assistant Medical Officer
• Assists in ensuring implementation of AMS activities.
4. Infection Control/ Link Nurse (optional)
• AMS teams frequently take opportunities to tighten infection control practices during
their course of work. Having an Infection Control/ Link Nurse within the team
complements the efforts of the AMS team in bringing down resistance rates.
5. Medical Laboratory Technologist (optional)
• Provides technical advice on correct sample collection and management.

• Ensures timely results of culture and antimicrobial sensitivity tests.
• Documents antimicrobial sensitivity test results.
6. Information Technology Officer (optional)
• Creates localized electronic decision-making systems that can be available through

the health clinic network system.
• Provides AMS team access for microbiological data and antibiotic utilisation data.
• Produces automated antibiotic utilisation data and other clinical data.
B.2 ANTIMICROBIAL STEWARDSHIP PROGRAMME ACTIVITIES
1. Implementation of Treatment Guidelines and Clinical Pathways

AMS team should ensure the implementation of clinical guidelines and pathways in the
management of URTI, UTI, SSTI, Pneumonia and Acute Bronchitis and AGE. (Refer NAG 2019).
2. Surveillance and Feedback

The surveillance on the use of antimicrobials enables us to compare the trend of antimicrobial
utilisation. It shall focus on the use of selected antimicrobial in primary care and shall be
conducted at least twice a year. Access to information on antimicrobial utilisation can be an
important source for healthcare professionals and policy makers to monitor progress towards
a more prudent use of antibiotics. The results of antimicrobial use should be discussed with
prescribers and necessary action should be taken based on relevant findings.
2.1 Measurement to determine the antimicrobial utilisation

• Defined Daily Dose (DDD) per 100 patient admissions.
2.2 Provision of data to district, state and national surveillance programs

• The report should be submitted twice a year to DIACC, State Infection and Antibiotic
Control Committee (SIACC) and Pharmacy Practice and Development Division,
MOH for National Surveillance on Antibiotic Utilisation annually.
3. Audit and Feedback

The AMS audit in primary care consists of process and structure audits
Process Audits generally are carried out annually to ensure adherence to clinical guidelines
and pathways and to evaluate the antibiotic prescribing practices. The AMS Process Audits
include Clinical Audit (Appendix 11) and Point Prevalence Survey (Appendix 12).
In addition, Structure Audit evaluates the implementation of AMS core elements and reviews
the progress of stewardship activities once a year. (Appendix 13).
The AMS Audit shall be conducted at:
Reports/
Type of Audit Frequency Responsibility Indicator
Data to
Clinical Audit Minimum of Clinic AMS 1. Percentage 1. PKD

once a year Team of clinics 2. State
and when implementing 3. National
indicated. clinical audits
* Minimum of
30 cases per 2. Percentage
clinic of good
practices in
antibiotic
prescription
(> 80 %)
Point Once a year in Clinic AMS 1. Percentage 1. PKD
Prevalence a selected Team of clinics 2. State
Survey (PPS) clinic. implementing 3. National
PPS
2. Percentage
of appropriate
antibiotic
prescription for
URTI
Structure Audit Once a year as Clinic AMS 1. Percentage 1. PKD

a cross audit. Team of clinics 2. State
implementing 3. National
Structure Audit
2. Percentage
of clinics with
score of > 80%
Reports of the AMS audit shall be presented in Infection and Antibiotic Control Committee
Meeting at the District, State and National level. Remedial actions on the shortfall in quality
shall be discussed and communicated to the implementation level.
In order to ensure the success of the program, two-way system communication has to be
established within the institution. Any feedback may be disseminated via:
a) Email/letter to heads of units
b) Email/letter to individual prescribers
c) Newsletter or bulletin
d) Presentation at unit or district meetings
4. Formulary Restriction
Formulary restriction is one of the pillars of AMS Programme. MOH drug formulary implements
restrictions based on category of prescribers; however, these restrictions may not be adequate
to guide the local prescribers about judicious use of antibiotic. Therefore, each district is
required to formulate their own district’s formulary with consideration of specific MOH
program such as Integrated Management of Childhood Illnesses and Modified Syndromic
Approach.
All prescribers should comply with formulary restriction either from local or national formulary
which can be implemented through pre-approval (can only be started after getting a specific
approval) either written or verbally.
5. Antibiotic Selection and Dose Optimization

