Antimicrobial stewardship is built around a simple principle: Give the right antibiotic, to the right patient, at the right dose, for the right duration. But what happens when the “right” antibiotic is not on the shelf?
For clinicians facing antimicrobial shortages, this is not a theoretical question. A guideline may identify the preferred agent, susceptibility testing may confirm it, and the stewardship team may agree with it. Yet the drug may simply be unavailable. At that moment, stewardship changes. The challenge is no longer only inappropriate use; it is how to preserve appropriate care when access itself has failed.
A shortage can rewrite the guideline at the bedside
Antibiotic shortages force clinicians to think about alternatives that may be broader-spectrum, less effective, more toxic, more expensive or less supported by evidence. They can also create unintended ecological consequences by shifting antimicrobial pressure from one drug class to another. During a piperacillin-tazobactam shortage, one study of 320 patients found a 111% increase in meropenem prescribing, illustrating how loss of one agent can redistribute selective pressure rather than eliminate it. (1)
This matters especially in low- and middle-income countries, where intermittent stock-outs, procurement limitations and fragile supply chains may coexist with a high burden of bacterial infection and antimicrobial resistance. In 2024, the World Health Organization and the Global Antibiotic Research and Development Partnership described shortages of quality-assured antibiotics as a major health-system challenge and a threat to efforts against multidrug-resistant organisms. (2)
The implication is important: Antimicrobial access and antimicrobial stewardship cannot be treated as competing priorities. Access without stewardship lead to antibiotic overuse. Stewardship without reliable access can become impossible to implement.
Stewardship can turn scarcity into a coordinated clinical response
Evidence shows what a proactive response can achieve. During a multi-antimicrobial shortage, an emergency stewardship program reduced meropenem use by 69% and piperacillin-tazobactam use by 73% without formulary restriction; hospital length of stay was unchanged and mortality did not worsen. (3)
More recently, a 2026 study evaluating 24,601 hospitalized patients during shortages involving multiple antimicrobials found that an infectious diseases specialist-led stewardship program was associated with significant reductions in carbapenem and antipseudomonal antibiotic use. (4) These findings reinforce an important point: Shortages should trigger more stewardship, not less. But shortage-responsive stewardship requires a different operating model.
From restriction to resilience
First, antimicrobial stewardship programs should have a formal role in shortage management alongside pharmacy procurement, infectious diseases, microbiology, infection prevention and hospital leadership. A shortage is not merely an inventory event; it is a clinical event.
Second, hospitals should develop evidence-informed substitution pathways before the crisis reaches the bedside. Alternatives should be ranked according to infection syndrome, local susceptibility patterns, pharmacokinetics and pharmacodynamics, toxicity, drug interactions, cost and available inventory. Clinicians should not have to create a replacement regimen for a critically ill patient at 2 a.m.
Third, diagnostic stewardship becomes even more valuable when antibiotics are scarce. Rapid organism identification, susceptibility testing, source control and timely de-escalation can prevent unnecessary exposure to both scarce agents and broad-spectrum substitutes.
Finally, stewardship metrics must be interpreted in the context of supply. A sudden increase in carbapenem or WHO Watch/Reserve antibiotic use may reflect a shortage of the preferred Access agent rather than poor prescribing. Antibiotic-use dashboards should therefore be connected to shortage data, allowing leaders to distinguish prescribing behavior from supply-driven substitution.
The next stewardship metric should be resilience
We have traditionally asked stewardship programs to reduce unnecessary antimicrobial exposure. We should now ask another question: Can the program maintain evidence-based treatment when the preferred therapy disappears?
For LMICs, that question is particularly urgent. Stewardship cannot simply mean reproducing recommendations developed in environments where uninterrupted antibiotic availability is assumed. Effective stewardship must translate evidence into the reality of local resistance patterns, diagnostics, resources and real-time access.
The absence of the preferred antibiotic should never mean the absence of stewardship. The next frontier of antimicrobial stewardship is not simply reducing unnecessary antibiotic use. It is building systems capable of preserving appropriate therapy when the preferred treatment is unavailable. Drug shortages expose whether stewardship programs are merely monitoring antibiotic use or whether they are truly capable of protecting antimicrobial therapy under pressure.
Acknowledgment: An artificial intelligence large language model (OpenAI ChatGPT) was used to assist with drafting and language refinement. The author reviewed, revised and verified the content and takes full responsibility for the final submission.
References
- Barber KE, Bell AM, Travis King S, et al. Impact of piperacillin-tazobactam shortage on meropenem use: implications for antimicrobial stewardship programs. Braz J Infect Dis. 2016;20(6):631-634.
- World Health Organization & the Global Antibiotic Research and Development Partnership. Policy and regulatory interventions to address antibiotic shortages in low- and middle-income countries. 2024.
- Hsueh K, Reyes M, Krekel T, et al. Effective Antibiotic Conservation by Emergency Antimicrobial Stewardship During a Drug Shortage. Infect Control Hosp Epidemiol. 2017;38(3):356-359.
- Itoh N, Okumura N, Akazawa-Kai N, et al. Impact of an infectious disease specialist-led antimicrobial stewardship program and consultations during multiple antimicrobial shortages: A Bayesian structural time-series analysis. PLoS One. 2026;21(2):e0340599.
