Strengthening Antimicrobial Stewardship via Diagnostic Stewardship Education
Main Article Content
Abstract
Background: Antimicrobial resistance (AMR) is a global health challenge requiring an integrated approach that includes antimicrobial, infection prevention and control, and diagnostic stewardship. Diagnostic uncertainty drives antibiotic overuse. Diagnostic stewardship enhances accurate diagnoses by optimizing test selection, reducing unnecessary antibiotic use, and improving surveillance, ultimately refining prescribing practices and patient outcomes. Despite diagnostic stewardship's potential to curb inappropriate prescribing and healthcare costs, its adoption remains limited due to low awareness and misconceptions among clinicians.
Methods: This cross-sectional pre-post study engaged 458 multidisciplinary participants to assess awareness regarding DS practices. An online educational intervention comprising five modules covered pre- and post-analytic practices, test interpretation, and the integration of diagnostic stewardship principles within antimicrobial stewardship (AMS) strategies.
Results: Out of 458 participants, 111 participants completed all tests in the five modules. There was a significant increase in knowledge, with mean test scores rising from 29.22 ± 5.80 to 35.45 ± 6.18 (p<0.001) post-intervention. Overall knowledge of antimicrobial stewardship improved substantially, with mean correct responses rising from 58% pre-test to 71% post-test. Antimicrobial resistance awareness increased from 83% to 90%, while report interpretation saw the greatest gain (43% to 63%), followed by AMS strategies (61% to 75%), pre-analytical processes (44% to 56%) and AMS actions (61% to 73%). However, some gaps remained in understanding the limitations of the Widal test, indications for respiratory cultures, redundant antibiotic cover, inappropriate drug-pathogen combinations, and the need to avoid unnecessary antimicrobials in asymptomatic bacteriuria.
Conclusion: The educational intervention led to marked improvements in both core awareness and applied stewardship competencies, especially enhancing appropriate test selection, result interpretation, and dispelling key diagnostic misconceptions. To sustain these gains and drive enduring behavioral change, regular refresher training, seamless integration of diagnostic stewardship into broader antimicrobial and infection prevention and control programs and periodic curriculum updates are essential.
Keywords:
Antimicrobial resistance, antimicrobial stewardship, diagnostic stewardship, educational intervention, rational prescribing, pre-analytical and post-analytical microbiological testing practices, Clinical decision-making
Article Details
How to Cite
SHARMA, Sangeeta et al.
Strengthening Antimicrobial Stewardship via Diagnostic Stewardship Education.
Medical Research Archives, [S.l.], v. 14, n. 1, jan. 2026.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/7185>. Date accessed: 16 mar. 2026.
doi: https://doi.org/10.18103/mra.v14i1.7185.
Keywords
Antimicrobial resistance, antimicrobial stewardship, diagnostic stewardship, educational intervention, rational prescribing, Pre-analytical and post-analytical microbiological testing practices, Clinical decision-making, Microbiological testing
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
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2. Painter, C., Faradiba, D., Chavarina, K. K., Sari, E. N., Teerawattananon, Y., Aluzaite, K., et al. (2023). A systematic literature review of economic evaluation studies of interventions impacting antimicrobial resistance. Antimicrobial Resistance & Infection Control, 12, 69. https://doi.org/10.1186/s13756-023-01265-5
3. Dik, J. H., Poelman, R., Friedrich, A. W., Niesters, H. G. M., Rossen, J. W. A., & Sinha, B. (2017). Integrated stewardship model comprising antimicrobial, infection prevention, and diagnostic stewardship (AID stewardship). Journal of Clinical Microbiology, 55(11), 3306–3307. https://doi.org/10.1128/JCM.01283-17
4. Sullivan, K. V. (2021). Diagnostic stewardship in clinical microbiology, essential partner to antimicrobial stewardship. Clinical Chemistry, 68(1), 75–82. https://doi.org/10.1093/clinchem/hvab206
5. Zakhour, J., Haddad, S. F., Kerbage, A., Wertheim, H., Tattevin, P., Voss, A., et al. (2023). Diagnostic stewardship in infectious diseases: A continuum of antimicrobial stewardship in the fight against antimicrobial resistance. International Journal of Antimicrobial Agents, 62(1), 106816. https://doi.org/10.1016/j.ijantimicag.2023.106816
6. Koch, C., Roberts, K., Petruccelli, C., & Morgan, D. J. (2018). The frequency of unnecessary testing in hospitalized patients. The American Journal of Medicine, 131(5), 500–503.
