The CDC recommends a focused, well-paced approach to introducing new antimicrobial stewardship (AMS) policies to ensure that staff have time for training and that hospitals can assess the impact of one initiative before adding others.
Recommendations from the CDC and the Infectious Disease Society of America (IDSA) encourage all AMS programs to include the following eight elements:1,2
Real support includes both a formal, written statement endorsing efforts to improve antimicrobial stewardship as well as dedicated times and resources to support AMS activities, such as salaries, training and IT support. Words alone will not get a program running; funding without overt leadership support risks more pushback from physicians and staff. Program leadership should have regularly scheduled meetings with senior executives and board to report activities and outcomes
A leader or co-leaders, preferably a physician and/or pharmacist with infectious disease training, provides an invaluable communication link and source of credibility with medical staff, particularly senior physicians who may be more resistant. The leader(s) also accepts accountability for the program and communicates with hospital administration. Do you have a clinician who is clearly in charge of your AMS program? If so, is this clinician’stime spent on antimicrobial stewardship adequately? That’s an important next step to ensure the leader can devote sufficient time and energy to making sure the program succeeds.
A pharmacist provides essential drug expertise and may serve as co-leader of the antimicrobial stewardship program. If the designated pharmacist has infectious disease training, that is even better.
Actions and interventions
Prospective audit and feedback, preauthorization, and facility-specific treatment recommendations should be your first priorities, then add from the lists here and on the CDC checklist:
- Infection-based interventions targeting respiratory tract infections, urinary tract infection, and skin and soft tissue infections. Examples may include improving diagnostic testing, review of microbiology results and adjusting therapies, and monitoring duration of therapies.
- Provider-based interventions such as antibiotic timeouts at 48 hours and allergy assessments
- Pharmacy-based interventions such as making the switch to oral antibiotic therapy from intravenous automatic when appropriate, dose optimization, documentation of indications, and duplicative therapy alerts
- Microbiology-based interventions such as selective reporting of susceptibilities and adding comments in reports to help clinicians interpret the results
- Nursing-based interventions such as education on proper techniques in obtaining specimens to reduce contamination.
Continuous improvement and ongoing funding depend on documenting and communicating results to both hospital administrators and to prescribers. Antibiotic usage should be tracked closely to determine the impact of AMS interventions. Sending usage data electronically to the National Healthcare Safety Network enables hospitals to benchmark their own performance using the Standardized Antimicrobial Administration Ratio (SAAR). Other outcomes to consider may include C difficile infection, resistance patterns, and financial metrics. Tracking and reporting on compliance with documentation policies is also important. Hospitals then often add reporting on adherence to facility-specific treatment recommendations and pharmacy interventions by unit and prescriber, with feedback to all clinicians.
AMS programs should operate transparently to ensure continual commitment from all stakeholders. Process and outcomes measures should be shared regularly with prescribers, pharmacists, nurses, and leadership.
Clinicians and staff need to understand why antimicrobial stewardship matters and how the hospital plans to improve its stewardship and what they need to do to help. Ongoing education is a critical component of all high-performing AMS programs. Case-based education in the setting of prospective audit or preauthorization can be particularly timely and effective with prescribers.
What's the next step for your hospital's antimicrobial stewardship program? Wolters Kluwer's Sentri7 clinicial surveillance software offers a comprehensive ASP toolkit that helps turn the latest evidence-based guidance into practice for your team, and informs continuos improvement via its robust analytics so hospitals can keep pace with the CDC's latest recommendations.
1. CDC. Core Elements of Hospital Antibiotic Stewardship Programs, 2019; Available at https://www.cdc.gov/antibiotic-use/core-elements/hospital.html
2. Dellit et al: Clinical Infectious Diseases 2007; 44:159–77.