CDC Core Elements of Hospital Antibiotic Stewardship Programs

Guide: Starting an Inpatient Antibiotic Stewardship Program

Obtain Support from Senior Leadership

  • Examples: chief medical officer, quality & safety officer, chief nursing officer, director of pharmacy
  • Obtain a Leadership Commitment Letter
  • Commit to providing: time for program leader(s), resources, regular meetings with leadership to present ASP outcomes data, appointing a senior executive leader as ASP “champion”, regular reporting to senior leadership

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 (see below)
  • Physicians from services impacted by the ASP (eg, Hospitalists, Surgeons, Intensivists)
  • Clinical Pharmacists
  • Family Advisor/Advocate
  • Quality Improvement Specialists

Nursing Expertise

Nursing Leader, Advanced Practice Registered Nurse, Bedside Registered Nurse

The CDC, the Joint Commission, and the American Nurses’ Association highlight the need to engage nurses in antibiotic stewardship efforts. Nurses hold a key role in communication with patients and families regarding all aspects of care, including antibiotic use. Nurses are highly trusted by the public and provide care in the community, hospital and home care environments. Nursing engagement can thus greatly extend the reach of antibiotic stewardship efforts.

Examples of nurses’ roles/involvement in improving antibiotic use:

  • Obtaining appropriate cultures with proper technique before antibiotics are started.
  • Improving evaluation of penicillin allergies
  • Prompting discussions of antimicrobial treatment, indication and duration
  • Include nurses in stewardship rounds
  • Encourage nurse antibiotic stewardship champions at the unit level
  • Patient education about antibiotic use
  • Telephone consultation and triage of ambulatory patients with acute infectious concerns

References for nursing expertise in antibiotic stewardship:

A pediatric infectious diseases physician is the ideal physician leader. Many hospitals effectively use a co-leadership model with an infectious diseases physician and pharmacist. In circumstances when an infectious diseases-trained physician leader is not available, other physician ASP leaders could be hospitalists, adult ID physicians, or other physicians interested in improving the use of antibiotics. In 2018, the median FTE for a pediatric infectious diseases physician at 60 United States’ children’s hospitals was 0.3 (IQR: 0.14 to 1.0).

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 pharmacists 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 2018, the median FTE at 60 United States’ Children’s hospitals was 1.0 (IQR: 0.5 to 1.725).

Pharmacy Training Programs

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:

Neonatal Specific Guidelines/Resources:

Early-Onset Neonatal Sepsis

Puopolo KM, Benitz WE, Zaoutis TE, Committee on Fetus and Newborn, Committee on Infectious Diseases. Management of Neonates Born at ≥35 0/7 Weeks’ Gestation With Suspected or Proven Early-Onset Bacterial Sepsis. Pediatrics. December 2018, 142 (6) e20182894.

Puopolo KM, Benitz WE, Zaoutis TE, Committee on Fetus and Newborn, Committee on Infectious Diseases. Management of Neonates Born at ≤34 6/7 Weeks’ Gestation With Suspected or Proven Early-Onset Bacterial Sepsis. Pediatrics. December 2018, 142 (6) e20182896.

Neonatal Early-Onset Sepsis Calculator (https://neonatalsepsiscalculator.kaiserpermanente.org/)

Puopolo KM, Lynfield R, Cummings JJ, Committee on Fetus and Newborn, Committee on Infectious Diseases. Management of Infants at Risk for Group B Streptococcal Disease. Pediatrics. August 2019, 144 (2) e20191881.

American College of Obstetrics and Gynecology Committee Opinion No. 797: Prevention of Group B Streptococcal Early-Onset Disease in Newborns: Correction. Obstet Gynecol. 2020. PMID: 32217968 https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/02/prevention-of-group-b-streptococcal-early-onset-disease-in-newborns

Late-Onset Neonatal Sepsis

There is a lack of consensus on the most appropriate antibiotic regimen to treat suspected late-onset neonatal sepsis. Empiric antibiotic regimens should be based on the most likely organisms for a particular unit and the clinical situation. Antibiotic choices should be guided by local susceptibility patterns and once an organism is identified, therapy should be tailored appropriately.

Necrotizing Enterocolitis

There is a lack of consensus of the most appropriate antibiotic regimen to treat suspected and/or confirmed necrotizing enterocolitis. In general, regimens should provide coverage for pathogens that cause late-onset sepsis and the addition of anaerobic coverage should be considered, although there is inadequate evidence to support a specific regimen. Antibiotic choices should be guided by local susceptibility patterns, and if an organism is identified, therapy should be tailored appropriately.

