An antimicrobial stewardship programme (ASP) that cannot measure itself cannot improve. Yet many hospitals either track nothing beyond total pharmacy spend, or drown in metrics nobody acts on. This guide sets out the key performance indicators (KPIs) that matter most, how to calculate them, and how to use them.
The US CDC's Core Elements of Hospital Antibiotic Stewardship Programs (updated 2019) list tracking and reporting as two of seven core elements, alongside leadership commitment, accountability, pharmacy expertise, action and education. In India, the ICMR's AMSP guidance and NABH standards similarly expect hospitals to monitor antimicrobial use. The KPIs below map to those expectations.
1. Antimicrobial consumption: DDD and DOT
Defined Daily Doses (DDD)
The WHO-defined DDD is the assumed average maintenance dose per day for a drug's main indication in adults. Consumption is calculated from the total grams dispensed divided by the DDD, and normalised as DDD per 1,000 patient days.
- Strengths: it can be derived from pharmacy dispensing data and is internationally comparable via the WHO ATC/DDD system.
- Limitations: it is misleading where actual doses differ from the DDD, such as paediatrics or renal dose adjustment.
Days of Therapy (DOT)
One DOT is any day a patient receives a given antimicrobial, regardless of dose. Two drugs on the same day count as two DOT. It is expressed as DOT per 1,000 patient days (or days present).
- Strengths: it is not affected by dose, works for children, and is the metric used in the NHSN Antimicrobial Use option.
- Limitations: it needs patient-level administration data.
Many programmes track both, using DDD for external comparison and DOT for internal, unit-level trends. Break both down by unit, prescriber group and drug class, because hospital-wide totals hide where the problems are.
2. WHO AWaRe profile
WHO's AWaRe classification groups antibiotics into Access (first-choice, lower resistance potential), Watch (higher resistance potential, to be prioritised for stewardship) and Reserve (last resort). WHO set a global target for at least 60% of total antibiotic consumption to come from the Access group. Hospital patterns naturally skew towards Watch, especially in ICUs, but trending your Access-to-Watch ratio over time, by unit, is a clear way to show progress.
Track Reserve antibiotic use (for example, colistin, ceftazidime-avibactam and tigecycline) separately, with 100% of starts reviewed.
3. Process KPIs: is the programme doing what it says?
- Restricted-antibiotic approval compliance: the percentage of restricted-drug starts with documented approval (preauthorisation).
- 48–72-hour antibiotic time-out completion: the percentage of courses reviewed for continuation, de-escalation or stopping.
- Prospective audit and feedback: the number of interventions made and the percentage accepted by prescribers. The CDC's 2019 update prioritises audit-and-feedback and preauthorisation as the two key interventions.
- Cultures before antibiotics: the percentage of empirical starts with relevant cultures sent first.
- Guideline adherence: the percentage of empirical choices consistent with the hospital's antibiogram-based guideline.
- IV-to-oral conversion: the percentage of eligible patients switched within the target time.
- Surgical prophylaxis: timing within 60 minutes before incision, and discontinuation within 24 hours where guidelines recommend it.
- Documented indication and stop date on antibiotic orders.
4. Outcome KPIs
- Clostridioides difficile infection rates.
- Resistance trends in key organisms, for example carbapenem-resistant Enterobacterales, MRSA and ESBL producers, from the antibiogram.
- Length of stay and readmission for priority infections (pneumonia, UTI, skin and soft tissue).
- Antimicrobial cost per patient day. It is useful, but should never be the headline measure.
Making KPIs drive action
- Few and stable: pick 8–12 core KPIs and keep definitions fixed so trends mean something.
- Targets and owners: every KPI needs a target, an accountable owner and a review cadence.
- Report to prescribers, not just committees: unit-level feedback to the teams who prescribe changes behaviour.
- Link to action: a KPI that misses target should open a tracked improvement action.
Why hospitals choose Ibhar
Ibhar gives stewardship teams these KPIs without the manual reporting, so committee meetings focus on action rather than data collection. Ibhar is the infection intelligence platform for infection prevention and control (IPC), antimicrobial stewardship (AMS) and antimicrobial resistance (AMR). Hospitals from India to the Middle East use it, and it works alongside Epic, Oracle Health (Cerner) and InterSystems.
- 800+ hospitals with Ibhar implementation experience.
- 25 large hospitals in the AHPI and Pfizer antimicrobial stewardship programme.
- Peer-reviewed research in the American Journal of Infection Control and the Indian Journal of Medical Microbiology.
To see what Ibhar could do for your hospital, talk to our team.