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Healthcare-Associated Infection (HAI) Advisory Committee

Antimicrobial Stewardship Subcommittee

HAI Prevention Strategies Subcommittee logo

The Antimicrobial Stewardship Subcommittee is a group of medical, microbiology and nursing professionals dedicated to providing education on antibiotic use both to providers and the public. This panel of experts provides information, best practices for stewardship, and technical assistance to healthcare facilities. The Antimicrobial Stewardship Subcommittee is currently working on an antimicrobial stewardship toolkit for healthcare providers and a resource list for providers and the public.

Anitmicrobial Stewardship Subcommittee Roster

  • Antimicrobial Stewardship Program (ASP) Slide Set
  • Antibiogram Toolkit
  • Frequently Asked Questions on Antimicrobial Stewardship Programs
  • Additional Resources

Antimicrobial Stewardship Program (ASP) Slide Set

Antimicrobial Stewardship Programs (ASP) ensures patient safety through judicious use of antimicrobial treatments which includes not using such agents when they are not clinically indicated or when infection has resolved. The objectives of an ASP include the processes and activities through which the goal is achieved - that every patient receives an antimicrobial agent only when one is needed using the right agent, at the right dose, by the right route, and for the right duration. Antimicrobial stewardship interventions have been proven to improve individual patient outcomes, reduce the overall burden of antibiotic resistance, and save healthcare dollars. The need for action, tools, and coordinated efforts to address this issue has been supported by many national healthcare societies, including the Infectious Diseases Society of America (IDSA), Association for Professionals in Infection Control and Epidemiology (APIC), Society for Healthcare Epidemiology of America (SHEA), and Centers for Disease Control and Prevention (CDC).

In fact, this issue was recently highlighted by the Center for Disease Control and Prevention report, Vital Signs: Antibiotic Prescribing Putting Patients at Risk, which focused on proper and judicious use of antibiotics. This report highlights prescribing practices and reaches out to all U.S. hospitals to improve their antibiotic-prescribing practices. This release falls in line with the Antibiotic resistance threats in the United States 2013 CDC report, which gave the first-ever snapshot of the burden and threats posed by antibiotic-resistant germs.

Arizona's Antimicrobial Stewardship Subcommittee has developed an Antimicrobial Stewardship Program (ASP) slide set to aid Arizona's efforts to battle this pressing public health problem. This set is a compendium of over 250 slides which review 14 subtopics, including development, implementation and justification of antimicrobial stewardship programs (ASPs), for use in education and discussion with clinician stakeholders and hospital administrators.

Complete Slide Set

Individual Slide Sets:

  1. Reasons to Optimize Antibiotic Use
  2. Pathways to a Successful ASP
  3. Antimicrobial Stewardship: Making the Case
  4. ASPs: Nuts & Bolts
  5. Antimicrobial Stewardship: Measuring Antibiotic Utilization
  6. Antimicrobial Stewardship: Daily Activities
  7. Antimicrobial Stewardship: Computerized & Clinical Decision Support Services
  8. Microbiology: Cumulative Antibiogram & Rapid Diagnostics
  9. Antimicrobial Stewardship Projects: Initiation & Advanced
  10. Antimicrobial Stewardship Barriers & Challenges: Structural & Functional
  11. Antibiotic Use in the Community
  12. Opportunities to Justify Continuing the ASP
  13. Antimicrobial Stewardship: Perspectives to Consider
  14. Summary

Note: Slide sets provided in PDF files.

Antibiogram Toolkit

Arizona's Antimicrobial Stewardship Subcommittee has developed an antibiogram toolkit that may be used as a guide for development of antibiograms, including templates and special projects in order to link bacterial resistance, empiric antimicrobial selection, and patient demographics. The Antibiogram Toolkit provides additional direction for clinicians involved in constructing the cumulative antibiogram report and educating others on it. This toolkit should be used in conjunction with approved CLSI documents and additional literature regarding microbial resistance. Hopefully, the toolkit enriches discussions on the challenges and opportunities with susceptibility data reporting. While the specific scenarios are detailed, a multidisciplinary antibiotic stewardship team should find ways to implement some of these projects and further analyze their own antibiogram data to produce more accurate and fruitful educational activities.

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Frequently Asked Questions on Antimicrobial Stewardship Programs

What state (Healthcare-Associated Infections (HAI) Advisory Committee)-supported tools are available to initiate and enhance antimicrobial stewardship programs?