Antimicrobial selection and dose optimization should be tailored to patient characteristics/
allergic history, causative organism, site of infection, and pharmacokinetic and
pharmacodynamic characteristics of the antimicrobial agent. Concomitant drug use should
be reviewed to prevent interaction.
Strategies that may be considered include:
• Weight-based dosing of certain antimicrobials for paediatric.

• Dose adjustments for patients with renal dysfunction, liver dysfunction and elderly.
• Selection based on local sensitivity and resistance pattern.
6. Education
Antimicrobial Stewardship team should provide continuous education for prescribers,
pharmacists and paramedics to enhance knowledge and promote good prescribing behavior
especially to new staffs. Educational Key Points (Appendix 10) must be highlighted during
these sessions to instill appropriate use of antimicrobial.
Recommended Educational Programs
1. Continuous Medical Education (CME)
2. Newsletter including a sub-topic on antibiotics in any publications
3. Prescribing aids
• Educational aids to guide prescribers at the point of prescribing. These may include
clinical algorithms for the diagnosis of infection, or methods to standardize the
documentation of treatment decisions, such as infection stamps or stickers to be
included in the clinical notes.
• Information technology support to provide guidance for prudent antimicrobial use.
• Electronic patient record which is able to highlight potential antibiotics interaction
and allergy.
Public awareness activities should be planned and carried out with the aim of creating
awareness towards the judicious use of antibiotics and challenges of antimicrobial resistance.
B.3 ANTIMICROBIAL STEWARDSHIP PROGRAM MEASUREMENT
Successful antimicrobial stewardship programme includes all the elements of successful

