Antibiotic Stewardship: Are We Training Future Leaders?
"Infectious disease fellowships may be missing the mark in preparing physicians to champion antibiotic stewardship, according to new research. Is a pharmacy-led approach the answer?"
The rise of antibiotic-resistant infections poses a significant threat to global public health, making the appropriate use of antibiotics more critical than ever. Antibiotic stewardship programs (ASPs) are designed to optimize antibiotic use, yet their success hinges on having well-trained leaders. In many hospitals, particularly academic centers, infectious disease (ID) fellows play a key role in these programs.
However, are these ID fellowships adequately preparing future physicians to be champions of antibiotic stewardship? A qualitative study published in Open Forum Infectious Diseases sheds light on this question, exploring the experiences and perspectives of ID fellows regarding their stewardship training and their perceived role as future stewards.
The study's findings reveal a potential disconnect: ID fellows often focus on the practical tasks of stewardship, such as approving antibiotic prescriptions, without fully grasping the broader public health implications or seeing themselves as leaders in this area. This raises concerns about the future of antibiotic stewardship and the need for improvements in fellowship training.
Tracking Antibiotic Use and Stewardship
CDC’s “Antibiotic Use and Stewardship in the United States, 2025” report, published February 9, 2026, presents surveillance data on antibiotic use alongside guidance and examples of collaboration. CDC describes stewardship as ensuring antibiotics are prescribed and used when they provide a clear health benefit, and identifies improving antibiotic use as a strategy to optimize patient safety and combat antimicrobial resistance in the United States. The 2024 report notes that regional and national comparisons of antibiotic use, considered alongside resistance and healthcare-associated infection data, can help inform, implement, and assess stewardship interventions.
Building Stewardship Skills in Fellowship
The IDSA Core Antimicrobial Stewardship (CAS) Curriculum provides infectious diseases fellows with foundational stewardship education, regardless of their eventual career plans. IDSA also distinguishes this core curriculum from an Advanced Curriculum intended to develop the knowledge and skills needed for stewardship leadership. The CAS curriculum was designed for use within existing ID fellowship programs, following a needs assessment of training program directors. IDSA’s listed core skills include explaining the rationale for stewardship, performing program interventions and activities, and measuring program processes and outcomes.
From Resistance Recognition to Modern Stewardship
A 2025 account in The Hospitalist traces antibiotic stewardship from early recognition of resistance in the 1940s to modern regulatory mandates and program implementation. A 2021 chapter describes the stakes: infections with antibiotic-resistant bacteria are associated with increased morbidity and mortality, longer hospital stays, and substantial cost burdens. It characterizes stewardship as increasingly important for optimizing antimicrobial use. ACGME’s Infectious Disease Milestones provide a framework for assessing fellows’ development in key dimensions of physician competency within accredited training programs.
The Fellow's Perspective: Tasks vs. Public Health
The study, which involved in-depth interviews with 17 ID fellows from across the United States, uncovered several key themes. One prominent theme was that fellows primarily associated antibiotic stewardship with concrete tasks, such as processing antibiotic approvals and interacting with other healthcare professionals. While these activities are important, the fellows often lacked a broader perspective on the public health relevance of their work.
- Focus on Tasks: Stewardship primarily seen as approvals, education, and interactions.
- Limited Public Health View: Little focus on the broader impact of antibiotic resistance.
- Pharmacist Reliance: Fellows often turned to pharmacists as primary resources for antibiotic knowledge.
- Leadership Gap: Few fellows envisioned themselves as future leaders of stewardship programs.
Leadership, Training, and Practical Skills
A depth review of hospital administration and stewardship reports that CDC guidance assigns accountability for antibiotic stewardship programs to a physician leader with a pharmacist co-lead, recognizing pharmacists’ central role. A qualitative study of physician and pharmacist stewards notes that its finding is consistent with prior research in which ID fellows viewed pharmacists as program leads. Separately, a study on implementing the IDSA core curriculum says its findings matter because ID fellows have had limited exposure to formal stewardship curricular material. A December 2025 quasi-experimental pre-post course study targeted physicians and pharmacists with practical prescribing instruction and used a validated 25-item questionnaire for self-assessments of confidence and knowledge.