The HAI Advisory Committee supports the work of the Antimicrobial Stewardship Subcommittee.  Recently developed tools include the following:

  • A compendium of over 250 slides that review 14 subtopics, including development, implementation and justification of antimicrobial stewardship programs (ASPs), for use in education and discussion with clinician stakeholders and hospital administrators;
  • A guide for development of antibiograms, including templates and special projects in order to link bacterial resistance, empiric antimicrobial selection, and patient demographics;
  • A stewardship mentor program whereby clinicians may submit questions regarding the structure, function and barriers of ASPs to be addressed by local experts; and
  • A collection of robust business tools that can be used as the framework for negotiating and continuing financial and administrative support for an ASP, highlighting ASP potential to decrease length of stay, improve outcomes, and raise the quality of care while minimizing hospital costs and antimicrobial use.

What are the goals and objectives of an antimicrobial stewardship program and how are these achieved?

The goals and objectives of the ASP should be established prior to ASP operations and daily activities.  The definition of antimicrobial stewardship can serve as the goal for the ASP – optimize clinical outcomes and minimize unintended consequences of antimicrobial use. The ASP ensures patient safety through judicious use of antimicrobial treatments, which includes not using such agents when they are not clinically indicated or when infection has resolved. The objectives of an ASP include the processes and activities through which the goal is achieved – that every patient receives an antimicrobial agent only when one is needed and using the right agent at the right dose by the right route for the right duration (see Part 2 of the slides).

The objectives are based on clinical issues of the institution identified by discussions with infectious disease clinicians, other prescribers, epidemiology, microbiology and hospital administration. These may include any or all of the following:

  • Elimination of unnecessary combinations
  • Optimize dosing through exercise of optimal patient-specific pharmacokinetics and pharmacodynamics
  • De-escalate the spectrum of antimicrobials based upon susceptibility reports
  • Decrease in vancomycin use through implementation of a program which emphasizes its appropriate use based upon indication, pathology reports, identification of blood culture contamination, optimization of therapy to appropriate beta-lactams (such as nafcillin) for methicillin-susceptible Staphylococcus aureus (MSSA), etc.
  • Conversion of intravenous agents to oral counterparts
  • Compliance with surgical care improvement project (SCIP) performance measures and outcomes
  • Reduce mortality, prevention of adverse outcomes related to hospital-acquired infections (HAIs), and reduced length of stay (LOS) resulting from optimal antimicrobial therapy
  • Improved patient satisfaction and hospital experience as assessed by discharge surveys

In summary, the goals and objectives of the ASP are facilitated through collaborations with members of multiple departments.  The ASP Team should meet regularly to ensure programs are effective and up-to-date with the latest literature including published research and regulatory requirements and reporting stipulations. Outcomes of interest, both short-term and long-term, should result from standardization of practices which are assessed through instruments such as audits using information technology and computer-assisted platforms.  Additional activities can achieve the goals from a variety of strategies, which include the following:

  • Increase healthcare provider education and awareness of the ASP, including frequent and appropriate use of antibiograms (refer to Antibiogram Toolkit on the ADHS HAI website, www.preventHAIaz.gov), patient-specific case reviews, grand rounds, epidemiologic studies, development of institution-specific empiric therapy guidelines, and computerized prescriber order-entry (CPOE) which incorporates order sets and alerts for antimicrobial treatment
  • Implement effective surveillance programs in the clinical microbiology laboratory which monitor imported (from the community) and exported (e.g., discharge to nursing homes) microbial resistance 
  • Review and update antimicrobial use policies and toolkits, such as issuance of revised Infectious Diseases Society of America (IDSA), Centers for Diseases Control and Prevention (CDC), and Society of Hospital Epidemiologists of America (SHEA) guidelines regarding antimicrobial therapy
  • Study and implement processes which reduce HAIs, such as device-related infections
  • Demonstrate the ASP’s cost-effectiveness through changing prescribing patterns which may reduce HAIs, reduce length of stay, and improve CMS reimbursement and private insurance value-based purchasing (VBP)
  • Develop a positive relationship and partnership with hospital administration, Chief Medical Officer, department chairs, and other stakeholders; such personnel and clinicians exist at the end of the “financial stewardship rainbow”
  • Ensure institutional compliance with performance measures addressing antimicrobial therapy and stewardship requirements issued by The Joint Commission (TJC, formerly JCAHO; specifically, National Patient Safety Goals – NPSGs), Centers for Medicare and Medicaid Services (CMS), Institute for Healthcare Improvement (IHI), and National Committee for Quality Assurance (NCQA)

Can antimicrobial stewardship programs produce financial rewards and savings?

