CDC Core Elements of Hospital Antibiotic Stewardship Programs

Guide: Starting an Inpatient Antibiotic Stewardship Program

Obtain a Leadership Commitment Letter

Develop a Business Plan

Develop a Hospital ASP Policy

Examples of Policies:

Organizational Structure

Areas where ASPs can report:

  • Quality and Safety - Preferred
  • Infectious Diseases Division
  • Infection Prevention and Control
  • Pharmacy and Therapeutics Committee

ASP Team and Committee Members

Core Personnel:

  • Pediatric Infectious Diseases Physician
  • ID Pharmacist preferably with training in antibiotic stewardship
  • Data Analyst

Other Essential Personnel

  • Infection Preventionist
  • Microbiologist
  • Nursing Leader
  • Physicians from services impacted by the ASP
  • Clinical Pharmacists
  • Family Advisor/Advocate
  • Quality Improvement Specialists

A Pediatric Infectious Diseases physician is the ideal physician leader. However, in some circumstances this is not possible, other leaders could be hospitalists, adult ID physicians, or other physicians interested in improving the use of antibiotics. In 2016, the median FTE for a pediatric infectious diseases physician at 44 United States’ Children’s hospitals was 0.3 (range: 0 to 0.8).

Additional Training Opportunities for Physicians

Job Description of Physician Role

The pharmacist leader is ideally infectious diseases trained. However, due to the paucity of training programs residency trained and/or other pharmacist with an interest in antimicrobial stewardship can be utilized. In addition to the residency training programs, the certificate programs and other meeting opportunities can help educate these pharmacists. In 2016, the median FTE at 44 United States’ Children’s hospitals was 0.9 (range: 0 to 3.0).

Pharmacy Training Programs

  • Pediatric ID Pharmacy Residencies
    • University of Arkansas: Contact Holly Maples at This email address is being protected from spambots. You need JavaScript enabled to view it.
    • University of Connecticut: Contact Jennifer Girotto at This email address is being protected from spambots. You need JavaScript enabled to view it.
  • Society of Infectious Diseases Pharmacist Certificate
  • MAD-ID certificate
  • Pediatric International ASP conference

Additional Training Opportunities for Pharmacists

Job Description Example

Literature Supporting ASP Pharmacist

Prospective Audit and Feedback (PAF)

PAF allows clinicians to order antibiotics and then the ASP team reviews the use of this antibiotic and when an opportunity for antibiotic optimization is identified, the stewardship team contacts the prescribing team to provide recommendations. Depending on the institution, recommendations may be documented in the medical record. Some programs have successfully augmented the recommendation process by delivering recommendations face-to-face on “stewardship rounds.”

References

Prior Approval

“Prior approval or preauthorization” refers to a policy in which Antibiotic orders must be approved by the stewardship program before the pharmacy will fill the order. So-called “restrictive policies” are highly effective in producing an immediate decline in utilization of targeted antibiotics (Davey et al, 2013). Prior approval encourages careful consideration of each case at the time of initial ordering, potentially preventing any unnecessary exposure to the targeted agent.

References:

Clinical Guidelines / Protocols / Care Process Models

Standardization of care for common conditions has been an effective strategy to improve Antibiotic use. Clinical guidelines/protocols/care process models are based on existing national or international practice guidelines and can be used to enhance guideline adherence. These guidelines can be adapted to best fit the particular settings and microbiologic patterns of the institutions that will utilize them.

References:

Utilization of Rapid Diagnostics

The implementation of rapid diagnostic tools have had the greatest success in improving antibiotic use and patient outcomes when an ASP is involved. Examples include:

  • Matrix-Assisted Laser Desorption and Ionization Time-of-Flight (MALDI-TOF)
    • Decreased duration of unnecessary antibiotic therapy for coagulase-negative staphylococcal bloodstream contaminants
    • Marked reduction (approximately 2.5 – 4 days) in duration of time prior to initiation of optimal antibiotic therapy for gram negative bacteria
    • Reduction in overall length of inpatient hospital stay by 2-3 days
    • Hospital cost savings of ~$20,000 - $30,000 per patient diagnosed with gram-negative sepsis
  • Multiplex Polymerase Chain Reaction (PCR)/Nucleic Acid Assays
    • Reduction in duration of therapy for blood culture contaminants
    • Decreased overall length of inpatient hospital stay
    • More rapid implementation of effective therapy aimed at treatment of multidrug-resistant pathogens
    • Hospital cost savings of ~$20,000 per patient diagnosed with Staphylococcus aureus bacteremia

References:

Food Procurement Resolutions

Statement Development

Including a statement with the support of hospital leadership in the ASP resolution on phasing out the purchase of meat raised with routine antibiotics will help expedite the adoption of a more comprehensive purchasing resolution. Review the resource Passing Food Purchasing Resolutions for guidance on the development, implementation of a resolution including sample policy language. Sample resolution templates are included. An effective policy statement should include:

  • Requirements for prescribers, education of patients/community and food service purchasing.
  • Details of the process that will be used to track and benchmark annual progress towards transitioning all meat and poultry products to sources raised without routine antibiotics.
  • The CCCAS Collaborative recommends including the following comprehensive policy statement: “Whereas our facility ASP will articulate a timeline for phasing out the purchase of meat raised with routine antibiotics and a reporting process to ensure benchmarks are met.”

