Nearly 40% of Hospitals Have Antibiotic Stewardship Programs

Marcia Frellick

May 26, 2016

In the first national assessment of antimicrobial stewardship program (ASP) numbers, 39% of United States acute care hospitals reported having comprehensive programs. However, the proportion of hospitals with ASPs varied greatly by state.

Comprehensive programs, as defined by the Centers for Disease Control and Prevention (CDC), include seven core elements:

  • hospital commitment: dedication of human, financial, and information technology resources;

  • reporting: regularly conveying to staff prescribing and resistance patterns;

  • educating: teaching antibiotic resistance and improving prescribing;

  • tracking: monitoring patterns;

  • action: performing at least one prescribing improvement action;

  • drug expertise: having at least one pharmacist responsible for improving antibiotic use; and

  • accountability: having someone in leadership responsible for improving outcomes.

The largest hospitals, with more than 200 beds (59%), were more likely to have ASPs, but 25% of those with fewer than 50 beds reported having all seven core elements as well, according to results from the 2014 National Healthcare Safety Network Annual Hospital Survey.

Lori A. Pollack, MD, MPH, from the Division of Healthcare Quality Promotion at the CDC in Atlanta, Georgia, and colleagues, reported the results in an article published online May 19 in Clinical Infectious Diseases.

California Tops the List

The percentage of hospitals in each state that had comprehensive programs swung from 7% in Vermont to 58% in California. California's success is notable because it likely reflects the effect of the 2009 mandate in California that hospitals engage in efforts to improve antibiotic use. It was the only state at the time of the survey under such a mandate.

When analyzed by facility type, the researchers found that 50% of children's hospitals had ASPs, as did 43% of general acute care hospitals, 33% of surgical hospitals, and 18% of critical access hospitals.

"Overall, 60% of respondents reported hospital leadership commitment to ASPs through either a written statement of support (53%) or salary support for stewardship staff (32%)," the authors write.

The authors said their finding that both written and salary support were independently predictive of having a comprehensive ASP is supported by extensive quality improvement studies that show that successful initiatives have leadership backing.

"We were somewhat surprised to find that written support was most strongly predictive," the authors write. "This finding is important in light of the need to expand stewardship programs in smaller hospitals, which are often more resource limited than larger ones."

"A leader responsible for the ASP outcomes was identified in 72% of hospitals," the authors write. That leader was more likely to be a pharmacist (37%) than a physician (30%).

Limitations of the study include that the survey respondents likely had varying understandings of the core concepts involved, and neither the scope nor the effectiveness of the reported ASP components could be independently verified.

Hard Work Ahead

In an accompanying editorial, David N. Schwartz, MD, from the John H. Stroger, Jr. Hospital of Cook County and Rush Medical College, both in Chicago, Illinois, emphasized the importance of these limitations and said although the trend is promising, much work remains.

Barriers to good performance, he says, include audit and feedback programs without clear treatment goals, prior approval programs that lack clear rationale for restricting targeted drugs, and requirements for documenting antibiotic indications or recommendations for antibiotic time outs without clear rationales.

Dr Schwartz said the authors appropriately recommend outreach to hospitals by the CDC, state health departments, and relevant stakeholder organizations and support mandates such as California's.

"In addition," he writes, "given that 18 of 28 [antibiotic stewardship] intervention guideline recommendations published recently by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America were characterized as weak and having only poor- or moderate-quality supporting evidence, the need for innovative AS-related research is self-evident, e.g., the development of antimicrobial use and clinical outcome measures based on electronic data that permit inferences about antibiotic use quality."

The authors and Dr Schwartz have disclosed no relevant financial relationships.

Clin Infect Dis. Published online May 19, 2016. Abstract

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