How to Make Antimicrobial Stewardship Work: Practical Considerations for Hospitals of All Sizes

Hosp Pharm 2010;45(11 Suppl 1):S10–S182010 � Thomas Land Publishers, Inc.www.thomasland.comdoi: 10.1310/hpj4511-S10

How to Make Antimicrobial Stewardship Work: PracticalConsiderations for Hospitals of All Sizes

Dimple Patel, PharmD, BCPSp; and Conan MacDougall, PharmD, MAS†

AbstractImplementation of an antimicrobial stewardship program in a hospital is complicated by a variety ofchallenges. Key issues facing stewardship personnel include recruiting personnel and buildingrelationships, establishing program metrics, selecting stewardship strategies, working with clini-cians, reporting results, and adapting the program. These issues can present different challenges atcommunity hospitals and academic medical centers. Strategies for overcoming these challengesrequire accounting for the unique characteristics of each institution.

Key Words—antimicrobial stewardship, microbiology, hospital pharmacy

Hosp Pharm—2010;45(11 Suppl 1):S10–S18

Antimicrobial stewardship programs are in-creasingly recognized as important qualityinitiatives for health care institutions. Recent

guidelines from professional societies1,2 and reviews3-6

describe the importance of stewardship, variousstrategies for achieving stewardship goals, and theevidence base supporting different interventions.Fewer publications adequately discuss the practicalaspects of implementing such programs.7 Moreover,most studies of antimicrobial stewardship programscome from academic medical centers or other largeinstitutions. Different challenges are likely to be facedby the community-based, non–teaching institutionsthat constitute the vast majority of US hospitals.8 Inthis article, we provide advice on some of the practicalaspects of starting a new stewardship program orexpanding an existing program, with special com-mentary regarding the unique challenges facingcommunity and teaching institutions.

BUILDING OR BUILDING UP A STEWARDSHIP PROGRAMPersonnel and Relationships

It is essential to identify and engage appropriatepersonnel during the early phases of antimicrobialstewardship program development. Recent guidelinesidentify infectious diseases (ID)–trained physicians and

ID-trained clinical pharmacists as core members of anantimicrobial stewardship team, with support andcollaboration from a clinical microbiologist, an in-formation system specialist, an infection control pro-fessional, and a hospital epidemiologist.1 The value ofID specialist team leaders cannot be underestimated.9

However, there are barriers to effective recruitment ofID-trained physicians and pharmacists for such posi-tions.7 Fear of forming a less-than-perfect team shouldnot hinder the program development. When faced withresource limitations, other personnel may be consid-ered, as outlined in Table 1. Programs in resource-limited settings may not be comprehensive, but theycan perform selected antimicrobial stewardship activi-ties appropriate to available resources.

Lines of authority and reporting structure shouldbe established early in program development. Becauseantimicrobial stewardship focuses on optimal patientoutcomes, the responsibility of holding the programaccountable to its goals should fall to the patient safetyand/or quality assurance departments. In addition,authority for stewardship activities should be achievedthrough policy and protocol approval from appro-priate medical staff committees, including infectioncontrol and pharmacy and therapeutics (P&T). Fur-thermore, to provide program initiatives with the

*Clinical Pharmacy Specialist, Infectious Diseases, Comprehensive Pharmacy Services, John F. Kennedy Medical Center, Edison,New Jersey; †Associate Professor of Clinical Pharmacy, University of California San Francisco School of Pharmacy, San Fran-cisco, California.

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necessary ‘‘teeth’’ to be successful, hospital adminis-tration must provide support in addressing issues withprotocol compliance upon implementation.