The objective of antimicrobial stewardship programs is to optimize the appropriate use of antimicrobials by ensuring that every patient receives an antibiotic only when one is needed, with the right agent at the right dose by the right route for the right duration, in order to optimize clinical outcomes and to minimize unintended consequences of antimicrobial use. If cost becomes a primary objective then the ASP runs a risk of being viewed as a cost-saving program without regard to patient well-being. However, given the realistic expectation of new programs and investments provided by administration, establishing cost-effective programs may be considered a secondary outcome. Naturally, an effective ASP which is properly documented may demonstrate cost-savings. The greatest challenge is assigning cost-savings to the various activities which are performed.

The IDSA/SHEA guidelines state that “effective antimicrobial stewardship programs can be financially self-supporting and improve patient care” and that “comprehensive programs have consistently demonstrated a decrease in antimicrobial use (22%–36%), with annual savings of $200,000–$900,000 in both larger academic hospitals and smaller community hospitals”.  By reducing the unnecessary use of antimicrobials, a well-designed ASP has the advantages of reducing the risk of drug-related adverse events and their associated costs as well as the emergence of resistance and, hence, minimizing infections caused by resistant pathogens. Infections caused by resistant organisms are associated with poorer clinical outcomes, prolonged hospital length of stay (LOS), and higher overall costs compared to infections caused by susceptible organisms. Many clinical outcomes associated with specific MDROs, such as bacteremia due to carbapenem-resistant Klebsiella pneumonia or MRSA, have been quantified.  Length of stay has institutional costs and can be recovered easily from a cost-to-charge billing document. Therefore, by promoting the appropriate use of antimicrobials, ASPs can have a broad impact on improving clinical outcomes while reducing overall health care costs.

A recent review analyzed cost-savings from ASPs.  During the period of January 2002 to November 2007, Patel and Guglielmo identified using PubMed 36 published studies which examined the effects of antimicrobial stewardship on defined outcomes of interest.  Of these, 29 studies evaluated the impact of an ASP on cost outcomes. Twenty-seven (93%) of these studies reported a reduction in costs associated with ASP interventions. In most instances the cost-savings resulted from a decrease in drug acquisition over time (Patel D, Lawson W, Guglielmo J. Expert Rev Anti Infect Ther. 2008;6(2):209-22).

While there is the potential for publication bias, the true “net cost avoidance” should consider drug cost savings as well as decreased costs associated with improved clinical outcomes and infection avoidance, but minus the costs of the program, such as staffing and computer decision software.  A decrease in surgical infection rates through appropriate antibiotic selection can also be extrapolated into real cost-savings over time but an appropriate evaluation period is important.

The ADHS HAI website, provides a collection to several business models which may be helpful as well as slide sections in the ASP Slide Toolkit.

How do I build a business case for an antimicrobial stewardship program, aimed specifically at the “C suite” administrators and pharmacy directors?

Presentation of a business case is usually provided in conjunction with a presentation on the planned goals and objectives of a formal program on antimicrobial stewardship.  While the presentation is useful to gain endorsement for an ASP in theory, hospital administrators need to know what resources are needed, specifically those which require financial outlays – Information technology, software for identifying and documenting interventions, and staffing. Staffing is especially important to the pharmacy director because additional full time employees (FTEs) may not be in the budget. These start-up costs should be estimated for the first year of the ASP and must include compensation of a physician champion.

Equally important to presenting the financial needs of the ASP, the pharmacist and physician should investigate the financial needs of the institution.  These may include improving suboptimal performance for core measures, improving the employee health vaccination program, reducing the pharmacy drug budget, and lowering rates of bloodstream infections, urinary tract infections, Clostridium difficile infections, and surgical site infections. Thirty-day readmissions may have an infection component as may be observed in patients discharged following C. difficile infection or pneumonia. Any of these can be evaluated for potential cost-savings against the cost of implementing programs and (fractional) FTEs to solve them.

A business plan presentation should assume cost-savings with and without an increase in FTEs. This provides hospital administrators and pharmacy directors with a range of options, sometimes referred to as “BATNA” – “best alternative to negotiating agreement” (see McQuillen DP, et al. Clin Infect Dis. 2008;47:1051-63).

