Cross-disciplinary reach

A key characteristic of a clinical auditor is the capacity to engage in collaborative, interdisciplinary work with various clinical specialties and healthcare team members. Several studies have demonstrated that ID specialists’ consultations are requested by most specialties in a healthcare setting, including various internal medicine specialties, surgical specialties, as well as critical care medicine in the intensive care unit (ICU). ^{Reference Al-Tawfiq4,Reference Hadano and Matsumoto11,Reference Itoh, Hadano, Yamamoto, Terada and Kurai12} Most ID specialists’ consultation requests are for diagnostic and therapeutic purposes in case of fever, elevated markers of inflammation without an apparent explanation, or an established infection, especially bacteraemia. ^{Reference Al-Tawfiq4,Reference Itoh, Hadano, Yamamoto, Terada and Kurai12} Other common inquiries are related to the management of multidrug-resistant, difficult-to-treat, and opportunistic infections, as well as immunization and infection control issues. ^{Reference Itoh, Hadano, Yamamoto, Terada and Kurai12} The necessity for ID specialists’ consultations becomes evident through studies that evaluate consultation patterns among medical subspecialties in a clinical setting. ^{Reference Bang, Yoon and Yoon13,Reference Jordan, Conley and Ghali14} These include, among others, a study published by Jordan et al., where researchers examined administrative hospital discharge data for 3,979 patients who were hospitalized receiving care under the general medicine service over a 2-year period in two academic teaching hospitals in Canada, and a study that was carried out between June 2006 and December 2013 in a single academic hospital in Seoul, assessing the type of consultations requested by intensive care physicians in the medical, oncology, and surgical ICUs. ^{Reference Bang, Yoon and Yoon13,Reference Jordan, Conley and Ghali14}

The interdisciplinary influence of ID specialists in a hospital environment can also be explained by the complex nature of their patients, which requires competency, broad knowledge, resources, as well as collaboration with other specialties. ^{Reference Tonelli, Wiebe and Manns15} In complexity analyses, patients seen by ID physicians ranked second overall, after nephrology, highlighting the level of interspecialty involvement required in their care. ^{Reference Tonelli, Wiebe and Manns15} These findings underscore the need for interaction with other physicians in the management of complex patients and indicate that ID specialists are among the most interspecialty connected, supporting their role in system-level audits.

Leadership in antimicrobial stewardship and infection prevention: a core competency for clinical auditing

Clinical auditors must possess leadership characteristics to ensure that audit findings translate into meaningful improvements. They need the ability to inspire engagement across diverse professional groups, foster a culture of accountability, and maintain credibility. Evidence indicates that ID physicians are able to assume such leadership mission, considering their role in the IPC and AMS programs. ^{Reference McQuillen and MacIntyre16} The World Health Organization (WHO) guidelines on core components of IPC Programs underscore the importance of ID physicians as infection preventionists. ¹⁷ Furthermore, according to the “Core Elements of Hospital Antibiotic Stewardship Programs’’ updated by the Centers for Disease Control and Prevention (CDC) in 2019, the AMS program must have a leader or co-leaders including a physician and a pharmacist. This document highlights the effectiveness of a co-leadership model, as well as the value of ID expertise. ¹⁸ Moreover, the Joint Commission has published a new AMS standard, emphasizing that AMS teams should include ID physicians, infection preventionists, pharmacists, and other practitioners, and highlighting that physician-led programs are successful. ¹⁹ ID specialists are equipped with experience in the management of complex infections and proper use of antimicrobials, knowledge of traditional and new microbiological diagnostic methods, understanding of resistance patterns and public health needs, as well as the ability to influence prescribing habits of other physicians and drive QI, being appropriate for leadership of an AMS program. ^{Reference Ostrowsky, Banerjee and Bonomo20}

As leaders of these programs, ID specialists work in close collaboration with physicians of other specialties who regularly prescribe antimicrobials, nurses who inform program members about antibiotic administration and patients’ clinical course, and pharmacists who monitor antimicrobial consumption and play a major role in improving antimicrobial use. ¹⁸ They are also in close contact with hospital epidemiologists and infection preventionists who provide surveillance data on multidrug-resistant and hospital-acquired infections (HAIs), ^{Reference Moody, Cosgrove and Olmsted21} microbiology laboratory staff who offer antimicrobial susceptibility reports and rapid molecular diagnostic methods contributing to diagnostic stewardship, ^{Reference Morency-Potvin, Schwartz and Weinstein22} information technology (IT) staff who incorporate program protocols and information regarding antibiotic use into electronic medical records, ^{Reference Tamma and Cosgrove23} and hospital leadership and administration for organizational purposes and allocation of resources. ¹⁸ Of note, many of these competencies are particular to ID physicians engaged in AMS and IPC programs and may not be uniformly represented across ID practice settings.

