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6. Education a. How many trained personnel in your AMS team?
• Number of AMS personnel trained under MOH AMS
training module.
• Number of AMS personnel trained under other
certified organization besides MOH. Please specify
the name of organization and date.
• Number of AMS personnel attended any AMS short
courses. Please specify the name of the course and
date.

7. Antibiogram a. Does your hospital have a local antibiogram?
b. Does your hospital distribute the current antibiogram
to the prescribers?

Note: Not all of the examples listed may be necessary and/or feasible in all hospitals.

Process Measures

INDICATOR INDICATOR CONSTRUCTION

Documented indication for Number of patients with a written indication for antibiotic
antibiotic use treatment / Total number of patients treated with
antibiotic(s).

Stop/review date Number of patients with a written stop/review date for
antibiotic treatment / Total number of patients treated with
antibiotic(s).

Compliance with current Number of patients with an indication receiving empirical
clinical treatment guidelines treatment with antibiotic(s) according to clinical
guidelines / Total number of patients with this indication.

Length of therapy by Total number of days of antibiotic treatment for a specific
indication indication / Total number of patients treated with
antibiotic(s) for that indication.

48-hour review Number of patients where a 48-hour review is performed
/ Total number of patients treated with antibiotic(s)
hospitalized >48 hours.

Second Edition 2022 | Protocol on Antimicrobial Stewardship (AMS) Programme in Healthcare Facilities 41