Antimicrobial Stewardship: A Local Imperative

Daniel J. Livorsi, MD, MSc; Jennifer H. Han, MD, MSCE


April 27, 2016

Editorial Collaboration

Medscape &

The Worldwide Antibiotic Resistance and Prescribing in European Children (ARPEC) Point Prevalence Survey: Developing Hospital-Quality Indicators of Antibiotic Prescribing for Children

Versporten A, Bielicki J, Drapier N, Sharland M, Goossens H; ARPEC project group
J Antimicrob Chemother. 2016;71:1106-1117

Antimicrobial Stewardship

The overuse of antimicrobial agents is a worldwide problem, spanning different countries, patient populations, and types of providers. In this point-prevalence study, Versporten and colleagues evaluated antimicrobial use in 226 pediatric hospitals in 41 countries. They found large regional differences in several stewardship metrics, including the use of broad-spectrum agents and the frequency with which indications for the use of antimicrobial agents were documented.

Two other recent studies demonstrate how antimicrobial stewardship is currently being practiced in local settings.

Chou and colleagues[1] described a 2012 cross-sectional survey of antimicrobial stewardship programs (ASPs) within the Veterans Health Administration (VHA). At that time, only 38% of VHA hospitals had an ASP team, but the vast majority of hospitals were using some stewardship processes. These processes included annual antibiograms (94%), formulary restrictions (92%), clinical pathways (74%), and educational programs to promote judicious antimicrobial use (72%). Automatic stop orders were associated with a 7% increase in inpatient antimicrobial use. Factors associated with reduced inpatient antimicrobial use included having at least one full-time infectious diseases (ID) physician (-3%), an ID fellowship program (-9%), an ID-trained pharmacist (-10%), and a policy to address antimicrobial use in patients with Clostridium difficile infection (-9%). A greater frequency of systemic antimicrobial reviews was also associated with less antimicrobial use.

Audit and feedback, a common stewardship strategy, was the focus of another recent cross-sectional study. Livorsi and colleagues[2] surveyed ASPs within the Society for Healthcare Epidemiology of America Research Network about their use of audit and feedback. Among the 65 respondents, pharmacists performed a majority of audits and provided a majority feedback. Only 19% of programs exclusively provided verbal feedback to the primary prescriber, and only 16% documented a majority of their recommendations in the medical record. Overall, the survey demonstrated variability in how ASPs have structured their audit-and-feedback processes, including differences in who performs audits, who provides feedback to prescribers, and how the feedback is communicated. It's unclear how these differences influence the effectiveness of audit and feedback or why programs have decided to implement processes in this way.


In response to the overwhelming need to reduce unnecessary antimicrobial use, a growing regulatory effort in the United States seeks to broaden the implementation of ASPs. For example, in 2014, the VHA mandated that every VHA facility develop and maintain an ASP. In 2017, having an ASP will become a condition of participation for all inpatient and long-term care facilities reimbursed by the Centers for Medicaid & Medicare Services.

Mandates to develop ASPs are a step in the right direction, but the mere existence of more ASPs will not automatically lead to better antimicrobial use. Programs must be tailored to local settings based on the availability of resources and expertise.

Although the need for antimicrobial stewardship may be universal, implementation is ultimately local. These studies raise several questions about tailoring stewardship to local circumstances. The findings of Chou and colleagues demonstrate how local ID expertise advances stewardship, but when this expertise is not available, how are local resources best used to improve antimicrobial prescribing? Likewise, given local circumstances, what are the most effective ways to design audits and deliver feedback? Current and future mandates to develop ASPs will provide ample opportunities to start answering these pressing questions.



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