A presentation should include information about how the ASP implementation will be evaluated. Many programs will be initiated for a “test period” – usually, 6 to 12 months.  Be prepared to document outcomes which can be checked for cost-savings, such as with the Chief Financial Officer. Total hours worked and FTE cost associated with ASP implementation should be incorporated into the evaluation.

Finally, it is difficult to assign a true cost to some interventions and outcomes. However, there is sufficient published data on many aspects, such as decreasing surgical site infections by optimizing antibiotic administration doses and times.  Also, the question should be answered regarding “workarounds” by prescribers.  For example, if carbapenem use decreased due to a specific implemented program, was use of piperacillin-tazobactam increased? Your presentation should include assessing the influences of antimicrobial restriction.

Who should be included on the antimicrobial stewardship team?

The antimicrobial stewardship program (ASP) team consists of three groups of healthcare professionals – the core team, supportive team, and collaborative team.  Core team members include those involved with the daily or near- daily activities of stewardship, such as chart review and communications with prescribers.  The core team includes clinical pharmacists with infectious diseases training and the infectious disease physician or physician champion. 

The supportive team includes members from infection prevention, epidemiology, quality assurance/patient safety, information technology, and microbiology.  These healthcare professionals have a vested interest in direct patient care activities or interventions surrounding bacterial resistance and hospital-associated infections (HAIs). The clinical microbiologist has a valuable role in identifying and reporting resistant and multidrug-resistant organisms (MDROs). 

The collaborative team consists of the Medical Executive Committee, Pharmacy and Therapeutics (P&T) Committee, hospital administration chiefs (such as CMO, COO, CFO, etc., often referred to as “C” suite personnel), and the Pharmacy Director.  These individuals provide financial and staffing support to the core and support teams and are often reviewers of ASP business models, operations outcomes and quarterly or annual reports. Further discussion is available in the slide sets, specifically Part 2, “Pathways to a Successful ASP

How do I decide how many FTEs are needed to serve on the antimicrobial stewardship program, especially the hours and/or remuneration of the infectious disease physician?

  • Estimating workforce requirements largely relies on the philosophy, experience, and anticipated intensity of the program. The IDSA/SHEA guidelines suggest that the core members of an ASP include a physician with interest in antimicrobial stewardship and a clinical pharmacist with ID training. Given the paucity of ID fellowship training programs for pharmacists, a fellowship-trained pharmacist may not be readily available.
  • Freeing a clinical pharmacist from traditional responsibilities or spreading responsibilities amongst the staff is an alternative to adding FTEs; however there are challenges to not increasing FTEs. These options require more staff education to avoid inconsistent interpretations of patient data and variations in communication skills. Also, additional job expectations may increase stress amongst staff and inconsistencies in staffing the ASP may be observed during high workload days. 
  • Besides the epidemiologist/infection preventionist and microbiologist, the hours allotted each week to ASP is negotiated with the pharmacy because this new role will be based upon daily workload adjustments.  The true full-time 40 hours/week ID pharmacist with no traditional pharmacist duties is definitely a rare scenario, but agreement on a series of ASP projects can help establish what workload requirements are needed to develop, implement, educate, and document each project. For example, initiation of an IV-to-PO therapy program might require initial investment of time for literature evaluation, development of a protocol and communication form, and discussion with key physicians and adoption by the Pharmacy & Therapeutics Committee. Even before implementation this phase may require 20 to 30 hours of work. If one staff member can be provided three 4-hour time slots per week, this phase may require 2 to 3 weeks (at least). Implementation and education may require a similar amount of time. Likely, the ASP pharmacist will be deluged with additional projects and meetings. To some degree, slots for ASP activities will require the availability of the physician champion. In conclusion, there is no established number of FTEs or hours devoted to the ASP but the greater dedication in hours to an ASP, the more that can be accomplished and at a quicker pace.
  • Most physicians who participate in ASPs do so when patient care is not scheduled.  Many are in private practice.  Therefore, it should be expected that the physician champion be remunerated for their services. However, the spectrum of compensation ranges from zero (“pro bono”) to an hourly rate equal to what is lost from patient care services such as office visits. McQuillen et al. suggested that “an ID specialist might estimate that his or her consultative work related to infection control would require 5 hours per week at a cost of $250 per hour In this instance, a retainage agreement could be developed that states that the global fee for these services is $65,000 per year, based on the estimate of $250 per h multiplied by 5 h per week.” While this appears an appropriate compensation, many hospitals would be reluctant to provide a global annual fee, at least initially. Therefore, any compensation negotiation and subsequent agreement  should outline the services expected, but prior knowledge of the institution’s needs should be considered as these may include, besides directing the ASP, patient and employee safety, outbreak management, surveillance, and microbiology laboratory use.    