Implementing Resolutions

It is important to plan out the implementation of your resolution with your multidisciplinary ASP team. This resource offers some guidance for consideration. Healthcare Procurement: Sustainable Meat and Poultry Guide. When aiming to change products purchased, it is important to work directly with the group purchasing organization and/or food service management company representatives to articulate the changes you aim to make. These entities will then work directly with supplier and distributors that are under contract to supply products to the organization. Should there be a limited number of available products through this avenue, you may then explore Identifying meat and poultry products available through institutional purchasing pathways outside of your GPO or management company’s purview – See Meat and poultry product list for some ideas. Ensure your Chief Financial Officer is amenable to this as there may be contractual or financial implications.”

Obtaining and tracking data is essential in establishing an effective ASP.

Process Measures

Antibiotic Use Data

  1. Days of therapy (DOT) per 1,000 patient days or 1,000 days present
    • Overall and for specific agents or groups of agents. DOT includes the cumulative days of therapy of each antibiotic. For example, if a patient received vancomycin and cefepime for 2 days, the DOT would be 4 (2 drugs x 2 days).
  2. Length of therapy (LOT) per 1,000 patient days or 1,000 days present
    • Overall and for specific agents or groups of agents. LOT includes the total duration of therapy of any Antibiotic therapy. For example, if a patient received vancomycin and cefepime for 2 days, the LOT would be 2.
  3. Denominator — patient days versus days present
    • Patient days are determined based on hospital census data captured each day at a specific time. Therefore, if you have a patient in the hospital Monday through Wednesday and the daily census is captured at midnight the number of patient days would be 2. If the patient received an antibiotic on all 3 days then the DOT would be 3.
    • Days present accounts for any time that the patient is present in the hospital. This data can be obtained from electronic health records through their admission, discharge and transfer data. Therefore, if a patient is in the hospital Monday through Wednesday, the days present is 3.
    • Moehring 2018 Denominator Matters in Estimating Antimicrobial Use
  4. SAAR
    • The Standardized Antibiotic Administration Ratios (SAARs) encompass observed-to-predicted antibacterial use for one of 16 antibacterial agent-patient care location combinations.
    • Outlier SAAR values may suggest possible overuse, underuse, or inappropriate use of Antibiotics.
    • CDC provides this metric through the National Healthcare Safety Network’s Antimicrobial Use and Resistance (AUR) Module.
  5. Proportion of patients compliant with institutional guideline/treatment algorithm
  6. Proportion of patients converted to oral therapy
  7. Type of recommendations made by the ASP
  8. Acceptance rate of the recommendations
  9. Proportion compliant with Choosing Wisely Campaign recommendations

Meat Purchasing

  1. Determine which label claims and standards the facility will use. Current food label certifications mean different things with regards to antibiotic use. This resource offers guidance on understanding meat and poultry certifications.
  2. Track purchases towards the goal of reducing or phasing out meat raised with routine non-therapeutic antibiotics. Tools for calculating meat reduction and tracking meat purchases can be found in the national Healthier HospitalsLess Meat, Better Meat” challenge Less Meat, Better Meat Food Measures Overview. For more guidance see the “Tracking” section of the Antibiotic Stewardship Through Food Animal Agriculture Module produced by CCCAS.

Methods to Collect the Data

  1. Medication administration record (preferable)
  2. Pharmacy dispensing data (less preferable)
  3. Pharmacy charge data

Outcome Measures

  • Length of stay
  • Antibiotic resistance, focusing on hospital-onset infections
  • Adverse drug reactions (rates)
  • Hospital-onset C. difficile infection rates
  • Hospital Readmissions for select infections (SSTI, pneumonia, pyelonephritis)
  • Antibiotic costs

Methods to Collect Data

Pediatric Health Information Systems Database

Medication Administration Record Data

Best data to show if a patient receives an antibiotic. This data is recorded often through bar code medication administration.

NHSN Antibiotic Use and Resistance Modules
  • Through the National Healthcare Safety Network (NHSN), healthcare facilities can now electronically monitor antibiotic resistance and antibiotic prescribing data. This data would be provided to the CDC and could allow for benchmarking antibiotic use and resistance data.
  • Participation in these modules would also provide the participating institution with SAARs (see below).

Methods to Present the Data (PIDS and AAP do not endorse any commercial products)

Notes:

For those seeking to establish an ASP at their institution, a number of hospitals already utilize these tools for non-stewardship purposes:

  • Infection Control – surveillance and epidemiology
  • Pharmacy - workflow optimization
  • Microbiology – antibiogram development/maintenance

Check with the departments in your hospital to determine if access can also be obtained for ASP purposes: one way to offset ASP start-up expenditures.

Education is an essential strategy for improving the use of antibiotics. Importantly, education should not be the only strategy utilized in performing antibiotic stewardship. Education should be provided for all healthcare workers and is an element of practice for The Joint Commission. Finally, educational strategies should also be developed for patients and their families/caregivers.

Clinical Staff Education

Education for Antibiotic Stewardship Directors

  • ID Listserv- contact Cindy Terrill at This email address is being protected from spambots. You need JavaScript enabled to view it.
  • SHARPS collaborative
  • Society of Infectious Diseases Pharmacist Certificate
  • MAD-ID certificate
  • Pediatric International ASP conference

Food Service Staff

  • Understanding labels
  • Institutional purchase of meat that was raised without antibiotics guidance
  • Ideally, education regarding stewardship in animal agriculture is provided in conjunction with clinical stewardship education in order to highlight its contributing role in stemming antibiotic resistance and its connection to an overall, comprehensive stewardship program. Practical strategies could include a focus on antibiotics in agriculture during one day of CDC’s U.S. Antibiotic Awareness Week, or serving samples of meat raised without antibiotics when providing clinical stewardship education to highlight the connection. See TABLE 1. of the Antibiotic Stewardship Through Food Animal Agriculture Module for educational resources relevant to key audiences listed below.

Patient/Family Education