Metrics and BenchmarkingMeasurement is a key issue in antimicrobial

stewardship. Stakeholders, especially in adminis-tration, will initially press for data on the justificationfor a stewardship program and will later press for datato demonstrate the program is having an effect.Obtaining as much preintervention data as practicableis key. These data should be both broad (across manyareas) and deep (as far back in time as is reasonable).Having a broad scope of data allows institutions todetermine where to best invest their limited resources.Does the institution have an issue with rampant car-bapenem use? High Clostridium difficile rates? PoorIV to PO conversion? These problems may requiredifferent approaches. Obtaining data that are deepallows for identification of trends over time. This isparticularly important when measuring the impact ofinterventions on aggregate measures such as totalantimicrobial use or percentage of resistant organ-isms. These indices, in the absence of (and often evenin the presence of) stewardship programs, tend toincrease over time.10-12 Thus, the ability of a steward-ship program to reduce the rate of increase of theseindicators is a substantial accomplishment, even if theabsolute level cannot be reduced. These effects cannotbe detected without several historical data points.

Studies have used a variety of measurements toevaluate stewardship programs. These can be cate-gorized as process metrics, such as how many rec-ommendations are made or what percentage ofrecommendations are accepted, or outcomes metrics,such as percentage of patients receiving guideline-appropriate therapy or hospitalwide antimicrobialresistance levels. Studies of antimicrobial stewardshiptypically incorporate both types of metrics.13-17 Table2 displays an approach to the process and outcomemetrics for antimicrobial stewardship programs. Inthis scheme, the ultimate outcome metric is the per-centage of patients with infections who are success-fully treated with a regimen that is minimally toxicand maximally cost-effective. This metric per se is notpractically measurable outside of research settings.However, by examining the determining factors thatdrive the components of this outcome, one can derivesome metrics that provide part of the picture as to thequality of care.

After these data are collected, institutions have 3options for interpreting them: (1) quality assurance –comparison of the data to some agreed-upon standard(eg, 90% of patients receive guideline-compliant ther-apy for pneumonia); (2) intrahospital comparisons –comparison of the data to the institution’s historicaldata or to other patient care groups in the institution(eg, percent of patients being switched from IV to POtherapy over time or on surgical vs medical services),and (3) interhospital comparisons – comparison of thedata to those obtained in similar institutions (eg,a methicillin-resistant Staphylococcus aureus [MRSA]infection rate below that of other hospitals). The in-terhospital comparison is typically known as bench-marking and is an approach to improving health carequality.18,19 Patient-level metrics are more appropriatefor intrahospital comparison and quality assurance.They are ‘‘closer’’ to the ultimate outcome metric ofappropriate, cost-effective treatment than ecologicmetrics, which involve data aggregated across largenumbers of patients. Ecologic metrics are suitable forintra- or interhospital benchmarking, but they aremore removed in the causality chain from patient-level outcomes. Ecologic metrics are best used inconjunction with some sort of risk adjustment thataccounts for differences in host factors (patient pop-ulations) between institutions.20

Considerations for community hospitalsPerhaps the most daunting challenge in building an

antimicrobial stewardship program at a small com-munity hospital is the lack of sufficient resources,

Table 1. Practical considerations for potentialantimicrobial stewardship team resources

Ideal resources Potential alternative resources

Infectious diseases(ID) physician

Other ‘‘physician champion’’� Staff physician with ID interest� P&T chair or committee member� Local thought/practice leader� Physician groups who frequently

prescribe antimicrobialsResidents/fellows

ID pharmacist Non–ID-trained clinical pharmacistStaff pharmacistsResidents/studentsWorking director of pharmacy

Clinicalmicrobiologist

Microbiology laboratory technicianPathologist

Infection controlcoordinator

Nursing staffPatient safety representative

Information systemsspecialist

Information systems staffCommercial data-mining programs

Note: P&T 5 Pharmacy & Therapeutics.

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Making Antimicrobial Stewardship Work

including core and support personnel. Many rural in-stitutions have few, if any, ID physicians on the medicalstaff available for routine consultations, let alone an IDphysician with the dedicated responsibility for directinga stewardship program. In these cases, recruitment ofan alternate physician champion with an interest ininfectious diseases is important for oversight of theprogram.