Is an infectious diseases-trained pharmacist necessary for an antimicrobial stewardship program? And how can my pharmacy staff receive antimicrobial stewardship training?

No. Although recent guidelines on the development of institutional antimicrobial stewardship programs (ASPs) recommend a pharmacist with infectious diseases training as a core member of the ASP team (IDSA and SHEA Guidelines Antimicrobial Stewardship Guidelines. Clin Infect Dis. 2007; 44: 159), the training and certification requirements for infectious diseases-trained clinical pharmacists have not been established (Dressr L. Can J Hosp Pharm.2010; 63). The Board of Pharmacy Specialties (BPS) considers the specialty of infectious diseases as an “added qualification," which implies “an enhanced level of training and experience within one segment of a BPS-recognized specialty that targets specific diseases or patient populations”. Where available, a pharmacist with clinical infectious diseases training should be included in the core ASP team. Such an individual may have a formal residency (i.e., PGY-2) or research fellowship training in infectious diseases. However, rural or small non-academic healthcare facilities may include on staff a pharmacist with competence and interest in antimicrobial stewardship. 

ASP pharmacists should have the necessary knowledge and clinical experience in infectious diseases and antimicrobial stewardship. While an infectious disease fellowship or a PGY-2 post-graduate year in infectious diseases is desirable, ASPs can be successful by training clinical staff.  Both basic and advanced training programs are available for pharmacists assigned to manage an ASP yet do not have advanced training. Pharmacists can attend educational courses such as Antimicrobial Stewardship Certificate Program for Pharmacists from the Society of Infectious Diseases Pharmacists (SIDP). The course offered by SIDP can be completed over approximately 40 hours, and by both pharmacists and well as trainees (e.g., residents, fellows, and graduate students). Another program is offered through Making a Difference in Infectious Diseases Pharmacotherapy (MAD-ID), which meets annually and offers both basic and advanced programs. Both SIDP and MAD-ID programs include a live component as well as on-line didactic review requiring several hours and a demonstration project for certification. Many other programs are being developed by academic institutions, such as Stanford University.

In summary, an institution which invests in a pharmacist with both advanced clinical and research experience in infectious diseases will realize a greater potential for the ASP to tackle a wider breadth of projects as well as developing projects for advanced ASPs once a basic program has been established and operating for 1-2 years. The Pharmacy Director and hospital administration should not underestimate the value of networking with other ID pharmacists in professional societies, including certification programs listed above and essential medical meetings sponsored by infectious diseases societies such as ID Week (Infectious Diseases Week, sponsored by the Infectious Diseases Society of America; www.idsociety.org), ICAAC (Interscience Conference on Antimicrobial Agents and Chemotherapy, sponsored by the American Society for Microbiology; www.icaac.org) , and SHEA (Society for Healthcare Epidemiology of America; www.shea-online.org).

What are the current state and federal requirements for antimicrobial stewardship programs? 

Increasingly, state health departments are required to publicly report on healthcare-associated infections. Currently California is the only U.S. state that mandates all general acute care hospitals to develop antimicrobial stewardship committees to ensure the appropriate use of antimicrobials (Trivedi K et al. Infect Control Hosp Epidemiol. 2013; 34) (see below). The CDC, AHRQ, NCQA, CMS, and The Joint Commission are working towards programs which will require documentation of basic and essential ASP activities in acute care and long-term care institutions. It is expected that penalties will be assessed by accrediting bodies. Documentation will be the responsibility of members of the ASP and Pharmacy.  At this time, it is difficult to anticipate the exact requirements of ASPs but a program established prior to any federal or state requirement will have much of the necessary documentation.

Are there any other regulatory agencies that have a requirement or are in the process of a requirement for antimicrobial stewardship programs? (JCAHO, etc.)

