ALARA in Antimicrobial Stewardship: Adapting Radiation Safety Principles to Address Antibiotic Overuse

Despite decades of antimicrobial stewardship programs, antibiotic overuse persists due to imprecise guidelines relying on subjective terms such as "optimal" and "appropriate" use. Current stewardship approaches lack a unifying communication framework that effectively bridges technical recommendations with real-world prescribing decisions across medical specialties. We propose adapting ALARA (As Low As Reasonably Achievable) from radiation safety as a transformative framework for antibiotic stewardship. Like radiation, antibiotics provide indisputable benefits while carrying hidden cumulative costs-including microbiome disruption, immune dysfunction, and increased mortality in specific populations. ALARA's three pillars (justification, optimization, and dose limitation) map directly to antimicrobial stewardship needs and could standardize prescribing approaches across specialties. This framework addresses the distributed nature of antibiotic prescribing by providing clear principles that transcend subjective judgments. By treating antibiotics as beneficial but inherently risky interventions requiring careful justification, ALARA could reduce unnecessary exposure while maintaining efficacy, ultimately improving both patient outcomes and global antimicrobial resistance patterns.