After 10 years of clinical practice, I began my journey in public health as the state health department’s Healthcare Associated Infections and Antimicrobial Resistance Program Pharmacist. With 4 years in this role, I have learned so much about what it truly takes to fight the spread of antimicrobial resistance and why it takes all of us. The same questions that matter at the bedside matter at the population level, where thousands of daily prescribing and infection-prevention decisions collectively influence resistance patterns. Resistant organisms do not remain within the walls of one hospital, long-term care facility, clinic, or community. Patients move among settings, and organisms move with them, so preventing and responding to antimicrobial resistance requires coordinated action across the entire healthcare continuum.

Antimicrobial stewardship pharmacists within state health departments are vital to bring clinical stewardship expertise into a setting where they can support many facilities at once, translate national guidance into practical tools, interpret antibiotic use and resistance data, provide education and technical assistance, and strengthen connections among healthcare partners. They help ensure that support reaches settings that have limited access to infectious diseases specialists or dedicated stewardship personnel, including rural hospitals, long-term care facilities, and outpatient practices.

One thing I have come to appreciate in this role is that appropriate antibiotic use must be paired with effective infection prevention and control. Preventing infections greatly reduces the need for antibiotics. Consistent hand hygiene, vaccination, transmission-based precautions, appropriate device use, and environmental cleaning as well as rapid recognition of outbreaks all help limit the spread of resistant organisms. When resistant organisms are identified, timely communication among facilities, laboratories, infection prevention teams, and public health partners can support a coordinated response and help protect patients across jurisdictions and settings.

Data are also essential. Healthcare facilities use antibiotic use and susceptibility data to identify opportunities for improvement, such as unnecessary treatment of asymptomatic bacteriuria, prolonged antibiotic durations, or high use of broad-spectrum agents. At the state level, public health programs connect these facility-level observations with broader surveillance trends, educational resources, technical assistance, and peer learning opportunities. Our health department antibiotic stewardship team works to communicate important antibiotic use and resistance data trends back to facilities, not as a report card, but rather as a tool for asking better questions, prioritizing limited resources, and measuring whether interventions improve patient care.

I’ve also come to appreciate how much collaboration matters. We recently completed a year-long focused antibiotic stewardship training collaborative for consultant pharmacists in long-term care. Consultant pharmacists are uniquely positioned to support safe, appropriate antibiotic use across multiple facilities while partnering closely with prescribers, nursing teams, infection preventionists, medical directors, and facility leadership, but structured antibiotic stewardship training in this context was unavailable. Through practical education, peer discussion, and application of stewardship principles to common long-term care challenges, the collaborative helped 35 consultant pharmacists identify opportunities to improve antibiotic use and translate them into meaningful, facility-level action.

However, this work depends on sustained investment. Public health antimicrobial stewardship programs often operate with limited staffing and temporary funding, even as healthcare partners face growing demands related to surveillance, outbreak response, infection prevention, and appropriate antibiotic use. Maintaining and expanding this capacity is essential, not only during an outbreak or when a new resistant organism emerges, but every day. Stable funding supports the relationships, data infrastructure, education, and technical assistance needed to prevent resistance before it spreads.

All in all, fighting antimicrobial resistance takes all of us: healthcare workers, facility leaders, laboratories, patients, families, and public health. By linking appropriate antibiotic use with strong infection prevention, surveillance, communication, and collaboration, we can reduce the spread of resistant organisms and preserve effective antibiotics for the patients who need them most.

Fighting antimicrobial resistance remains a top priority for hospital-based antimicrobial stewardship programs. However, the demanding workload of hospitalists and limited time and resources for antimicrobial decision-making can present significant challenges to stewardship efforts. These challenges also create opportunities for stewardship pharmacists to partner with hospitalists at multiple points throughout the care continuum to optimize antimicrobial decision-making and facilitate transitions of care. Our hospital system has implemented several interventions at admission, during hospitalization, and at discharge to support antimicrobial stewardship and improve the quality and safety of antimicrobial use.

At admission, our hospital system supplies providers with several tools within the electronic medical record, including access to the hospital antibiogram and targeted order sets. Over the years, we have partnered with our hospitalist colleagues on several initiatives to improve the utilization of disease-specific order sets. One such project focused on the cellulitis order set, which was designed to promote appropriate single-agent therapy with either cefazolin or vancomycin. Through collaboration with our hospitalists, we identified that the order set was not being used consistently because it was not available as an admission order set. After converting it to an admission order set, utilization increased substantially, with hospitalists using it for the majority of cellulitis admissions. This project provided an excellent example of how collaboration can help identify barriers to resource utilization and lead to practical solutions that make evidence-based tools more accessible and easier to use.

In addition to supporting appropriate admission antibiotics, our stewardship team helps prevent unnecessary hospitalizations using long-acting dalbavancin for cellulitis and single-dose aminoglycosides for multidrug-resistant, uncomplicated urinary tract infections in the emergency department (ED). In partnership with our ED providers, these strategies enable effective treatment for patients who can be safely managed in the outpatient setting.

During the inpatient stay, we practice typical antimicrobial stewardship habits that include prospective audit and feedback, preauthorization, and education. In addition, we strive to be proactive to make our recommendations known ahead of time to providers. For example, when susceptibilities are available for a patient with gram-negative bacteremia who is approaching clinical stability, we often proactively provide recommendations for oral antibiotic selection and dosing. In the past year, we also implemented a group chat at each site that allows providers to reach the stewardship team with questions as they arise. Established provider relationships and open lines of communication have helped prevent antibiotic errors and created more opportunities to provide education and support.