There are currently no national mandates or specific national regulatory agency requirements for antimicrobial stewardship.  However, the National Patient Safety Goals (NPSGs) require healthcare organizations to implement evidence-based practices to prevent healthcare-associated infections (HAIs) due to multidrug-resistant organisms (MDROs) [see 2014 Hospital National Patient Safety Goals), specifically the sections listed under “Prevent Infection” which include NPSG.07.01.01 (hand hygiene improvement), NPSG.07.03.01 (use proven guidelines to prevent infections that are difficult to treat), NPSG.07.04.01 (prevent bloodstream infections related to central lines), NPSG.07.05.01 (prevent surgically-related infections), and NPSG.07.06.01 (prevent urinary tract infections caused by catheters)].  The Joint Commission has issued a toolkit for implementing antimicrobial stewardship and many national organizations such as SHEA and IDSA recommend mandatory implementation of antimicrobial stewardship throughout the healthcare continuum.

At this time only California has mandated antimicrobial stewardship through a legislative process, although specific metrics and penalties are being revised.  Health and Human Services has also issued an action plan to eliminate healthcare-associated infections via implementation of several phases.  However, the most recent CMS Surveyor worksheet contained specific metrics for evaluation of antimicrobial stewardship activities (issued May 18, 2012; see pages 28-29 of PDF document - Section 1. C. Systems to prevent transmission of MDROs and promote antibiotic stewardship, Surveillance). These were not associated with penalties during the most recent survey year.

Finally, hospital-acquired conditions (HACs) continue to grow from 13 measures in October 2012 to 21 measures in October 2016.  The most recent published list is available (accessed December 31, 2013).  Clostridium difficile infection (CDI), currently reported to CMS via the CDC’s National Healthcare Surveillance Network (NHSN), is slated to become a HAC in FY 2017 (CDI is proposed to be added to the list in October 2016) and acute care hospital performance and FY 2017 payment determination will be based on NHSN reported rates during 2013 and 2014.  Since CDI’s major cause is overuse of antimicrobials in healthcare settings, the activities of an ASP may play a major role in reducing CDI rates.

What are current practices and requirements in implementing antimicrobial stewardship programs in unique settings, such as long-term care (LTC), long-term acute care hospital (LTACH), telemedicine, etc.?

While most of the ASP literature addresses the acute care setting, there are a growing number of published studies involving antimicrobial stewardship activities, in the long-term care, pediatric, community, and telemedicine arenas. The concepts of stewardship in both traditional and non-traditional settings are very similar.  Thereby, stewardship in the acute care setting can be easily transitioned into the long-term acute care setting provided adequate staffing and leadership to implement an ASP.  Likewise, antimicrobial stewardship is similar for both adult care and pediatric care areas and there is a growing amount of data supporting the benefits of the latter.

Variations of stewardship in other settings include staffing and regulations, while challenges include the availability of expertise and innovation in leadership.  For example, in the long-term care setting, lack of an ID pharmacist at a single facility may require a system-wide approach and travel of trained personnel between several facilities.  An ID physician or physician champion may be lacking, especially in rural areas. Staffing is often thought of as filling medication cassettes where there is inadequate time for direct patient care contact and chart review beyond current requirements for licensing.  Medical directors frequently rely on heads of nursing to provide education and proposal for innovative services. 

An example of truly innovative practice is infectious disease-related telemedicine practices.  One such practice has flourished in northern California and it has contracted with several hospitals for 24/7/365 services in several specialties. Unfortunately, a search of PubMed results using search phrase of ‘antimicrobial stewardship and telemedicine’ yielded a single hit for North American practice (search run 12/31/2013).  In this program a rural hospital where physician specialists in infectious diseases or pharmacists with advanced ID training were not available, a multidisciplinary team was formed to implement a stewardship program targeting six antimicrobials with a high potential for misuse. A key part of the program was the participation of a remotely located ID physician specialist in weekly case review teleconferences. An evaluation of the first 13 months of the initiative (May 2010-June 2011) indicated that pharmacist-initiated ASP interventions increased from a baseline average of 2.1 interventions per week to an average of 6.8 per week.  The rate of antimicrobial streamlining increased from 44% to an average of 96%. An analysis of 2010 purchasing data demonstrated a decrease in annual antibiotic costs of about 28% from 2009 levels (and a further decrease of about 51% in the first two quarters of 2011). The rate of nosocomial Clostridium difficile infection decreased from an average of 5.5 cases per 10,000 patient-days to an average of 1.6 cases per 10,000 patient-days (Yam P et al. Am J Health Syst Pharm. 2012; 69(13):1142-8).