quality improvement programs and measuring the effectiveness of program activities is a key
component. Monitoring and analysis of antimicrobial usage is critical to measure the
effectiveness of stewardship interventions. Process and outcome measures should be
incorporated into the AMS plan.
A. Process indicators
• Percentage of clinics implementing structure audits.
• Percentage of clinics implementing clinical audits.
• Percentage of clinics implementing antibiotic PPS.
B. Outcome indicators
• Percentage of clinics with structure audit score of > 80%.
• Percentage of good practices in antibiotic prescription (clinical audit score > 80 %).
• Percentage of appropriate antibiotic prescription for URTI from PPS (based on
National Antimicrobial Guideline/ clinical guidelines/ pathways for URTI patients).
• Pattern of selected antibiotics utilisation using DDDs.
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sepsis, severe sepsis or septic shock.Thecochrane collaboration.
10. Kuti,J.L., Shore, E., Palter, M., Nicolau,D.P. 2009. Tackling empirical antibiotic therapy for VAP in
your ICU. SeminRespirCrit Care Med;30(1):102-115.
11. Masterton, R.G. 2011. Antibiotic de-escalation. Critical Care Clin;27(1):149-62.
12. Joung, M.K., Lee, J., Moon, S. et al. 2011. Impact of de-escalation therapy on clinical outcome for
intensive care unit—acquired pneumonia. Critical Care, 15:R79
13. Ramirez JA, Srinath L, Ahkee S, et al. Early switch from intravenous to oral cephalosporins in the
treatment of hospitalized patients with community-acquired pneumonia. Arch Intern Med.
1995;155: 1273-1276.
14. Weingarten SR, Riedinger MS. Varis G, et al. Identification of low-risk hospitalized patients with
pneumonia: implications for early conversion to oral antimicrobial therapy. Chest. 1994;105:1109-
1115.
15. Ahkee S, Smith S, Newman D, et al. Early switch from intravenous to oral antibiotics in hospitalized
patients with infections: a 6-month prospective study. Pharmacotherapy. 1997;17:569-575.
16. Przybylski KG, Rybak MJ, Martin PR, et al. A pharmacist-initiated program of intravenous to oral
antibiotic conversion. Pharmacotherapy. 1997;17:271-276.
17. Rimmer D. Third generation cephalosporins in the parenteral to oral switch. Pharmacoeconomics.
1994;5 (suppl 2):27-33.
18. Chan R, Hemeryck L, O'Regan M, et al. Oral versus intravenous antibiotics for community acquired
lower respiratory tract infection in a general hospital: open, randomised controlled trial. Br Med J.
1995; 310:1360-1362.
19. Ehrenkranz NJ, Nerenberg DE, Shultz JM, et al. Intervention to discontinue parenteral antimicrobial
therapy in patients hospitalized with pulmonary infections: effect on shortening patient stay. Infect
Control HospEpidemiol. 1992;13:21-32.
20. Hendrickson JR, North DS. Pharmacoeconomic benefit of antibiotic step-down therapy: converting
patients from intravenous ceftriaxone to oral cefpodoximeproxetil. Ann Pharmacother.
1995;29:561- 565.
21. Paladino JA, Sperry HE, Backes JM, et al. Clinical and economic evaluation of oral ciprofloxacin
after an abbreviated course of intravenous antibiotics. Am J Med. 1991; 91:462-470.
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AntimicrobChemother 2007; 60 ; Suppl 1: i87-i90
23. Timothy H. D, Robert C. O, John E. McG, Dale N. G, Robert A. W et al; Guidelines for Developing
an Institutional Program to Enhance Antimicrobial Stewardship; Antimicrobial Stewardship
Guidelines • CID 2007:44 (15 January)
24. Guidelines for Antimicrobial Stewardship in Hospitals in Ireland; SARI Hospital Antimicrobial
Stewardship Working Group December 2009
25. Richard H. Drew ; Antimicrobial Stewardship Programs:How to Start and Steer a Successful Program
J Manag Care Pharm. 2009;15(2)(Suppl):S18-S23
26. Mohd. Fozi K, Kamaliah MN. The effect of profiling report on antibiotic prescription for upper
respiratory tract infection. Malaysian Family Physician 2013;8(2):26-31.
27. J. Moody et al. APIC-SHEA Position Paper: American Journal Of Infection Control 40(2012): 94-95
28. https://www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements-small-critical.html
29. World Health Organization. ( 2019) . Antimicrobial stewardship programmes in health-care
facilities in low- and middle-income countries: a WHO practical toolkit. World Health
Organization. https://apps.who.int/iris/handle/10665/329404.
30. Hutchinson, J. M., Patrick, D. M., Marra, F., Ng, H., Bowie, W. R., Heule, L., Muscat, M., & Monnet,
D. L. (2004). Measurement of antibiotic consumption: A practical guide to the use of the Anatomical
Thgerapeutic Chemical classification and Definied Daily Dose system methodology in Canada.
The Canadian journal of infectious diseases = Journal canadien des maladies infectieuses, 15(1),
29–35. https://doi.org/10.1155/2004/389092
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and Human Services, CDC; 2014. http://www.cdc.gov/getsmart/healthcare/ implementation/core-
elements.html
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Collaborative. https://www.uhfnyc.org/assets/1042
33. A Practical Guide to Antimicrobial Stewardships in Hospital. bsac.org.uk/practical-guide-to-
antimicrobial-stewardship-in-hospitals/
34. Barlam, T. F., Cosgrove, S. E., Abbo, L. M., MacDougall, C., Schuetz, A. N., Septimus, E. J., ... &
Hamilton, C. W. (2016). Implementing an antibiotic stewardship program: guidelines by the
Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.
Clinical Infectious Diseases, 62(10), e51-e77
35. National Antimicrobial Guideline 2019
APPENDICES
APPENDIX 1: District Infection and Antibiotic Control Committee (DIACC)
a) Composition of District Infection and Antibiotic Control Committee. The following will
be members of the DIACC:
1. Medical Officer of Health- chairman
2. Appointed District Pharmacist - (Secretariat)
3. Public Health Specialist (Primary Care) - (Infection Control Coordinator)
4. Public Health Specialist (Epidemiology)
5. Public Health Specialist (KPAS)
6. Appointed Family Medicine Specialist (AMS Coordinator)
7. District Matron
8. District Assistant Medical Officer
9. Appointed Infection Control Nurse/Personnel
10. Appointed District Medical Laboratory Technologist
11. Information and Communication Technology Officer (ICT)
12. Three (3) Representatives of Pharmacist from Health Clinic
13. Three (3) Representatives of Link Nurse/Personnel from Health Clinic
b) Chairman
The committee will be chaired by the District Health Officer and the chairman:
• Leads facilitation and coordination of district public health efforts in promoting good
infection control practice and judicious use of antimicrobial.
• Provides a platform for programme planning and implementation.
• Leads DIACC meetings.
• Reviews and approves DIACC output.
• In the absence of the Chairman, the meeting will be chaired by a delegate assigned
by the chairman.
c) Infection Control and AMS District Coordinator