Academic medical centers tend to be the most ap-pealing options as practice sites for ID-trained phar-macists, thus creating a recruiting challenge for smallercommunity hospitals. When ID pharmacists are notavailable as resources, non–ID-specialist clinical phar-macists should make efforts to increase their comfortlevel and improve competency with ID-related issues inorder to serve as a team member. Acquiring IDknowledge and skills may be achieved by shadowing

other pharmacist, physician, or microbiology experts;reading key guidelines and review articles; attending IDprofessional conferences; or completing one of thestewardship certification programs currently underdevelopment.

Unfortunately, in many rural hospitals – particu-larly critical access facilities (with 25 acute care beds orless) – a single pharmacist may serve the entire facility.In this setting, the pharmacist’s responsibilities typicallyinclude operational patient care activities, such as orderentry and medication distribution, inventory manage-ment, and serving as director of pharmacy, clinicalpharmacist, and P&T committee member. The phar-macist may be unable to prioritize and incorporatetime-intensive antimicrobial stewardship activities intothe work flow. Thus, stewardship strategies should betailored according to available resources.

Table 2. Potential antimicrobial stewardship program metrics

Determining factors Patient-level metrics examples Ecologic metrics examples

Outcome metrics

What percent ofpatients with infections. . .

-Host factors-Appropriatediagnostics performed

-% VAP patients withrespiratory cultures-% of patients withpaired blood cultures

-No. of blood cultures/infection-related ICD-9

are successfully treated. . . -Host factors-Selection of effectiveantimicrobial-Effective dose-Adequate duration

-% of guideline-appropriateregimens by disease state-% of regimens with invitro activity-No. of days to in vitroactive drug-% of patients witheffective dose

-Antibiogram (% susceptibleby drug-organism)-No. of resistantinfections/1000 PD-DDD or DOT/1000 PD-Mean duration of therapy

with minimal toxicity. . . -Host factors-Selection of least toxiceffective antimicrobial-Safe dose-Minimal effective duration

-Audit of high-toxicityantimicrobials-% of patients withappropriate dose-% of serum levels insafe range

- DDD/1000 PD ofhigh-toxicity antimicrobialsvs peer institutions

with the mostcost-effective regimen?

-Selection of least expensiveeffective antimicrobial-Cost-effective dose-Cost-effective route-Cost-effective duration

-Audit of high-costantimicrobials-Eligible patientsswitched IV/PO forhigh-bioavailabilityantimicrobials

-Total antimicrobialexpenditures/PD-Total expenditures by infection-Days of IV vs PO for high-bioavailability antimicrobials

Process metrics

What is the level of activityand acceptance of thestewardship program?

-Number of stewardshippersonnel-Time dedicated tostewardship-Attitude of clinicianstowards stewardship

-Types of recommendationsmade-No. of recommendationsmade/time period-% of recommendationsimplemented

-No. of FTEs/1000 PD dedicatedto stewardship

Note: Italics identify modifiable factors. VAP 5 ventilator-associated pneumonia; PD 5 patient days; DDD 5 defined daily dose; DOT 5 days of therapy; FTE 5 full-time equivalent positions; IV 5 intravenous; PO 5 oral.



Beyond physician and pharmacist core members,availability of important support personnel is often farfrom ideal at community hospitals. Many small com-munity hospitals do not have the resources to supportan in-house microbiology laboratory and thereforemust outsource this service. This situation poses chal-lenges such as delays in obtaining routine culture andsusceptibility results and uncertainty about the meth-odologies used to provide cumulative antibiograms. Inother cases, a community hospital may have a micro-biology laboratory onsite, but it may be run by tech-nicians who lack clinical microbiology expertise. Insuch situations, the core members of the stewardshipteam should be empowered to spearhead a collabora-tion to ensure that certain policies and procedures of thelaboratory are designed to complement key programinitiatives. For example, if a nonformulary antimicro-bial agent is routinely tested as part of an automatedsusceptibility testing panel, the results for this drugshould be suppressed from reporting to medical staff.Likewise, to supplement efforts to encourage antimi-crobial streamlining, results for broad-spectrum agentsshould be suppressed when the organism is susceptibleto a more narrow-spectrum, clinically appropriateagent, per the guidelines of the Clinical and LaboratoryStandards Institute (CLSI).21