7. Callen, J., Georgiou, A., Li, J., & Westbrook, J. I. (2011). The safety implications of missed test results for hospitalized patients: A systematic review. BMJ Quality & Safety, 20(2), 194–199.
8. Vaughn, V. M., Szymczak, J. E., Newton, D. W., & Fakih, M. G. (2019). Addressing the overuse of cultures to optimize patient care. Annals of Internal Medicine, 171(7 Suppl.), S73–S74. https://doi.org/10.7326/M18-3442
9. Skodvin, B., Wathne, J. S., Lindemann, P. C., Harthug, S., Nilsen, R. M., Charani, E., et al. (2019). Use of microbiology tests in the era of increasing AMR rates: A multicenter hospital cohort study. Antimicrobial Resistance & Infection Control, 8, 28. https://doi.org/10.1186/s13756-019-0480-z
10. Ku, T. S. N., Al Mohajer, M., Newton, J. A., Wilson, M. H., Monsees, E., Hayden, M. K., et al. (2023). Improving antimicrobial use through better diagnosis: The relationship between diagnostic stewardship and antimicrobial stewardship. Infection Control & Hospital Epidemiology, 44(12), 1901–1908. https://doi.org/10.1017/ice.2023.156
11. Morgan, D. J., Malani, P. N., & Diekema, D. J. (2023). Diagnostic stewardship to prevent diagnostic error. JAMA, 329(15), 1255–1256. https://doi.org/10.1001/jama.2023.1678
12. Schinas, G., Dimopoulos, G., & Akinosoglou, K. (2023). Understanding and implementing diagnostic stewardship: A guide for resident physicians in the era of antimicrobial resistance. Microorganisms, 11(9), 2214. https://doi.org/10.3390/microorganisms11092214
13. Buchan, B. W., & Ledeboer, N. A. (2014). Emerging technologies for the clinical microbiology laboratory. Clinical Microbiology Reviews, 27(4), 783–822.
14. Jinks, T., Subramaniam, S., Bassetti, M., Gales, A. C., Kullar, R., Metersky, M. L., et al. (2024). Opportunities to enhance diagnostic testing and antimicrobial stewardship: A qualitative multinational survey of healthcare professionals. Infectious Diseases and Therapy, 13, 1621–1637.
15. Olliaro, P., Nkeramahame, J., Horgan, P., Tinto, H., Kiemde, F., Baiden, R., et al. (2023). Synthesis and meta-analysis of 3 randomized trials conducted in Burkina Faso, Ghana, and Uganda comparing the effects of point-of-care tests and diagnostic algorithms versus routine care on antibiotic prescriptions and clinical outcomes in ambulatory patients <18 years of age with acute febrile illness. Clinical Infectious Diseases, 77(Suppl.), S199–S205. https://doi.org/10.1093/cid/ciad324
16. Rolfe, R., Kwobah, C., Muro, F., Ruwanpathirana, A., Lyamuya, F., Bodinayake, C., et al. (2021). Barriers to implementing antimicrobial stewardship programs in three low- and middle-income country tertiary care settings: Findings from a multi-site qualitative study. Antimicrobial Resistance & Infection Control, 10, 60. https://doi.org/10.1186/s13756-021-00929-4
17. Eysenbach, G. (2004). Improving the quality of web surveys: The Checklist for Reporting Results of Internet E-Surveys (CHERRIES). Journal of Medical Internet Research, 6(3), e34. https://doi.org/10.2196/jmir.6.3.e34
18. Shorten, R., Pickering, K., Goolden, C., Harris, C., Clegg, A., & J. H. (2024). Diagnostic stewardship in infectious diseases: A scoping review. Journal of Medical Microbiology, 73(5), 001831. https://doi.org/10.1099/jmm.0.001831
19. Fabre, V., Carroll, K. C., & Cosgrove, S. E. (2022). Blood culture utilization in the hospital setting: A call for diagnostic stewardship. Journal of Clinical Microbiology, 60, e01005-21.
20. Doern, G. V., Carroll, K. C., Diekema, D. J., Garey, K. W., Rupp, M. E., Weinstein, M. P., et al. (2019). A comprehensive update on the problem of blood culture contamination and a discussion of methods for addressing the problem. Clinical Microbiology Reviews, 33, e00009-19.