• Represents District Infection and Antibiotic Control Committee (DIACC) meeting.
• Assists Chairman in facilitation and coordination of the district infection and
antibiotic control stewardship activities.
• Prepares reports on progress and performance of infection and antibiotic control
stewardship activities.
• Recommends necessary intervention and improvement to the chairman and
committee.
• Acts as head of the secretariat for DIACC
- Schedule and prepare the agenda of bi-annual DIACC
- Draft minutes for DIACC meetings
- Maintain a spreadsheet to track progress on recommendations
- Facilitate DIACC correspondence
- Draft and maintain DIACC documents, reports and meeting minutes as
appropriate
d) Members of District Infection and Antibiotic Control Committee (DIACC)

• Participate in the biannual DIACC meeting.
• Provide technical input.
e) Meeting format for District Infection and Antibiotic Control Committee
i) Frequency of meetings
• Meetings shall be held at least twice a year.
• Members of the committee shall be notified of the date and agenda of the
meeting at least two weeks prior to the meeting.
• Minutes should be kept and ratified.
ii) Agenda of the meetings

The agenda of the meeting should include:
• Report on the incidence and prevalence of MDRO organisms and/or emerging
resistant organisms where applicable
• Report on District Surveillance of Antibiotic Resistance (Primary Health Care)
where applicable
• Report on Healthcare-Associated Infection Surveillance
• Report on Infection Prevention and Control Performance (Primary Health Care)
- Infection Prevention and Control Audit
- Hand Hygiene Compliance Surveillance
• Report on AMS Performance (Primary Health Care)
- Antibiotic Utilisation Surveillance (DDD)
- Point Prevalence Survey
- AMS Clinical and Structure Audit
- Antibiotic Awareness Program
• Report on Sharp Injuries among Healthcare Worker (Primary Health Care)
• Report on Tuberculosis among Healthcare Worker (Primary Health Care)
iii) Members of the meeting
• The quorum of meeting shall consist of at least 2/3 of the committee members.
iv) Emergency meetings and outbreak control

• The Chairman may call for an emergency meeting of the DIACC at any time and
all members or their representatives will be notified accordingly.
• Emergency meetings are arranged for the control of infection outbreak, when the
Infection Control Team requires additional support and notifications of the
problem, in accordance with the Major Outbreak Policy.
Appendix 2: Antimicrobial Stewardship Programmes in Healthcare Facilities in Low- and
Middle-income Countries
Example of Terms of Reference:
Appendix 3: How to Perform an Audit
WORK PROCESS OF PROSPECTIVE AUDIT

PREAUDIT
Area of Problem Identified Specified agreed criteria to

be determined
No
Source of data
1. Antibiotic consumption
(DDD)
Intervention
2. Antibiotic prescription
3. Culture & Susceptibility
data
AUDITT
4. Patient progress note