Many community hospitals may not have thesophisticated information technology needed to opti-mally support antimicrobial stewardship activities.For example, physician order entry offers nearly un-limited potential to provide guidance and decisionsupport to improve antimicrobial prescribing on thefront end. However, implementation of this programcan be costly and require a massive training effort andtherefore may not be practical for smaller hospitals.These hospitals must rely on more labor-intensivemethods of policy implementation. Without adequateinformation systems resources, data gathering andanalysis can be cumbersome and sometimes nearlyimpossible. These limitations should be consideredwhen selecting metrics for reporting at program onset.The team should ensure that it is feasible to gather andanalyze the metrics pertaining to each program goal ina timely manner, given limited availability of in-formation systems resources.

Considerations for teaching hospitalsMost teaching hospitals do not have a lack of

qualified ID-trained physicians. However, given thecommitments these physicians have to teaching andresearch, it may be difficult to find a physician willingto commit the time to become the stewardship

champion. It is important that all of the ID physiciansunderstand and endorse the stewardship program,even those who may only spend a small amount of timeon clinical service because of research commitments.

Academic medical centers may be able to expandthe pool of stewardship personnel by recruitingtrainees. Some centers have fellowship programs fortraining future physicians to become ID specialists.These fellows may be incorporated as active membersof stewardship programs to good success because oftheir close working relationship with the housestaffthat do the antimicrobial prescribing. However, it isimportant that the fellows feel invested in the program,otherwise they may serve as ‘‘rubber-stamp’’ stewardsor, worse, actively undermine the stewardship per-sonnel. Participation in antimicrobial stewardship isan excellent learning opportunity for pharmacy stu-dents or residents and provides more personnel to helpwith day-to-day stewardship activities.

Many large teaching hospitals have the informationtechnology infrastructure – electronic medical records,computerized physician order entry – to make key dataeasier to access. However, there is likely to be quite a bitof data to sift through, so engaging the services of aninformation technology specialist is helpful. Personneltasked with support of the infection control programshould be cross-trained to handle stewardship queries.The effect of stewardship programs on various metricsmay be of interest as a research question to academi-cians, who can provide assistance with data collection,study design, and statistical analysis.

Benchmarking program metrics is key in tertiarycare institutions. There is a tendency among cliniciansat these institutions to believe that the care of complexpatients justifies almost any level of antimicrobial use.The comparison of antimicrobial use and outcomesdata with those of peer institutions to the finest level ofdetail available (eg, by service or diagnosis group) canprovide an honest picture of how a program is mea-suring up. Such data may be readily available if thehospital participates in groups such as the UniversityHealthSystem Consortium (www.uhc.edu).

PUTTING STEWARDSHIP INTO PRACTICESelecting Stewardship Strategies

After the decision is made to launch a stewardshipprogram or re-evaluate an existing one, key stake-holders are engaged, and data for metrics are located,the next consideration is what to do. In other words,what activities will be performed, by what personnel,with what frequency, and with what authority. Table3 lists these considerations with examples of each.



Details of different strategies have been extensivelyreviewed.1,3,4 Tailoring the activities to the goals andresources of the individual program is the task of thestewardship committee.

The importance of marketing and advertising a newor revised stewardship program should not be under-estimated. Few things are more frustrating to health carepersonnel than dealing with new rules and proceduresthey are unaware of. Moreover, the misunderstandingsthat result from a lack of knowledge of stewardshipprocedures may compromise patient care. Advertisingcan be pursued through a number of mechanisms, in-cluding new practitioner orientation, staff newsletters,grand rounds, or other educational forums, and viahospital Internet/intranet and e-mail systems.

