Transforming an antimicrobial stewardship program at a tertiary military medical center in Saudi Arabia: An institutional quality improvement report.

BACKGROUND: Antimicrobial resistance remains a major public health challenge, the World Health Organization has reaffirmed the priority of resistant Gram-negative pathogens in its 2024 Bacterial Priority Pathogens List and 2025 GLASS surveillance report. In Saudi Arabia, recent surveillance and review data continue to show substantial use of Watch-category antimicrobials and ongoing concern regarding extended-spectrum beta-lactamase-producing and carbapenem-resistant Enterobacterales, underscoring the need for mature institutional antimicrobial stewardship programs (ASPs).

OBJECTIVE: To describe the implementation of a restructured antimicrobial stewardship program (ASP) at a tertiary military medical center in Saudi Arabia and to report early descriptive changes in prespecified stewardship and quality indicators, including antimicrobial consumption, prescribing appropriateness, patient-level stewardship intervention patterns, emergency department blood-culture quality, and surgical antibiotic prophylaxis adherence.

METHODS: This single-center institutional quality improvement report was conducted at a 1,200-bed tertiary military medical center in Riyadh, Saudi Arabia. The overall implementation period extended from January 2024 through September 2025. Foundational ASP activities had existed since 2012 for adult services and were expanded to pediatric services in 2017; a comprehensive restructuring toward a Center of Excellence model began in 2024. A multidisciplinary stewardship team implemented a restructured program incorporating prospective audit and feedback in high-risk inpatient units, tiered antimicrobial restrictions, electronic clinical decision support, diagnostic stewardship in the emergency department, and procedure-specific prophylaxis monitoring. Hospital-wide antimicrobial consumption is reported using a 2024 reference period during early restructuring, whereas systematic clinical indicator monitoring for other domains began in early 2025 with domain-specific observation windows. Analyses were descriptive; no inferential statistical testing was performed. The report follows the SQUIRE 2.0 reporting framework.

RESULTS: Hospital-wide antimicrobial consumption showed reductions in days of therapy (DOT) per 1000 patient-days for meropenem (28.5%), piperacillin-tazobactam (20.3%), vancomycin (22.3%), and tigecycline (34.4%), with a concurrent 20.8% increase in ceftriaxone. In audited high-risk inpatient units (intensive care, oncology, and transplant), overall prescribing appropriateness increased from 54% to 89%. Between January and September 2025, 666 patient-level stewardship recommendations were documented: stop therapy (324), recommend infectious diseases consultation (241), dose adjustment (66), de-escalation (29), and other recommendations (6). In the emergency department, blood-culture ordering appropriateness improved from 70% to 97%, and the contamination rate declined from 3.5% to 0.4% between January and June 2025. Cesarean-section surgical prophylaxis adherence reached 100% for antibiotic choice, timing, and dose, while duration adherence improved from 27% to 46%.

CONCLUSION: Restructuring of an existing antimicrobial stewardship program at a tertiary military medical center was accompanied by favorable descriptive changes across several prespecified stewardship and quality indicators during the reporting period. The transition from a predominantly restrictive model toward facilitative, consultation-based stewardship may offer practical implementation lessons for similarly resourced tertiary-care settings. Because this is a single-center descriptive quality-improvement report without inferential analysis or a formal control period, these observations should not be interpreted as causal; longer follow-up and more rigorous evaluation designs are needed to assess sustainability.