In the United States, hospitals are required by accreditation and regulatory bodies to have dedicated, multidisciplinary programs to focus on improving antimicrobial use. The CDC devised the Core Elements of Antimicrobial Stewardship to help optimize the effectiveness of ASPs.^{Reference Pollack and Srinivasan1} Follow-up work on the core elements has shown that leadership support, most often in the form of dedicated time and salary for team members, is a key ingredient of robust ASPs.^{Reference Pollack, van Santen, Weiner, Dudeck, Edwards and Srinivasan2} However, in many countries, ASP efforts are carried out by the already clinically busy infectious disease consultation team without separate staff time carved out purely for ASP efforts. Little is known about how best to structure and support stewardship efforts without a formal ASP. For this reason, we welcome the article in this issue of Infection Control and Hospital Epidemiology by Park et al^{Reference Park, Chang and Kim3} describing the South Korean experience with antimicrobial stewardship and calculating full-time equivalents (FTEs) to optimize ASP activities.

Notably, the South Korean model is not uncommon. In our experience working with ASP teams in India, Korea, Japan, and Italy, ASP work is usually done by the inpatient clinical infectious diseases team without clear-cut dedicated FTEs and a separate ASP team. Park et al performed a careful study to evaluate the time required to review information and make recommendations to improve antimicrobial use in a sample of >200 patients in 8 hospitals. An average of 10–16 minutes per patient was required to conduct stewardship activities. Extrapolated to the nation, they estimate that optimizing hospital stewardship in South Korea would require ∼2.4–2.8 FTEs per 1,000 beds.^{Reference Park, Chang and Kim3}

This finding clearly leads to this question: Is such an investment in dedicated time for leadership and stewardship work worth it? We strongly believe it is. In the United States, the largest integrated healthcare system is the Veterans’ Health Administration (VA), which has provided leadership support by mandating ASP throughout its facilities and supporting many hospitals with dedicated FTEs. The VA system has achieved decreases in overall antimicrobial use and CDI rates, and it is a leader in ASP research.^{Reference Kelly, Jones and Echevarria4,Reference Ramakrishnan and Patel5} Contrast these outcomes with an experience at the University of Maryland in which the institution shifted dedicated resources away from the ASP and toward a model where the inpatient ID team was responsible for stewardship in addition to its regular clinical work (similar to the current model in countries like South Korea). After the ASP was eliminated, they reported a dramatic increase in antimicrobial use, measured by costs, especially among broad-spectrum agents, which led to the reinstitution of a dedicated ASP.^{Reference Standiford, Chan, Tripoli, Weekes and Forrest6}

We believe that separating out infectious diseases consultations from the ASP team is a model that should be replicated globally, particularly in countries that are not resource limited, to move the ASP needle forward. Clearly, this is easier said than done. Each country and each hospital have unique barriers, including the availability of and training for an ASP workforce. Developing and dedicating ASP staff in hospitals will require an investment, but failing to do so has costs as well. As described by Park et al, less labor and staffing directed toward ASP activities leads to less stewardship, which could have downstream effects for patient safety, cost, and antimicrobial resistance.^{Reference Park, Chang and Kim3} Collecting evidence to strengthen an institutional request staffing or a business case for stewardship is a first step to establishing the leadership support and funding to make ASPs a reality in more hospitals around the world. We look forward to contributing to this effort.