Antimicrobial Stewardship in the Era of Antibiotic Resistance: From Appropriate Prescribing to Precision Therapy
Abstract
Francesco Saturno, Giulia Monaco, Angela Salerno, Antonio Cianciola, Nicole Cianciola and Emidio Cianciola
Background: Antimicrobial resistance (AMR) represents one of the most important threats to modern healthcare. The progressive emergence and dissemination of antimicrobial-resistant microorganisms compromises the effectiveness of established therapies and increases the complexity, duration and cost of patient care. Inappropriate antimicrobial exposure, including unnecessary treatment, excessive duration, inappropriate spectrum and inadequate dosing, contributes to the selection of resistant organisms.
Objective: This narrative review examines the principal challenges associated with antibiotic prescribing and evaluates the role of antimicrobial stewardship (AMS) in promoting appropriate, individualized and precision-oriented antimicrobial therapy.
Methods: A narrative review of international recommendations, stewardship frameworks and major scientific literature was undertaken. Particular attention was given to antimicrobial prescribing, diagnostic stewardship, empirical therapy, microbiological reassessment, antimicrobial susceptibility testing, pharmacokinetic/pharmacodynamic optimization, therapeutic drug monitoring, de-escalation, intravenous-to-oral conversion, treatment duration, antimicrobial consumption and One Health strategies.
Results: Effective AMS requires an integrated multidisciplinary approach. Antibiotic prescribing should be based on clinical probability, severity of infection, local epidemiology, previous microbiological data, individual patient characteristics and pharmacological principles. Empirical therapy should provide adequate initial coverage when clinically indicated, but treatment must be reassessed after the initial diagnostic and therapeutic phase. De-escalation, discontinuation, spectrum narrowing, optimization of dose and duration, and intravenous-to-oral conversion represent fundamental stewardship interventions. Contemporary stewardship is increasingly evolving toward precision antimicrobial therapy, integrating rapid diagnostics, susceptibility data, patient-specific pharmacokinetics and pharmacodynamics, and real-time clinical response.
Conclusions: Antimicrobial stewardship should not be regarded simply as a strategy to reduce antibiotic consumption. Its primary objective is to optimize antimicrobial therapy for the individual patient while preserving antimicrobial effectiveness at the population level. The integration of AMS with diagnostic stewardship, infection prevention and control, microbiological surveillance, pharmacokinetic/pharmacodynamic optimization and the One Health framework represents a central strategy for addressing AMR.