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How to improve your antimicrobial stewardship program
Antibiotic resistance is a major national and international concern and in recent years the CDC, the Centers for Medicare & Medicaid Services, and the Joint Commission, among others, have all emphasized the importance of antimicrobial stewardship programs.

In the February 2018 issue of The Joint Commission Journal on Quality and Patient Safety, investigators report what they learned from interviews with leaders of stewardship programs at four academic medical centers, ranging in size from 250 beds to more than 750 beds. The most-important finding was that antimicrobial stewardship programs (ASPs) at leading medical centers involve more personnel than just a few physicians and pharmacists.

“The traditional model of ASP consists of interventions conducted by a small group of physician and/or pharmacy leaders on the ASP team, typically with specialized training in ID (infectious diseases). Our respondents described an evolution outside that model, in which generalist clinical pharmacists and physicians from disciplines outside of ID were engaged in improving antimicrobial prescribing or empowered to perform stewardship activities,” the researchers report.

One program allowed generalist clinical pharmacists to approve or disapprove antibiotics and “if the physicians don't take their recommendations, then they kick it up to our stewardship team.” Another program adopted a “train the trainer” model in which unit-based pharmacists were provided education on antimicrobial stewardship they could then use to make interventions and educate caregivers.

Leaders interviewed in the Joint Commission study stressed that ASPs should not create an “antibiotic police scenario or a dictatorship” and advised against a “top-down, heavy handed approach.” Programs involved providers from a broad array of specialties, including surgery, critical care, oncology, emergency medicine, and hospital medicine. This multidisciplinary involvement was seen as essential to disseminate, promote, and adopt ASP guidelines. As one respondent stated, “if prescribers within a given specialty are involved in coming up with something, then they're more likely to sell it to their colleagues.”

Another finding was that stewardship programs are relying on IT to identify problems and help in making real-time interventions. Dedicated antimicrobial stewardship software was present at each of the programs and was used for generating alerts for stewardship personnel to identify opportunities for intervention, communication between members of the stewardship team, documentation of interventions, and data analysis.

Examples of alerts included opportunities for de-escalation, patients who were receiving ineffective antibiotic therapy, positive blood cultures, and multidrug-resistant organisms. One pharmacist stated that software alerts directed at ASP personnel were “game-changing,” and found it “rewarding when you get a critically ill patient on appropriate therapy faster and improve their outcomes.”

But even medical centers with dedicated stewardship software did not devote enough resources to allow for optimum analysis of data and subsequent follow-up. One respondent cited a “several-month turnaround time.” Another respondent stated that antibiotic use data were “the messiest data there is” and that they “don't have the dedicated support that [they] need.”

Although the Joint Commission study sheds light on antimicrobial stewardship programs, the investigators note one important limitation of their work is that the study focused on academic medical centers that were leaders in the ASP field.

“Our findings may not be representative of the experience in different hospital settings. Another limitation is that our interviews focused on ASP physician and pharmacist leadership and did not include the perspective of other key stakeholders, such as hospital executives and prescribing clinicians. Additional qualitative research to understand the attitudes of these groups would further inform implementation strategies,” they added.