Antimicrobial stewardship programs are usually judged by technical outputs, yet they most often succeed or fail at the human interface. We describe nearly a decade of experience at a pediatric tertiary hospital in Bogotá, Colombia, where a relationship-based program—real-time prospective audit with daily, in-person feedback rather than hard restriction—was paired with deliberate education (weekly “PROA tips,” syndrome-specific algorithms, and explicit macrolide-use criteria). Against a 2016 baseline, hospitalwide annual days of therapy (DOT) for ceftriaxone, cefepime, meropenem, and vancomycin fell by approximately 26%–73%. These reductions were maintained through 2020, when COVID-19 disrupted in-person rounds: ceftriaxone and cefepime continued to decline, and although meropenem and vancomycin rose modestly, neither returned to preprogram levels, with the downward trend resuming in 2021. The education-led macrolide intervention reduced clarithromycin DOT by approximately 73% between 2019 and 2020 and by more than 90% by 2022, while guideline-concordant prescribing rose from 45% to over 90%. Our experience suggests that behavioral competencies—communication, persuasion, negotiation, and relational leadership—function as the core of stewardship rather than as adjuncts. Enablement and in-person feedback, not restriction, sustained behavior change and protected program gains through a major disruption; education was effective when embedded in practice and linked to feedback. These observations are from a single center and are uncontrolled, but they suggest that investing in the human skills of stewardship—and teaching, recruiting for, and measuring them—may help similar programs, particularly in pediatric and resource-limited settings.