21. Fabre, V., Davis, A., Diekema, D. J., et al. (2023). Principles of diagnostic stewardship: A practical guide from the Society for Healthcare Epidemiology of America Diagnostic Stewardship Task Force. Infection Control & Hospital Epidemiology, 44(2), 178–185. https://doi.org/10.1017/ice.2023.5
22. Romann, L., Werlen, L., Rommers, N., Hermann, A., Gisler, I., Bassetti, S., et al. (2023). Factors impacting the pre-analytical quality of blood cultures: Analysis at a tertiary medical center. PLOS ONE, 18(3), e0282918. https://doi.org/10.1371/journal.pone.0282918
23. Shapiro, N. I., Wolfe, R. E., Wright, S. B., Moore, R., & Bates, D. W. (2008). Who needs a blood culture? A prospectively derived and validated prediction rule. Journal of Emergency Medicine, 35, 255–264.
24. Pawlowicz, A., Holland, C., Zou, B., Payton, T., Tyndall, J. A., & Allen, B. (2015). Implementation of an evidence-based algorithm reduces blood culture overuse in an adult emergency department. General Internal Medicine Clinical Innovations, 1(2), 20–25. https://doi.org/10.15761/GIMCI.1000108
25. Watson, K. J., Trautner, B., Russo, H., et al. (2020). Using clinical decision support to improve urine culture diagnostic stewardship, antimicrobial stewardship, and financial cost: A multicenter experience. Infection Control & Hospital Epidemiology, 41(5), 564–570. https://doi.org/10.1017/ice.2020.37
26. Lee, A. L. H., Leung, E. C. M., Lee, M. K. P., & Lai, R. W. M. (2021). Diagnostic stewardship programme for urine culture: Impact on antimicrobial prescription in a multi-centre cohort. Journal of Hospital Infection, 108, 81–89. https://doi.org/10.1016/j.jhin.2020.10.027
27. Hooton, T. M., Bradley, S. F., Cardenas, D. D., Colgan, R., Geerlings, S. E., Rice, J. C., et al. (2010). Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical Infectious Diseases, 50(5), 625–663. https://doi.org/10.1086/650482
28. Nicolle, L. E., Gupta, K., Bradley, S. F., Colgan, R., DeMuri, G. P., Drekonja, D., et al. (2019). Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 68, 1611–1615. https://doi.org/10.1093/cid/ciz021
29. Sur, D. K. C., & Plesa, M. L. (2022). Antibiotic use in acute upper respiratory tract infections. American Family Physician, 106(6), 628–636.
30. Chandra Deb, L., McGrath, B. M., Schlosser, L., Hewitt, A., Schweitzer, C., Rotar, J., Leedahl, N. D., Crosby, R., & Carson, P. (2022). Antibiotic prescribing practices for upper respiratory tract infections among primary care providers: A descriptive study. Open Forum Infectious Diseases, 9(7), ofac302. https://doi.org/10.1093/ofid/ofac302
31. Fine, A. M., Nizet, V., & Mandl, K. D. (2012). Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Archives of Internal Medicine, 172(11), 847–852. https://doi.org/10.1001/archinternmed.2012.950
32. Pendleton, K. M., Huffnagle, G. B., & Dickson, R. P. (2017). The significance of Candida in the human respiratory tract: Our evolving understanding. Pathogens and Disease, 75(3), ftx029. https://doi.org/10.1093/femspd/ftx029
33. Dimopoulou, D., Moschopoulos, C. D., Dimopoulou, K., Dimopoulou, A., Berikopoulou, M. M., Andrianakis, I., Tsiodras, S., Kotanidou, A., & Fragkou, P. C. (2024). Duration of antimicrobial treatment in adult patients with pneumonia: A narrative review. Antibiotics, 13(11), 1078. https://doi.org/10.3390/antibiotics13111078
34. Kotwani, A., Roy Chaudhury, R., & Holloway, K. (2012). Antibiotic-prescribing practices of primary care prescribers for acute diarrhea in New Delhi, India. Value in Health, 15(1 Suppl.), S119. https://doi.org/10.1016/j.jval.2011.11.008
35. Mounsey, A., Lacy Smith, K., Reddy, V. C., & Nickolich, S. (2020). Clostridioides difficile infection: Update on management. American Family Physician, 101(3), 168–175.
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