In a community setting, antimicrobial stewardship programs have been lacking. Most prescriber education is acquired in the hospital setting. However, the focus needs to shift to patients who seek medical attention and receive therapy in the home setting. The CDC’s Get Smart program is very valuable in emphasizing prudent use of antibiotics.  However, concerns about medico-legal “what-ifs” and recalcitrant patients who expect or demand antibiotics remain two challenges. With the advent of accountable care organizations (ACOs), increased attention from insurers, and HEDIS performance measures from the NCQA, solutions may be just around the corner.  However, the importance of patient safety, rise of MDROs, and consequences of unnecessary antibiotic use need to be a focus rather than financial penalties.

Additional Resources

  • Improving the Quality of Antibiotic Prescribing: Empiric and Pathogen-Directed Antimicrobial Therapies
    People infected with drug-resistant organisms are more likely to have longer and more expensive hospital stays, and may be more likely to die as a result of the infection. When the drug of choice for treating their infection doesn’t work, they require treatment with second- or third-choice drugs that may be less effective, more toxic, and more expensive. This means that patients with an antimicrobial-resistant infection may suffer more and pay more for treatment. The HAI Advisory Committee hopes this document can be used in your institution and by your peers to improve antibiotic prescribing in various clinical scenarios.
  • Vital Signs: Antibiotic Prescribing Putting Patients at Risk
    A Vital Signs report from the Center for Disease Control and Prevention was released March, 2014. This report focused on proper and judicious use of antibiotics. This report also highlights poor antibiotic prescribing practices put patients at unnecessary risk and reaches out to all U.S. hospitals to improve their antibiotic-prescribing practices. This release falls in line with CDC Antibiotic resistance threats in the United States, 2013 report, which gave the first-ever snapshot of the burden and threats posed by antibiotic-resistant germs.
  • Landmark Report
    On September 16th, 2013 the CDC released a report entitled Antibiotic resistance threats in the United States, 2013. This is the first-ever snapshot of the burden and threats posed by the antibiotic-resistant germs having the most impact on human health. The report highlights specific HAI pathogens and rates them on a threat level of concerning, serious, and urgent. This report has even spurred discussion and action in the United States Senate!
  • Multidrug-resistant Organisms (MDROs) Fact Sheet
    Multidrug-resistant organisms (MDROs) are increasing and present challenges in all healthcare settings. Due to their importance and the dedication of Arizona's Healthcare Associated Infection (HAI) Advisory Committee to address them, an informative fact sheet has been developed. It is focused to assist healthcare workers and the general public that have an interest in obtaining more information pertaining to MDROs.
  • National Strategy for Combating Antibiotic Resistant Bacteria
    This report identifies priorities and coordinates investments: to prevent, detect, and control outbreaks of resistant pathogens recognized by CDC as urgent or serious threats, including carbapenem-resistant Enterobacteriaceae (CRE), methicillin-resistant Staphylococcus aureus (MRSA), ceftriaxone resistant Neisseria gonorrhoeae, and Clostridium difficile (which is naturally resistant to many drugs used to treat other infections and proliferates following administration of antibiotics); to ensure continued availability of effective therapies for the treatment of bacterial infections; and to detect and control newly resistant bacteria that emerge in humans or animals. This National Strategy is the basis of a 2014 Executive Order on Combating Antibiotic Resistance, as well as a forthcoming National Action Plan that directs Federal agencies to accelerate our response to this growing threat to the nation’s health and security.
  • Core Elements of Hospital Antibiotic Stewardship Programs
    This document summarizes core elements of successful hospital Antibiotic Stewardship Programs (ASPs). It complements existing guidelines on ASPs from organizations including the Infectious Diseases Society of America in conjunction with the Society for Healthcare Epidemiology of America, American Society of Health System Pharmacists, and The Joint Commission. There is no single template for a program to optimize antibiotic prescribing in hospitals. The complexity of medical decision-making surrounding antibiotic use and the variability in the size and types of care among U.S. hospitals require flexibility in implementation. However, experience demonstrates that antibiotic stewardship programs can be implemented effectively in a wide variety of hospitals and that success is dependent on defined leadership and a coordinated multidisciplinary approach.
  • Do your Bugs need Drugs?
    Antibiotics are a powerful medicine, but limited resource. When antibiotics are taken for the wrong reasons or inappropriately, they can become less effective when needed in the future. This pamphlet has been developed to help educate and inform the general public about antibiotic resistance. It provides tips on using antibiotics for the right reasons, how to stop the spread of infections, and answers commonly asked questions.
This page last updated March 5, 2015