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General Policies

1. Formulation of AMS team in each hospital, Health District Office and Health Clinics

The core members of AMS team should be multidisciplinary and appointed by Hospital
Director/ District Health Officer/ FMS/ Medical Officer In-Charge.

2. Development and documentation of local antimicrobial policy

Every healthcare facility shall develop and document their local antimicrobial policy.
The policy should be endorsed by the Drugs and Therapeutics Committee (JKUT) and
ultimately the hospital director / District Health Officer/ FMS/ Medical Officer in Charge
and publicized to the whole health care facility.

The antimicrobial policy shall include as below:

• Indications for antimicrobials are to be explicitly spelt out at the time of
prescribing to assist with audit efforts.
• Appropriate microbiology investigations (culture or serology) prior to
antimicrobial commencement. **
• Clinicians to prescribe antimicrobials guided by the National
Antimicrobial Guidelines or local antimicrobial guideline where
applicable.
• A list of restricted antimicrobials and the procedures for obtaining
approval.
• To limit the use of broad-spectrum antimicrobials unless necessary.
• To review patient’s antimicrobial therapy on a regular basis based on
microbiology result and the patient’s progress.

**according to availability in primary care setting

3. Educational programme on AMS via continuous medical education (CME) and
antibiotic awareness campaign

Provide regular updates on antimicrobial prescribing, practice and usage for healthcare
professionals.

18 Protocol on Antimicrobial Stewardship (AMS) Programme in Healthcare Facilities | Second Edition 2022