IMPORTANCE Antimicrobial resistance (AMR) poses an urgent global health challenge, undermining treatment efficacy and threatening patient safety. Antimicrobial stewardship (AMS) programs are recognized as essential interventions to optimize antibiotic use, but implementation has often been fragmented and underresourced. The Republic of Korea (ROK), facing high antibiotic consumption and increasing multidrug resistance, launched a national pilot program for AMS as part of its Second National Action Plan on AMR (2021-2025). This program represents the first government-coordinated effort to establish a standardized framework for hospital-based stewardship nationwide.

OBSERVATIONS The pilot program, initiated in November 2024, was developed by the Korea Disease Control and Prevention Agency with academic and clinical partners. It set explicit eligibility criteria, requiring hospitals with at least 300 beds to form multidisciplinary AMS teams with minimum physician and pharmacist staffing. Core program components include leadership commitment, workforce development, guideline implementation, real-time audit and feedback, surveillance, reporting, and education. Institutions undergo annual evaluation based on both foundational and advanced criteria, with operational funding linked to performance grades. Depending on size and evaluation outcomes, hospitals may receive financial support from the government annually. Early implementation highlights both progress and challenges. The program has enabled the establishment of dedicated AMS teams, integration of stewardship into hospital governance, and initiation of national monitoring systems. However, persistent workforce shortages, uneven institutional readiness, limited awareness of AMS among clinicians and the public, and disparities between tertiary and smaller hospitals pose significant barriers. Sustained progress will require workforce expansion, awareness-building, stable long-term financing, and integration of stewardship into broader quality and safety frameworks.

CONCLUSIONS AND RELEVANCE The ROK's national AMS pilot illustrates how government-led policy, financing, and accountability mechanisms can motivate large-scale stewardship implementation. The initiative provides a replicable model for embedding stewardship into health systems while aligning public health priorities with clinical practice. Lessons from the Korean experience are relevant for countries seeking to strengthen national AMR strategies, particularly in resource-limited settings. By institutionalizing stewardship at the policy level, the program offers critical insights for sustaining progress against AMR and advancing global health security.