A Leadership Gap in Fellowship Training
A qualitative study of infectious diseases fellows found that the physician’s role in antibiotic stewardship was not being communicated effectively and that fellows were not being educated to become program leaders. The study’s conclusions also say fellowship training was not successfully conveying stewardship’s public health importance or the role of ID physicians as program leaders. Several fellows suggested that stewardship programs should instead be led by pharmacists. Fellows were described as focusing more on concrete stewardship tasks.
Dedicated ID Pharmacist and Program Adherence
A comparison of two antimicrobial stewardship programs found a strong association between having a dedicated infectious diseases pharmacist and higher adherence to recommended stewardship strategies. The comparison was with a similar program at a similar hospital that relied on a geographic model of clinical pharmacists. A second listing of the study describes the dedicated-pharmacist program as having greater adherence to recommended antimicrobial therapy practices than the program relying on ward pharmacists.
Re-evaluating ID Fellowship Training: A Call to Action
The study's findings suggest that ID fellowship programs need to re-evaluate their approach to antibiotic stewardship training. While fellows gain valuable experience in the practical aspects of stewardship, they may be missing the bigger picture: the critical role they can play in combating antibiotic resistance and protecting public health.
Mentorship and Applied Stewardship Experience
The University of Chicago ID fellowship describes faculty experts in antimicrobial stewardship and medical education as mentors who help shape fellows’ careers in clinical medicine and research. Henry Ford’s infectious diseases pharmacy fellowship says trainees gain experience developing research questions, designing protocols, managing and analyzing quantitative data, and publishing findings. These program descriptions illustrate training pathways that combine mentorship with research and practical skills relevant to stewardship work.
Preparing Future Stewardship Leaders
The article “Antibiotic Stewardship: Are We Training Future Leaders?” reports a gap in ID fellowship programs’ emphasis on stewardship leadership. Its summary says fellows may view stewardship as a series of tasks rather than a public health imperative, potentially limiting their future ability to lead effective programs. A separate 2026 article shares incoming infectious diseases pharmacy residents’ reasons for choosing the field, including interest in antimicrobial stewardship and patient care, and highlights mentorship and openness to opportunities in advice for future trainees.
Stewardship as a System-Wide Effort
A 2023 review describes antimicrobial resistance as a “silent pandemic” and defines antimicrobial stewardship as coordinated actions promoting responsible antimicrobial use. It emphasizes judicious prescribing by clinicians and careful compliance by patients. A Mass General Brigham fellowship track describes infection control, healthcare epidemiology, and antibiotic stewardship as critical to safe and effective patient care. The track’s stated purpose is to prepare fellows for careers in these areas, with an emphasis on competencies needed for leadership roles.
How Fellows Experience Stewardship
A qualitative study explored infectious diseases fellows’ experiences and perspectives on antibiotic stewardship. Its background describes antibiotic-resistant bacterial infections as a major public health threat and notes that improper antibiotic use remains high. The study was motivated by the limited research on how fellows view stewardship activities, despite fellows’ role in stewardship efforts. Its focus on fellows’ perspectives brings trainees’ experiences into discussions of how stewardship leadership is taught.
To address this gap, the authors recommend several key changes: <ul><li><b>Enhance Curriculum:</b> Develop robust curricula that emphasize the public health importance of antibiotic stewardship and the leadership role of ID physicians.</li><li><b>Promote Engagement:</b> Actively involve fellows in all aspects of stewardship programs, including decision-making processes and committee meetings.</li><li><b>Foster Collaboration:</b> Encourage collaboration between fellows, ID physicians, and pharmacists, recognizing the unique expertise that each brings to the table.</li></ul>
Ultimately, by strengthening antibiotic stewardship training in ID fellowship programs, we can better prepare future physicians to be effective leaders in the fight against antibiotic resistance, safeguarding public health for generations to come. Further research is warranted and needed to determine which factors have majorly led to lack of education regarding the antibiotic stewardship.