Updated tactics for combating antimicrobial resistance are featured in the stewardship toolkit published earlier this year by the Accreditation Association for Ambulatory Health Care (AAAHC).1

The toolkit provides some specific, evidence-based guidelines on how surgery centers and other ambulatory sites can prevent the spread of microbial-resistant infections.

“When it comes to surgical care considerations, what [try] to encapsulate and provide a brief overview of where the use of antibiotics, according to evidence, could be reduced or eliminated,” says Belle Lerner, MA, director of research at the AAAHC Institute for Quality Improvement. “We list certain types of procedures where we found this to be true in doing our research. These include cataract surgery, dental implants, hand surgery, and dermatological surgery.”

Antimicrobial stewardship is an important part of drug management in an ambulatory surgery center (ASC). “As ambulatory surgery centers are usually independently owned, cost is a major issue with ASCs,” says Cheryl Pistone, RN, MA, MBA, clinical director of AAAHC. “Drug management is always a factor at an ASC, and doing it well is important.”

A good antibiotic stewardship program will improve patient care by giving patients the right medications at the right time. A proper program also will prevent staff from prescribing too much medication, which will reduce spending.

The five-page kit includes more than 40 references and a flowchart that condenses information, making it easier to see evidence-based best practices. The flowchart describes typical protocols for various surgical types, including clean, clean-contaminated, and contaminated. The guide gives answers and recommendations, including specific details on when and how much to dose for a patient before surgery, she adds.

Core elements of the toolkit’s checklist come from CDC data. The main topics related to antimicrobial stewardship are as follows:

Make a commitment. “That includes getting buy-in from stakeholders and leadership and being held accountable,” Lerner says. “One way to do this is through action.”

Take positive steps. “Agree to implement at least one policy related to antimicrobial stewardship,” Lerner says. “Figure out which procedures you are doing at high volume at your facility and see what national clinical guidelines are related to conducting that procedure.”

Those guidelines may include information on antibiotic use. Surgery centers should follow those national recommendations, adopting them as part of the stewardship program.

Track and report. “You don’t know what you’re doing until you track it and see where you are relative to the other providers at the facility,” Lerner says. “Or, you can do external benchmarking to see how other prescribers are practicing.”

When two providers are performing the same procedure, it is important to collect data on each provider’s rate of prescriptions and compare each to national guidelines.

Ask experts. “Rely on expertise within your organization and educate your staff about the antimicrobial stewardship program you are implementing at your facility,” Lerner says. “There should be some expertise at your facility to really set up a proper program.”

The toolkit spells out how to dose antibiotics and which types would work in different situations. It suggests surgery centers consult with an infection preventionist, as needed.

The information also incorporates antimicrobial stewardship activities related to COVID-19. “It has to do with an awareness issue,” Lerner explains. “There’s a concern that there is an increase in prescribing for patients with mild to moderate disease who are not presenting with a bacterial infection.”

Another issue is related to how the pandemic led to more hospital admissions, which increased the risk of hospital-acquired infections. This results in higher prescribing of antibiotics.

The AAAHC toolkit contains the latest evidence-based information, but surgery centers should regularly check with the CDC and the World Health Organization for information that can change daily and is always up to date. Using an evidence-based toolkit is useful, but not the most important step in antimicrobial stewardship. Leadership also is needed.

“It’s important to have a champion to implement an antimicrobial stewardship program,” Lerner says. “You’re more likely to have the implementation be successful if you can get a champion.”

The champion can be the infection preventionist, a physician, a nurse, or anyone who can successfully explain the program and gain traction among staff. “Know who your stakeholders are,” Lerner says. “Creating teams will more likely lead to buy-ins and positive outcomes.”

It also is a good idea to track the procedures the surgery center performs most frequently and tailor antimicrobial stewardship to the organization’s identified needs.

“Look at the national guidelines to see what they say about antibiotics for your procedures and benchmark against your peers,” Lerner says. “This could be a quality improvement project.” 


  1. Accreditation Association for Ambulatory Health Care. AAAHC toolkits. Universal toolkits (for all ambulatory settings). Antimicrobial stewardship (2021).