Yes
5. Other relevant data
Feedback
All feedback has to communicated and

documented through:
1. Direct interactions
2. Note or stickers in the chart or
Electronic Medical Records
Published Audit Findings
1. Email/letter to heads of units

POST AUDIT
2. Email/letters to individual prescribers

3. Newsletter or bulletins
4. Presentation at ward or unit meetings
5. Presentation at Drug Committee and
Therapeutic Meeting
EXAMPLE OF AUDIT USING DDD DATA
AMS Pharmacist monitors DDD
NO
E.g. Baseline = DDD Increases beyond the upper limit END
• Average DDD previous (e.g.>30% from baseline)
year
Upper limit: YES

Antibiotic to be prioritized
• Percentage of increase for auditing:
from baseline. Discussed
and agreed among the 1. Carbapenem
AMS Team members AMS Pharmacist alert the AMS Team
2. Colistin
3. Cephalosporin (e.g.
Ceftriaxone)
4. Vancomycin
5. Piperacillin/Tazobactam
AMS Doctor and ward pharmacist to investigate the cause of the

increase in DDD (e.g: investigate the last 10-30 cases)
• Check indication of antibiotic whether it is clearly stated and
compliance to Antibiotic Guideline (Pharmacist)
• Diagnosis (ID Physician/Physician/Clinician)
1 week
Present finding to AMS Team
NO
Require intervention?
YES 1 week
AMS Doctor and ward pharmacist meet up with

relevant ward/department to give feedback
1 month
Follow-up on the outcome of the

intervention & feedback. Present to
AMS Team.
64
EXAMPLE OF ANTIBIOTIC AUDIT FORM
ANTIBIOTIC:
If Definitive/
Empiric If Empiric
Empiric/ to Definitive
Indication Definitive/ Compliance
Month Ward Dose & Patient MRN of Treatment Prescriber Remarks
Empiric to Duration
Frequency Antibiotic to Reason for
guideline (Days)
Start Date
cont.
Stop Date
Definitive Culture Source
beyond
72 hours
Protocol on Antimicrobial Stewardship (AMS) Programme in Healthcare Facilities | Second Edition 2022
Appendix 4: How to Perform Antibiotic Point Prevalence Survey (PPS)
EXAMPLE OF PPS WARD DATA COLLECTION FORM
EXAMPLE OF PPS FORM
Appendix 5: How to Perform Surgical Antibiotic Prophylaxis Audit
EXAMPLE OF SURGICAL ANTIBIOTIC PROPHYLAXIS FORM
SURGICAL PROPHYLAXIS AUDIT WORK PROCESS (Continuous Improvement Cycles)
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Appendix 6: Example of Formulary Restriction
Antimicrobials are divided into 3 categories – the first being antimicrobials that require
preauthorization before it can be prescribed. Authorization is issued by the relevant consultant
of the department and in accordance with preapproved indications. The second category
involves antimicrobials that can be prescribed for certain indications which will be subject to
a review by the stewardship team within 3 working days and justification for its continuation
is required. The last category is other antimicrobials that do not require pre-approvals.
Example:
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Appendix 7: Example of Antibiotic Order Form
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Appendix 8: Example of IV to PO Therapy Conversion
IV-Oral Antibiotic Switch Therapy Protocol
Example of Anmicrobials That Can Be Included in IV to PO Therapy Conversion
(Not all IV Antimicrobial are available in Oral formulation)
=Sequential therapy with direct conversion (same medication but different IV to oral dose)
=Sequential therapy without direct conversion (same medication but different IV to oral dose)
> =Switch or step-down therapy (same or different class of medication with same/similar spectrum of
activity)
(Source: National Antimicrobial Guideline 2019)
Appendix 9: The WHO EML AWaRe classification of commonly used antibiotics
Appendix 10: Educational Key Points
The educational programs should include the interventions points as below:-