Working With CliniciansCollaboration with clinicians who are outside of

the formal stewardship team is encouraged to ensurebuy-in for various initiatives. Key stakeholders fromhospital departments that will be affected by stew-ardship activities should be identified and consultedduring the development and introduction of a newinitiative. For example, during the development ofa pneumonia order set, stakeholders might includepulmonologists and emergency medicine physicians;for a surgical prophylaxis guideline, a surgeon shouldbe involved in development and implementation. Bygiving clinicians ownership of these initiatives, theybecome invested in the success of the program.

Early involvement of key stakeholders may help toavoid resistance among clinicians; however, unforeseen

issues may arise despite valiant efforts to ‘‘cover all thebases.’’ In such situations, attempts should be made tounderstand the reasons for noncompliance in order toeffectively address the concerns. Oftentimes, clinicianresistance can be overcome with direct education.Perhaps the physician is unaware that Candida speciesisolated from a sputum culture likely represents colo-nization and need not be treated 22 or that definitivedata exist for shortening the course of antibiotic ther-apy for most ventilator-associated pneumonias.23 Ed-ucation about these issues can reassure the physicianthat stewardship team recommendations are, in fact,evidence-based and in the best interest of the patient.Feedback to departments or physicians regardingcompliance to stewardship guidelines and/or inter-ventions in the form of a regular ‘‘report card’’ mayalso be effective in improving compliance.24,25 Clini-cians are often willing to change their prescribingpatterns when they become aware that their practicesvary significantly from those of their peers. This feed-back must be provided diplomatically with an un-derstanding of the political climate of any individualhospital. If one-on-one feedback is ineffective, these‘‘report cards’’ can be sent to hospital administrationor medical staff leadership for further action.

Considerations for community hospitalsStrategy selection when starting a stewardship

program at small community hospitals should startwith identification of areas for improvement whileaccounting for the availability of stewardshipresources. In contrast to academic centers where many

Table 3. Considerations when selecting stewardship activities

Examples

What activities will be performed. . . -Authorization of restricted antimicrobials-Audit of and feedback regarding targeted antimicrobials-Pharmacokinetic dosing of antimicrobials-IV to PO conversion

by what personnel. . . -Dedicated, trained ID pharmacist-ID physicians or physician trainees-Non–ID-trained clinical pharmacists-Hospital pharmacists-Pharmacy residents or students

with what frequency. . .. -Performance of stewardship activities during evenings and weekends-Stewardship activities during ID pharmacist vacations-Authorization of restricted antimicrobials during off-hours

with what authority? -Require preauthorization for restricted antimicrobials-Protocols for IV to PO conversion-Pharmacokinetic dosing protocols-Communication of recommendations via chart notes

Note: IV 5 intravenous; PO 5 oral; ID 5 infectious disease.



supplemental strategies may be implemented prior tothe formation of a formal antimicrobial stewardshipprogram, small community hospitals must often ‘‘startfrom scratch.’’ This can be overwhelming when con-sidering where to start, taking into account theremaining work involved in formulating a compre-hensive program. A potential strategy may be to worktoward training staff pharmacists to assist with ini-tiatives that require less ID expertise, such as IV to POconversion or pharmacokinetic dosing. In addition,nontraditional personnel, such as case managers, maybe of assistance in monitoring for appropriate dura-tion of therapy per infection as well as IV to POconversion initiatives.

Once these initial efforts gain traction, dedicatedstewardship personnel may focus on more labor-in-tensive, ID-specific supplemental and core strategies.Even with these efforts, starting small and sub-sequently expanding may be more practical and suc-cessful than attempting to launch a comprehensiveprogram from the start. For example, when beginninga prospective audit and feedback initiative, start withone targeted antimicrobial and add others whensuccess has been demonstrated. Regardless of initialstrategies, each new initiative must progress throughthe appropriate channels. Specific, medical staff–ap-proved policies and procedures should guide the dailyactivities of the stewardship team. Even with thisgroundwork, a major challenge arises when admin-istrators are unwilling or unable to effectively dealwith resistant clinicians. When roles and respon-sibilities of stewardship team members are initiallyoutlined, administrator roles and consequences forlack of compliance should be discussed as well.