Surveillance and metrics literacy

Surveillance is a cornerstone of ID practice and a natural extension of the clinical audit cycle. For instance, in the United States, ID specialists already oversee reporting to the National Healthcare Safety Network (NHSN), particularly through the Antimicrobial Use and Resistance (AUR) Module, which tracks antimicrobial consumption and resistance data. ²⁴ One of the most widely used benchmarking tools from this system is the Standardized Antimicrobial Administration Ratio (SAAR), a risk-adjusted metric comparing observed to predicted antibiotic use, considering patient case mix and facility characteristics. ^{Reference Van Santen, Edwards and Webb25} Because clinical audits require explicit, measurable standards, ID physicians’ familiarity with SAAR and other antimicrobial consumption metrics provides a validated framework for audit projects. ^{Reference Paton, Ranmal and Dudley1,Reference Esposito and Dal Canton7}

Within these surveillance frameworks, high-yield audits that ID physicians can lead include assessments of empiric therapy appropriateness, time-to-appropriate therapy, IV-to-PO transitions, de-escalation practices, and treatment-duration concordance with established standards. ^{Reference Dyar, Huttner, Schouten and Pulcini26,Reference Barlam, Cosgrove and Abbo27} These audits support compliance with organizational and regulatory expectations outlined in the CDC Core Elements of Hospital Antibiotic Stewardship Programs ¹⁸ and allow benchmarking through systems such as the NHSN AUR Module ²⁴ and the European Surveillance of Antimicrobial Consumption Network (ESAC-Net). ²⁸

A comparable structure exists in Europe, where the European Centre for Disease Prevention and Control (ECDC) coordinates continentwide surveillance networks. The Healthcare-Associated Infections network (HAI-Net) monitors device- and procedure-associated infections, the European Antimicrobial Resistance Surveillance Network (EARS-Net) benchmarks resistance rates across member states, and the ESAC-Net tracks antimicrobial use using defined daily doses (DDD). ^{28,Reference Perez and Villegas29} As in the United States, these systems embed ID specialists in the processes of surveillance, benchmarking, and feedback.

In parallel, ID and IPC teams conduct and interpret surveillance of HAIs. ^{Reference Magill, O’Leary and Janelle30} These systems rely on standardized case definitions and denominators which are embedded in regulatory reporting systems worldwide. ¹⁷ ID-led audit indicators of HAI prevention include insertion-bundle and maintenance-bundle adherence, documentation of device necessity, timely device removal, and device-utilization ratios. Because ID specialists routinely interpret risk-adjusted HAI metrics, they can translate audit findings into targeted interventions aligned with evidence-based recommendations. ^{Reference Magill, O’Leary and Janelle30–Reference O’Grady, Alexander and Burns32} These audits also support compliance with organizational HAI prevention goals and accreditation standards.

Surveillance extends beyond microbiology; ID teams integrate pharmacy dispensing data, microbiology susceptibility patterns, and clinical documentation into composite metrics that guide AMS and IPC interventions. This ability to triangulate multiple data streams supports robust audits, which require validated data sources and consistent denominators.

Digital and IT integration for high-leverage audits

As hospitals adopt electronic health records (EHRs) and increasingly embed clinical decision support systems, digital infrastructure has become central to the scalability and efficiency of clinical audit. ID specialists, already leaders in AMS and IPC and control activities, are able to leverage these tools to conduct valuable, data-driven audits.

Evidence demonstrates that computerized interventions can improve prescribing practices. A Cochrane review of inpatient AMS interventions confirmed that digital and decision support strategies improve antibiotic appropriateness and reduce unnecessary use. ^{Reference Davey, Marwick and Scott33} In addition, clinical decision support systems and real-time audit/feedback interventions have shown the greatest impact when seamlessly integrated into clinician workflows, ensuring higher uptake and sustained behavior change. ^{Reference Ivers, Yogasingam and Lacroix34,Reference Shojania, Jennings, Ramsay, Grimshaw, Kwan and Lo35} More recently, digital stewardship tools have also been associated with reductions in broad-spectrum antimicrobial use and excessive treatment durations. ^{Reference Bosetti, Grant and Catho36,Reference Monaci, Rake, Acampora and Barello37} These systems create standardized, reproducible data sets that fit seamlessly into the audit cycle. Drawing on their stewardship and IPC leadership, ID specialists are ideally placed to synthesize these metrics and convert them into targeted audits that inform both frontline practice and organizational policy.