Adapted from recommendations produced by the UK Specialist Advisory Committee on
Antimicrobial Resistance (SACAR)
• Antimicrobials should be used after a treatable infection has been recognized or there is a
high degree of suspicion of infection. In general, colonization or contamination should not
be treated. Antimicrobials should be used for the prevention of infection where research
has demonstrated that the potential benefits outweigh the risks. Long-term prophylaxis
should be avoided unless there is a clear clinical indication (for example, rheumatic fever
and post-splenectomy).
• The choice of antimicrobial should be determined by the sensitivity of the identified

causative organism when this is known. Empiric therapy, for the likely causative organism
(s) should be governed by local guidelines that have been informed by recent information
about trends in antimicrobial sensitivities.
• Targeted therapy should be used in preference to broad-spectrum antimicrobials unless

there is a clear clinical reason (for example, mixed infections or life-threatening sepsis).
The prescription of broad-spectrum antimicrobials should be reviewed as soon as possible
and promptly switched to narrow spectrum agents when sensitivity results become
available. Mechanisms should be in place to control the prescribing of all new broad-
spectrum antimicrobials.
• The timing, regimen, dose, route of administration and duration of antimicrobial therapy
should be optimized and documented. The indication for which the patient is being
prescribed the antimicrobials should be documented in the drug chart and case notes by
the prescriber.
• Wherever possible, antimicrobials should be given orally rather than intravenously. Clear
criteria should be defined for when intravenous therapy is appropriate. As soon as possible
the prescription should be switched to an oral equivalent. The intravenous prescription
should be reviewed after 48 hours as a minimum.
• Antimicrobial treatment should be stopped as soon as possible. A stop date or review date
should be recorded by the prescriber on the drug chart. In general, antimicrobial courses
should be reviewed within five days.
To ensure rapid treatment and infection control, mechanisms should be in place to ensure that
patients receive antimicrobial drugs in a timely manner.
Appendix 11: Clinical Audit Guidelines in Health Clinic
Introduction:
Clinical audit for AMS is a tool that looks into details in clinical practice by individual health care
provider that prescribed antibiotic and overall trend of prescription by health clinic. This can be
further used for quality improvement cycle that involves assessment of the effectiveness of clinical
services against agreed standards of best practice.
Stage of implementation:
STAGE 1 - PREPARATION:
• Done annually by random sampling of minimal 30 case notes as samples or as needed
whenever there are issues in the trend of antibiotic prescription.
• Identify available resources, e.g. audit team headed by FMS in charge of health clinic.
• Existing guidelines defining desired standards as reference, such as NAG and clinical
pathways.
• Define criteria: All antibiotic prescription on any health care provider to be randomly selected
with minimum of 30 record within the past 1 month.
STAGE 2 - MEASURING LEVEL OF PERFORMANCE:

• Data collection maybe from computerised records or manual collection. Data entered in
excel format with embedded formulas.
• Audited clinical record will be scored based on criteria of best practice with score of 80%
and above would be consider as appropriate.
• Analyse the data collected:
o Compare actual performance with the set standard based on previous scoring.
o Discuss how well the standards were met.
o If the standards were not met, note the reasons for this.
STAGE 3 – MAKING IMPROVEMENTS:

• Present the results and discuss them with the relevant individual or teams in the -organisation.
• The results should be used to develop an action plan, specifying what needs to be done, how
it will be done, who is going to do it and by when.
STAGE 4 - MAINTAINING IMPROVEMENTS:

• This follows up the previous stages of the audit, to determine whether the actions taken have
been effective, or whether further improvements are needed.
• It involves repeating the audit (i.e. targets, results, discussion); hence the terms “audit cycle”.
Any adhoc audit for individual prescriber or health clinic performance in AMS prescription
performance can be done when necessary throughout the year. Data can be used for self-
monitoring audit that does not require any report submission.
Excel format for clinical audit:
Appendix 12: Workflow of PPS in Health clinic
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Pharmaceutical Services Programme
Medical Development Division
Family Health Development Division
Ministry of Health Malaysia

Second Edition 2022

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MOH/S/FAR/69.