At discharge, providers at our institution often face pressure to discharge patients quickly to reduce length of stay and associated costs. This can lead to potential errors such as inappropriate antibiotic selection, duration, or discharging before cultures are finalized. By monitoring positive blood cultures, we can quickly identify inappropriate antimicrobial therapy at discharge and work with providers to transition patients to appropriate therapy. Providing discharge order review also helps reduce inappropriate antimicrobial selection and durations at discharge. A team of pharmacy technician specialists helps review medication copays and identify potential affordability barriers, including assisting with prior authorizations when needed. For patients with challenging dispositions, long-acting glycopeptides may provide an option to facilitate earlier discharge when clinically appropriate. Lastly, utilizing transitions of care pharmacies help ensure that critical discharge medications are filled and available to patients before they leave the hospital, including antimicrobials and antiretroviral therapy.

By incorporating antimicrobial stewardship throughout the inpatient journey—from admission through discharge—we create multiple opportunities for stewardship checkpoints. These touchpoints allow us to support providers, address antibiotic decisions as they arise, and ensure that patients receive appropriate antimicrobial therapy throughout and after their hospitalization.

1. Mack, M., & Nagel, J. (2020). Collaborative antimicrobial stewardship. Infectious Disease Clinics of North America, 34(1), 67–81. https://doi.org/10.1016/j.idc.2019.11.006
2. Collins D, Dumkow L, Kufel W, et al. Am J Health-System Pharm 2023;80:1577-81 https://doi.org/10.1093/ajhp/zxad164
3. Smith J, Frens J, Mehta D, et al. Antimicrobial Steward Heathc Epidemiol. 2023;3(1):e228 https://doi.org/10.1017/ash.2023.504

In October 2026, the Centers for Disease Control and Prevention (CDC) published new data regarding the impact of antimicrobial resistance (AR) in the United States, highlighting the top 19 antimicrobial-resistant organism threats. These microbes are responsible for an estimated 9.7 million infections and 50,800 deaths each year in the U.S.¹ This is in contrast to the 2019 AMR report, which estimated that antimicrobial-resistant infections contributed to over 35,000 deaths annually.² However, the CDC also updated their methodology, cautioning that statistics should not be directly compared between current and past versions.¹

The 2026 AR threats report highlights four drug-resistant organisms as urgent threats, which is their highest level¹:

• carbapenem-resistant Enterobacterales (CRE),
• carbapenem-resistant Acinetobacter baumannii,
• drug-resistant Neisseria gonorrhoeae, and
• Candidozyma auris (formerly Candida auris)

Of these, CRE is associated with the highest mortality rate, contributing to an estimated 14,878 hospitalizations, 1,252 deaths, and over $174 million dollars in healthcare costs in 2023. A common cause of carbapenem-resistance in Enterobacterales is the production of one or more carbapenemases. The annual incidence of carbapenemase-producing CRE (CP-CRE) in the U.S. is shown in the figure below, with a notable upward trend since 2020.

Development of AR is associated with exposure to anti-infectives.^3,4 Homing in on CRE, the literature shows an association between infection with this organism and prior exposure to fluoroquinolones, cephalosporins, aminoglycosides, or other broad-spectrum antibiotics.^4,5 This link connects the threat of AR with the importance of appropriate antibiotic use.

Antibiotic Awareness Week, hosted by the CDC and recognized annually during November 18–24, is a time dedicated to this message. Notably, it runs concurrently with World Antimicrobial Resistance Awareness Week, sponsored by the World Health Organization (WHO). Each year has an additional, more specific theme for these weeks, which recently have focused on the importance of interdisciplinary collaboration in optimized anti-infective use and slowing the spread of AR; in 2026, the CDC’s theme is ‘It Takes All of Us’, and the WHO’s theme is ‘One Health, One Action: Prevent AR Now’.

To promote these themes in Arizona, we engage multiple partners throughout the state to show support and provide education for appropriate antibiotic use. To see this in action, visit the Arizona Department of Health Services social media channels (Instagram, Facebook, and LinkedIn) or attend the webinar series, which will be held November 18th, 19th, and 20th from 11:00 AM to 1:00 PM MST. Each day’s presentations will have a theme, with November 18th focusing on Arizona state updates, November 19th discussing antifungal stewardship from a One Health perspective, and November 20th targeting antibiotic stewardship. Free ACPE credits will be provided for the sessions on November 19th and 20th! If interested in joining, I encourage you to register here.

Although Antibiotic Awareness Week ends November 24th, our fight against AR does not. I’m proud to continue working alongside public health partners, professional organizations such as the Society of Infectious Diseases Pharmacists, and clinicians in all specialties to promote the importance and impact of appropriate anti-infective use year-round!

1. Centers for Disease Control and Prevention’s Antimicrobial Resistance Threats Report. Published October 26, 2026. Accessed October 28, 2026. https://arpsp.cdc.gov/artr/CRE
2. Antibiotic Resistance Threats in the United States 2019. Centers for Disease Control and Prevention. Published December 2019. Accessed October 28, 2026. https://www.cdc.gov/antimicrobial-resistance/media/pdfs/2019-ar-threats-report-508.pdf
3. Teshome BF, Vouri SM, Hampton N, Kollef MH, Micek ST. Duration of exposure to antipseudomonal beta-lactam antibiotics in the critically ill and development of new resistance. Pharmacotherapy. 2019;39(3):261-270.
4. Wu J, Xie Z, Li X, et al. Risk factors and outcomes of antibiotic-resistant Klebsiella pneumoniae bloodstream infections in adult patients with acute leukemia. BMC Microbiol. 2025;25(1):394. doi: 10.1186/s12866-025-04111-3
5. Perez-Galera S, Bravo-Ferrer JM, Paniagua M, et al. Risk factors for infections caused by carbapenem-resistant Enterobacterales: an international matched case-control-control study (EURECA). eClinicalMedicine. 2023;57:101871.