A major challenge is posed when the hospital’s IDphysicians are not fully supportive of the program.These ID physicians should serve as role models instewardship for the remainder of the medical staff.Therefore, it is of utmost importance that theirpractices reflect initiatives of the stewardship team. Inthe community hospital setting, most consultantphysicians are in private practice and may be unawareof how their practices differ from those of their col-leagues and from the latest evidence-based recom-mendations. Although forums such as antimicrobialsubcommittees, grand rounds, and ID divisions areconsistently available at academic centers, communityhospitals often lack this infrastructure. To ensure buy-in of these key physicians, the stewardship team shouldwork to establish a forum for ID physicians to meet anddiscuss changes affecting the hospital as well as advancesin the field in general. To overcome the possibility of

poor attendance or lack of interest, participation may berequired for medical staff re-credentialing.

Considerations for teaching hospitalsTeaching hospitals with strong levels of personnel

and information technology support can implementa broad package of stewardship interventions. If thereis a group of clinical or decentralized staff pharmacists,some stewardship tasks (IV to PO switch, audit, andfeedback) may be able to be ‘‘off-loaded’’ to thesepersonnel instead of being performed by an IDpharmacist. At the same time, the high patient volume,acuity, and all-hours activity in many teaching hos-pitals can be a challenge to stewardship programs. Forexample, strategies requiring preauthorization ofcertain antimicrobials must be designed so that timelyadministration of these agents off-hours (weekends,evenings) is not compromised.

Medical residents as the primary prescribers ofantimicrobials in a hospital presents opportunities andchallenges. Residents are generally receptive to theeducational and feedback interventions that form thecore of stewardship programs. From a practical point ofview, the near-constant presence of housestaff in theinstitution enables modifications to patients’ therapy tobe executed more rapidly than when patients are caredfor by private practice physicians who may only bein the hospital an hour a day. On the other hand,residents may be hesitant to directly implement sug-gested stewardship interventions (eg, changing ordiscontinuing antimicrobials) without consulting su-pervisory clinicians (attending physicians, fellows). Onsome services, the housestaff have very little discretionin antimicrobial prescribing: ‘‘Because my attendingsaid so’’ may be the leading indication for antimicrobialtherapy. In this case, there may be a substantial delayin implementing suggested stewardship interventionswhile the recommendation makes its way ‘‘up theladder.’’ Thus, the importance of getting the buy-in ofsenior supervisory physicians to a stewardship programcannot be underestimated. It will be more productive toconsult with senior clinicians to reach agreement on anacceptable set of guidelines for standard therapy foreach service than to deal with each patient on a case-by-case basis.

EVALUATING AND ADAPTING A PROGRAMReporting Results and Managing Expectations

Upon beginning or expanding a stewardshipprogram, goals of the program should be explicitlystated (eg, using the metrics described previously) anda timeline for measuring progress toward the goals



should be specified. Once a program is up and running,there will be pressure to show positive results; pre-specified reporting dates and outcomes can help toclarify expectations. It is very important to note thatsome metrics, particularly ecologic measures such astotal antimicrobial use and antimicrobial resistance,may require a very long time horizon (greater thana year) to show noticeable changes from the historicalbaseline.26,27 Thus, early program reports (a year orless after program implementation) should focus onprocess measurements (eg, number of interventionsperformed), patient-level outcomes (eg, compliancewith guidelines), and cost savings/cost avoidanceachieved. A full yearly report measuring progress oneach of the program’s prespecified metrics should beprepared. The report should be disseminated to thepersonnel and committees that have authority overthe stewardship program and to other stakeholdergroups outside of the ‘‘chain of command.’’