Second Edition 2022

Second Edition, 2022

Produced and distributed by:

Antimicrobial stewardship is based on fundamental principles to guide the

The antimicrobial stewardship team provides feedback on prescribing practices,

To support the nationwide implementation of antimicrobial stewardship, the Ministry

I want to congratulate all contributors, reviewers, Pharmaceutical Services Programme,

The first edition of Protocol on Antimicrobial Stewardship Programme in

Overuse and misuse of antimicrobials have been associated with more

I believe this protocol will benefit all healthcare professionals in

Antimicrobial stewardship programmes have shown to decrease inappropriate

YBhg. Datuk Dr. Asmayani Khalib

YBhg. Datuk Dr. Norhayati Rusli

YBhg. Mdm. Norhaliza A Halim

YBhg. Dato’ Dr. Mahiran Mustafa

EDITORIAL COMMITTEE & CONTRIBUTORS LIST

Mdm. Rohana Hassan Dr. Suraya Amir Husin

Mdm. Hazimah Hashim Dr. Nor Farah Bakhtiar

Ms. Nur Salima Shamsudin Dr. Noor Amelia Abd Rasid

Mdm. Mardhiyah Kamal Prof. Dr. Sasheela Sri La Sri

Dr. Suraya Hanim Abdullah Hashim Dr. Cheng Joo Thye

Dr. Rahela Ambaras Khan Mdm. Siti Hir Huraizah Md Tahir

Dr. Janattul Ain Jamal Ms. Izyana Munirah Idham

Dr. Syamhanin Adnan Ms. Thong Kah Shuen

Mr. Tan Chee Chin Ms. Hannah Md Mahir

EDITORIAL COMMITTEE & CONTRIBUTORS LIST

Dr. Nazrila Hairizan Nasir Dr. Ho Bee Kiau

Dr. Noraini Mohd Yusof Dr. Salmiah Md Sharif

Dr. Husni Hussain Dr. Vickneswari a/p Ayadurai

Dr. Izan Hairani Ishak Dr. Norhazirah Mohd Noor

Dr. Izwan Effendy Ismail Mdm. Mardhiyah Kamal

Dr. Hazaimah Shafii Ahmad Sufardy Mohamad

Prof. Madya Dr. Petrick @ Dr. Mohd Fozi Kamaruddin

Dato’ Dr. Chow Ting Soo Mdm. Lau Chee Lan

Dr. Sahlawati Mustakim

EDITORIAL COMMITTEE & CONTRIBUTORS LIST (HOSPITAL) 10

EDITORIAL COMMITTEE & CONTRIBUTORS LIST (PRIMARY CARE) 11

SECTION A: ANTIMICROBIAL STEWARDSHIP PROGRAMME IN HOSPITAL 21

A.1 ANTIMICROBIAL STEWARDSHIP TEAM 21

A.2 ANTIMICROBIAL STEWARDSHIP ACTIVITIES 26

A.3 ANTIMICROBIAL STEWARDSHIP PROGRAMME MEASUREMENT 40

SECTION B: ANTIMICROBIAL STEWARDSHIP PROGRAMME IN PRIMARY CARE 43

B.1 ANTIMICROBIAL STEWARDSHIP TEAM 43

B.2 ANTIMICROBIAL STEWARDSHIP PROGRAMME ACTIVITIES 45

B.3 ANTIMICROBIAL STEWARDSHIP PROGRAMME MEASUREMENT 49

In the last 40 years, the prevalence of multidrug-resistant microorganisms (e.g. extended

Antimicrobial management or stewardship programme has been developed as a response to

The development of antimicrobial resistance strains in hospitals is intensified because of a

1. To optimize antimicrobial therapy in order to maximize clinical cure or prevent

2. To minimize the unintended consequences such as the emergence of antimicrobial

4. To reduce healthcare costs without adversely impacting the quality of care.

Antimicrobial Stewardship Implementation

Functional structure of AMS at districts and health clinics

District Infection and Antibiotic Control Districts

Health Clinic Infection and Antibiotic Health

Antimicrobial Infection Control

* Responsible in Infection Control and the implementation of AMS

2. Development and documentation of local antimicrobial policy