Beyond Resistance: Prioritizing Safety in Antimicrobial Stewardship for Older Adults

Antimicrobial resistance remains a leading global health threat, often exacerbated by inappropriate antibiotic use, particularly among the growing population of older adults. This commentary highlights the urgent need for geriatric-focused antimicrobial stewardship programs that balance efficacy, safety, and resistance mitigation. Age-related physiological changes, multimorbidity, and polypharmacy significantly increase the risk of antibiotic-associated adverse effects and drug interactions in older adults. Key challenges include inaccurate estimation of renal function and hypoalbuminemia, which alter antibiotic pharmacokinetics, as well as inappropriate treatment of asymptomatic bacteriuria and increased susceptibility to Clostridioides difficile infection. Clinical complexities such as prosthetic joint infections and antibiotic-induced neurotoxicity further underscore the need for individualized dosing regimens and vigilant monitoring. Certain antimicrobial classes, including fluoroquinolones, and specific agents such as trimethoprim/sulfamethoxazole and rifampin, require particular caution because of their potential for serious toxicities and drug interactions in this population. Pharmacists play a central role in optimizing antibiotic selection, dosing, and monitoring across care settings. Expanding their leadership in antimicrobial stewardship programs is critical to improving outcomes and minimizing preventable harm. Strengthening antimicrobial stewardship requires targeted policies and outcomes-driven research to identify best practices that effectively reduce adverse events. As the aging population continues to grow, it is imperative that pharmacists in geriatric and long-term care settings develop and implement robust antimicrobial stewardship programs that prioritize safety across the continuum of geriatric care.