Health Care-Associated Infections in the NICU

Polin RA, Denson S, Brady MT, Committee on Fetus and Newborn, Committee on Infectious Diseases. Strategies for Prevention of Health Care–Associated Infections in the NICU. Pediatrics. May 2016, 137 (5) e20160592.

Polin RA, Denson S, Brady MT, Committee on Fetus and Newborn, Committee on Infectious Diseases. Epidemiology and Diagnosis of Health Care–Associated Infections in the NICU. Pediatrics. May 2016, 137 (5) e20160592.

Antibiotic Stewardship in Neonatal Intensive Care Units

Patel SJ, Saiman L. Principles and strategies of antimicrobial stewardship in the neonatal intensive care unit. Semin Perinatol. 2012; 36(6): 431–436.

Cantey SB, Patel SJ. Antimicrobial stewardship in the NICU. Infect Dis Clin North Am. 2014 Jun;28(2):247-61.

Mukhopadhyay S, Sengupta S, Puopolo KM. Challenges and opportunities for antibiotic stewardship among preterm infants. Arch Dis Child Fetal Neonatal Ed. 2019;104:F327–F332.

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:

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 40 antimicrobial 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

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 (refer to ‘Process Measures’ located under ‘Tracking Data’).

Pharmacy Dispensing Data

Less preferable than Medication Administration Record Data

Pharmacy Charge Data

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.

Methods to Analyze and Compare Data

Pediatric Health Information Systems Database

NHSN AUR Modules

Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) Collaborative

Antimicrobial stewardship collaborative among children’s hospitals located throughout the U.S. and internationally.

  • The collaborative’s mission is to utilize prescribing data for development of interventions to improve the safety and clinical outcomes of children who receive antimicrobials and to decrease the rate at which antimicrobial resistance develops.
  • Member institutions share antimicrobial use data to develop customized antimicrobial use reports for benchmarking. SHARPS also provides opportunities for shared learning with monthly webinars, an email listserv for participants to ask stewardship-related questions of peers, and an annual in-person meeting at the International Pediatric Antimicrobial Stewardship Conference.

Newland JG, Gerber JS, Kronman MP, et al. Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS): A Quality Improvement Collaborative. J Pediatric Infect Dis Soc. 2018; 7(2): 124-128.

McPherson C, Lee BR, Terrill C, et al. Characteristics of Pediatric Antimicrobial Stewardship Programs: Current Status of the Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) Collaborative. Antibiotics(Basel). 2018; 7(1).

Children’s Hospitals’ Solutions for Patient Safety (SPS) Antimicrobial Stewardship Program Cohort

SPS is a collaborative of children’s hospitals located throughout the U.S. and Canada focused on reduction of harms via cooperative approaches to patient care.

  • The collaborative’s mission is to work together to eliminate serious harm across all children’s hospitals, so that every child receives safe care every time.
  • Antimicrobial Stewardship Program Cohort member institutions work together to develop, implement and test antimicrobial stewardship interventions and submit monthly usage data pertaining to the interventions. Participation in monthly webinars and sharing of successes/challenges related to intervention implementation is expected.

SPS Antimicrobial Stewardship Operational Definition

SPS Antimicrobial Stewardship Key Driver Diagram Example

diagram

Education is an essential strategy for improving the use of antibiotics. Importantly, education should not be the only strategy utilized in performing antibiotic stewardship. We have identified three distinct groups of individuals for whom education about antimicrobial stewardship is valuable: clinical staff outside of Infectious Diseases and Antimicrobial Stewardship (note that this education is required by The Joint Commission); Infectious Diseases and Antimicrobial Stewardship providers; and, patients and their families/caregivers.

The Pediatric Committee on Antimicrobial Stewardship maintains a stewardship education resources repository (PIDS Stewardship Education Share Folder).This repository includes educational curricula, didactic lectures, and other materials that can help provide education to a variety of learners. Access to this folder for sharing and uploading educational materials can be requested through PIDS.

Non-ID/Stewardship Clinical Staff

These materials are aimed at frontline clinicians, pharmacists, nurses, and other clinical providers. ASPs should educate clinical staff about antimicrobial resistance and the role of the ASP in promoting patient safety and optimizing clinical outcomes. The Joint Commission requires education of healthcare employees about antimicrobial resistance and stewardship (https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf)

Infectious Diseases and Antimicrobial Stewardship Practitioners

Physicians and pharmacists (and other personnel when applicable) involved in the ASP have many opportunities for professional development, both during and after formal training.

Patients and Families