Establishing INtegrated Stewardship for Appropriate Antimicrobial usage Framework (INSAAF) in Indian tertiary care hospitals: A call for 20-point-action

BACKGROUND: Antimicrobial resistance (AMR) is an escalating global health threat, with India bearing a disproportionately high burden of resistant infections. Although awareness of antimicrobial stewardship (AMS) is increasing, its practical and consistent implementation in Indian tertiary care hospitals remains variable and fragmented. OBJECTIVE: To highlight the pivotal role of hospital microbiologists in operationalizing integrated antimicrobial stewardship practices and to translate national consensus recommendations into actionable, laboratory-driven stewardship leadership. CONTEXT AND FRAMEWORK: The Society of Antimicrobial Stewardship PractIces (SASPI), India, recently released 42 consensus practice statements outlining an INtegrated Stewardship for Appropriate Antimicrobial usage Framework (INSAAF), encompassing diagnostic stewardship, therapeutic optimization, infection prevention and control, and administrative governance tailored to the Indian healthcare setting. KEY STEWARDSHIP DOMAINS: This article emphasizes the transition of microbiologists from traditionally laboratory-bound diagnosticians to active clinical stewards who bridge pathogen-level data with bedside decision-making. Through pathogen-specific diagnostic stewardship, precision antimicrobial therapy guidance, real-time resistance alerts, and infection-prevention interventions, microbiologists can directly influence prescribing behaviour, optimize antimicrobial use, and limit AMR propagation. BROADER IMPACT: Stewardship actions initiated within hospital laboratories have downstream effects on patient outcomes, institutional epidemiology, One Health ecosystems, and national and global AMR surveillance systems. CONCLUSION: Twenty practical action points, distilled from the SASPI 42 consensus statements, are presented to facilitate the operationalization of INSAAF. These recommendations position microbiologists as central leaders in integrated antimicrobial stewardship, enabling measurable clinical, institutional, and public health impact.