Several randomized controlled trials further highlight the potential of digital integration for audits. The COMPASS trial, a cluster randomized control trial conducted in Swiss hospitals, showed that a multifaceted clinical decision support system combined with peer feedback improved the appropriateness of antibiotic prescribing, although effects on clinical outcomes were more modest. ^{Reference Catho, Sauser and Coray38} The WISCA tool (Weighted Incidence Syndromic Combination Antibiogram), which integrates local microbiology and resistance data into the EHR, tailored empiric therapy recommendations; in a crossover randomized control trial, WISCA was associated with improved prescribing appropriateness and reduced length of stay. ^{Reference Salm, Ikker and Noory39}

Digital platforms also allow scalable auditing. Instead of manual chart review, automated EHR queries can identify prolonged antibiotic courses, perioperative prophylaxis given beyond 24 hours, or therapy discordant with culture results. These outputs can be directly integrated into dashboards and automated reports, providing clinicians with timely, individualized feedback, an approach consistent with Cochrane findings that feedback is most effective when salient, specific, and actionable. ^{Reference Ivers, Yogasingam and Lacroix34}

Nonetheless, challenges exist. Poorly designed alerts can contribute to alert fatigue, and some contextualized clinical decision support systems have shown limited effects on patient-level outcomes. ^{Reference Bosetti, Grant and Catho36} Implementation also requires alignment with IT governance, adequate training, and integration into clinician workflows. Despite these barriers, ID physicians are able to lead digital audits, given their dual familiarity with prescribing practices and data-driven surveillance. By embedding audits into existing digital infrastructures, ID specialists can ensure audits are not only efficient but also sustainable and effective across the hospital ecosystem.

Demonstrable impact of ID involvement on patient outcomes

The existing literature provides substantial evidence that ID consultation and interventions improve adherence to quality measures and patient outcomes.

Systems interfaces beyond clinical services

Many high-priority hospital audit domains extend beyond direct patient care and into the built environment, where the responsibility often rests with facilities, engineering, or environmental services. Despite this, their impact on HAI risk is substantial. ID specialists, by virtue of their leadership in IPC, can bridge these clinical–nonclinical interfaces and ensure that technical standards translate into measurable improvements in patient safety.

Water management is a prime example. Following recurrent outbreaks of Legionella and other waterborne pathogens, regulatory authorities such as the US Centers for Medicare and Medicaid Services (CMS) mandated that hospitals implement water management programs that include risk assessment, parameter monitoring, and documentation of corrective actions. ⁷⁰ Similarly, ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Standard 188 provides detailed guidance on auditing hot-water temperatures, chlorine residuals, and flushing practices. ⁷¹ In Europe, the ECDC has highlighted the importance of water safety plans and environmental monitoring within broader HAI prevention frameworks, supporting member states in implementing structured audits in line with national and WHO guidance. ⁷² Although these activities are executed by facilities staff, ID specialists may provide the infection-risk perspective, determine thresholds for intervention and ensure findings are incorporated into hospital safety programs.

Environmental cleaning and disinfection represent another nonclinical but important audit domain. Fluorescent marker testing, ATP bioluminescence assays, and targeted cultures have been validated to measure cleaning thoroughness and correlate with reductions in C. difficile and multidrug-resistant organism transmission. ^{Reference Carling73,Reference Donskey74} ID specialists play a key role in validating audit tools, interpreting results in the context of HAI epidemiology, and linking them to clinical outcomes.

Air handling and ventilation standards also intersect with ID specialist audit leadership. Transplant and oncology units require high-efficiency particulate air filtration and positive-pressure environments, while tuberculosis wards or bronchoscopy suites rely on negative pressure. Audits of airflow rates and pressure differentials, though technical, directly affect risks of the transmission of multiple respiratory pathogens. ^{Reference Sehulster and Chinn75} ID specialists collaborate with engineering teams to define audit standards and translate compliance data into patient safety language for clinical and executive stakeholders.

In view of the foregoing, ID specialists are suitable to lead the clinical audit cycle. They are engaged in various domains such as antimicrobial resistance, infection control, or water safety, given their cross-disciplinary reach. Therefore, they are among the most suitable to select significant topics for clinical audit. In setting standards, ID physicians are adept in translating evidence-based guidelines into measurable criteria. This measuring practice aligns with their expertise in surveillance systems, metrics literacy, and use of standardized indices such as the NHSN and SAAR data. Comparing results is strengthened by their experience with benchmarking, dashboard development, and audit-feedback interventions. Their leadership in AMS and IPC committees, their ability to generate behavior change and their multidisciplinary collaboration with pharmacy, nursing, IT, and facilities management, make them appropriate to implement changes. Finally, re-auditing reflects their continuous QI mindset, supported by integration of digital health tools, updated guidelines, and cyclical stewardship programs. In this framework, an “ID competency cycle’’ is established, which effectively mirrors the audit cycle (Figure 2).

Figure 2.

The ID competency cycle as a reflection of the audit cycle. Each step of the audit cycle can be effectively executed through the specific competencies of the ID physician.