Antibiotic Stewardship in Daily Hospital Rounds: Practical Tips

In the whirlwind of daily hospital rounds—multiple patients, shifting beds, staff shortages, and never-ending progress notes—antibiotic stewardship can feel like a luxury reserved for the ID team. But inappropriate antibiotic use is no longer an abstract public health issue. It’s right here, in our wards, quietly steering us toward a post-antibiotic era.

Antibiotic stewardship isn’t about being rigid or indecisive. It’s about thoughtful prescribing, clinical reasoning, and timely action. When done right, it becomes second nature—a silent part of clinical excellence. The goal? Integrate stewardship into our daily routine without adding to the existing chaos.

Start with the Why: The Real-World Impact of Poor Stewardship

We’ve all heard the numbers—more than half of inpatients are on antibiotics, and a significant portion of those prescriptions are unnecessary or poorly chosen. But here’s how it’s actually manifesting:

C. difficile is showing up in younger and previously healthy patients.

Multi-drug resistant organisms (MDROs) like CRE and ESBL-producing bacteria are now seen outside the ICU.

New antibiotics are scarce, yet we’re rapidly exhausting our current options.

Every time we start empirical therapy, we set a trajectory. Let’s be intentional about where it leads.

Include Antibiotic Review as a Standard Part of Rounds

This might sound obvious, but it’s not always practiced. Many teams get caught up in vitals, imaging, and discharge planning, while the antibiotic plan gets a half-hearted “Continue antibiotics” note.

Instead, build antibiotic review into your routine. Ask:

What antibiotic is being used and why?

Is it still the right one based on culture or clinical status?

Can we de-escalate or narrow the spectrum?

These questions alone begin to shift the rounding culture toward stewardship.

48–72 Hour Timeout: Use It Religiously

The antibiotic timeout after 48–72 hours is a powerful moment. By then, we usually have culture results and a sense of the patient’s trajectory. But we often skip this opportunity to streamline therapy.

On rounds, it can sound like:

“Blood cultures are negative—should we stop the pip-tazo?”

“She’s improved with ceftriaxone—can we plan for PO switch and discharge?”

“We now know it’s a UTI—do we still need vancomycin?”

These questions save patients from days of unnecessary broad-spectrum coverage.

Don’t Ignore the Route of Administration

IV doesn’t mean superior. Once the patient can tolerate oral medications and the drug has good bioavailability, it’s time to switch.

On rounds, this could mean asking:

“Is there a reason we’re still on IV?”

“Can this be converted to oral today?”

This not only prevents line-associated complications but improves comfort and reduces costs.

Document the Indication—Always

It’s astonishing how often antibiotics are started without a documented indication. This leaves the night team, handovers, and pharmacists guessing.

Always include:

Suspected infection source

Culture status

Planned duration

Clear documentation makes stewardship a shared responsibility, not a guessing game.

Involve Pharmacists—They’re Your Stewardship Allies

Pharmacists are an underutilized powerhouse on rounds. They can help:

Recommend narrower or more targeted options

Adjust for renal function

Catch unnecessary overlaps (e.g., pip-tazo and metronidazole)

Create space for them to speak during rounds. Stewardship is collaborative, and they often know the antibiogram better than most physicians.

Think Beyond Bugs: Consider Host Factors

Not every fever means infection. Not every leukocytosis signals sepsis. Not every infiltrate on CXR equals pneumonia.

During rounds, consider:

Could this be a drug-induced fever?

Is the leukocytosis post-op or steroid-related?

Are we missing non-infectious causes like pulmonary edema or atelectasis?

Assumptions can lead to antibiotic misuse. Clinical curiosity prevents it.

Avoid Double Coverage Unless Justified

In unstable patients, the knee-jerk reaction is to “cover everything.” But this can do more harm than good.

Vancomycin plus linezolid? Unnecessary and toxic.

Cefepime, levofloxacin, metronidazole, and azithromycin all at once? Often unjustified.

Don’t fall into the trap of overlapping agents without a sound reason. Redundancy increases toxicity, not efficacy.

Mind the Duration

“14-day antibiotic course” often stems from habit, not evidence.

Recent data supports shorter courses for many conditions:

Uncomplicated pyelonephritis: 5–7 days

Community-acquired pneumonia: 5 days

Cellulitis: 5–7 days

Ask: “Do we have a planned stop date?” Add it to the plan so that it becomes visible and actionable.

Create a Stewardship Checklist for Daily Rounds

It doesn’t need to be fancy—just a simple script in your mental workflow:

What antibiotics is the patient on?

Why were they started?

Are cultures back?

Can we narrow or stop?

Can we switch to oral?

Is there an end date?

With repetition, this checklist becomes as routine as checking fluid balance or DVT prophylaxis.

Educate the Juniors—Normalize Stewardship Thinking Early

Junior doctors and students often prescribe broadly “just to be safe.” It’s our job to model and encourage good habits.

Encourage them to:

Review the microbiology reports

Ask if IV can be switched to oral

Look up guidelines like IDSA’s during case discussions

Normalize these questions as clinical maturity—not risk aversion.

Create a Culture Where De-escalation = Competence

In some hospitals, escalation is seen as caution, while de-escalation is misunderstood as negligence.

Change the tone:

“De-escalation doesn’t mean neglect—it means precise medicine.”

“The fact that a patient got better doesn’t mean we must continue all initial empiric choices.”

Highlight that de-escalation is the real marker of attentive, evidence-based care.

Stewardship During Night Calls and Weekends

Night teams are often under pressure, making decisions without the full context.

Help them succeed by:

Leaving clear notes like: “Hold antibiotics unless WBC >15 or patient febrile”

Making the stewardship plan part of the handover

Encouraging trust in clinical judgment rather than blind continuation

This extends stewardship to the full 24-hour cycle.

Involve the Patient (Yes, Really)

Today’s patients are well-informed. They read their medication lists and look up unfamiliar terms.

Use that awareness to educate:

“We’re using a narrower antibiotic to avoid unnecessary side effects.”

“You’re improving—so we’re stepping down to oral meds.”

This builds trust and helps patients understand that good medicine isn’t always “more medicine.”

Celebrate Wins

You narrowed therapy before ID was consulted? Celebrate it.

You converted to PO ahead of schedule? Talk about it.

You stopped antibiotics early based on updated guidelines? Mention it in the doctors’ room.

These mini victories make stewardship visible and contagious.

Final Thought: Stewardship Is Everyone’s Job—Not Just Infectious Disease

Antibiotic resistance isn’t a theoretical concern. It’s a slow-burning code blue for the future of medicine.

The best time to start proper antibiotic stewardship was two decades ago. The second-best time? Your next set of rounds.

Embed it. Normalize it. Let it become part of your clinical fingerprint. Because being a good doctor isn't just about treating today's infection—it’s about preserving the tools we rely on to treat tomorrow’s.