Systemic Barriers to Sustainable Stewardship in Tertiary Care
The institutional implementation of antimicrobial stewardship programmes across academic medical centres demonstrates that structured governance and multidisciplinary oversight can significantly mitigate irrational anti-infective usage. Empirical evaluations of tertiary healthcare environments confirm that formal stewardship interventions, combining physician and pharmacy leadership with prospective audit and feedback, achieve measurable decreases in total antimicrobial prescribing despite pervasive operational challenges such as staffing shortages and shifting clinical priorities (OFID 2021). Furthermore, departmental stratification reveals that baseline antimicrobial consumption varies substantially across specialized clinical units, indicating that general inpatient floor settings, intensive care units, and neonatal wards require tailored institutional interventions rather than uniform, undifferentiated hospital policies (OFID 2021). However, long-term stewardship sustainability within complex university hospitals remains vulnerable to behavioral and structural barriers, including resource limitations, unstandardized surgical prophylaxis durations, and escalating rates of multidrug-resistant pathogens (CMJ 2024). Observational findings indicate that while initial protocol introductions—such as formulary categorization aligned with World Health Organization guidelines and dedicated prescribing documentation charts—yield immediate reductions in carbapenem utilization, maintaining these improvements requires sustained human resources and protected clinical time allocated directly to stewardship activities (CMJ 2024). Consequently, academic medical centres must transcend temporary audit models by embedding continuous multidisciplinary feedback into routine clinical workflows. By systematically addressing department-specific prescribing determinants and providing dedicated institutional support, tertiary hospitals can successfully curtail excessive broad-spectrum antibiotic exposure, prevent the post-intervention resurgence of restricted agents, and establish resilient institutional governance against antimicrobial resistance.