A challenge for initially successful programs is toimprove on that success in subsequent years. There are

likely to be diminishing returns after successful im-plementation of any one particular strategy. This iswhere historical baseline data becomes key. By trendingprior data (such as aggregate antimicrobial use, anti-microbial costs, or resistance) and extrapolating to thefuture, programs can demonstrate a continuing benefiteven when these measures remain stable over time.Figure 1 illustrates a hypothetical scenario in which anantimicrobial stewardship program is initiated in aninstitution with increasing total antimicrobial use.Although total antimicrobial usage at the last timepoint is higher than at the beginning of data collection,it is substantially lower than that predicted from thepreintervention data. If a group wants to performformal analyses on such longitudinal data, appropriatestatistical techniques should be used.28,29

Adapting the ProgramAfter reports around selected metrics are compiled,

they should be critically analyzed to determine the levelof progress toward prespecified goals. If the goal is far

Figure 1. Measuring effects of antimicrobial stewardship interventions. Hypothetical changes in total antimicrobialuse (days of therapy per 1000 patient days) at a hospital before and after implementation of an antimicrobialstewardship program. Triangles indicate antimicrobial use preintervention; circles indicate antimicrobial use post-intervention; solid line indicates linear trend of antimicrobial use preintervention; dotted line indicates linear trend ofantimicrobial use postintervention; vertical line indicates difference between predicted and actual antimicrobial use.



from accomplished, what are the barriers to success?Are these barriers insurmountable? Aggressive pursuitof exact compliance to program goals increases theprobability of alienating clinicians and compromisingpatient care. If progress has been slow but steady,a reassessment of time lines for attainment of a goal maybe needed. For successful strategies, it is useful to reflecton the key components of the process to potentiallyapply a similar approach in future initiatives.

Considerations for community hospitalsWhen reporting results, consideration should be

given to the audiences. Administrators will be in-terested in cost metrics as well as quality and processmetrics. Medical staff at community hospitals areoften further removed from the cost concerns and maybe more interested in quality and patient care out-comes as well as ecologic metrics. Excessive focus oncost savings/avoidance metrics during reports tomedical staff may convey the impression that theantimicrobial stewardship program is purely a cost-containment effort, potentially damaging the credi-bility of the team’s efforts.

Barriers to success should also be reported.Bringing attention to the challenges the program facesmay engage physicians to help provide solutions.Furthermore, any positive results can be used as a toolto demonstrate the importance of compliance withstewardship initiatives.

Considerations for teaching hospitalsEfforts should be made to include trainees in the

reporting of stewardship measures. A brief educationalsession on the hospital’s stewardship policies anddiscussion of the hospital antibiogram should be a partof orientation for new housestaff and fellows, ashospital policies and local drug resistance issues likelydiffer from where they previously trained. Yearlyupdates in educational sessions such as grand roundscan keep them informed about changes to the anti-biogram and hospital policies. These sessions also letthem know that the inconveniences that the programmay pose for them on a daily basis are ultimatelycontributing to positive outcomes.

CONCLUSIONProfessional societies and government organ-

izations have begun advocating for the widespreadadoption of antimicrobial stewardship programs inhospitals. However, little guidance is generally offeredon the practical aspects of implementing such pro-grams across the wide spectrum of hospitals in the

United States. There is no ‘‘one-size-fits-all’’ approach.Our recommendations can be summarized as follows:(1) understand what the problem areas are at yourinstitution; (2) determine what resources are available(or may become available with the right appeals); (3)select stewardship strategies that best address theproblems while accounting for the resources; (4) showoff your success (or explain why success was notpossible); and (5) use your success to secure moreresources to address more problem areas. Never feelthat a program needs to be built from scratch. Phar-macists across the country have been running anti-microbial stewardship programs for years and aregenerally more than willing to share advice, examples,and encouragement.

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29. Wagner AK, Soumerai SB, Zhang F, Ross-Degnan D.Segmented regression analysis of interrupted time series studiesin medication use research. J Clin Pharm Ther. 2002;27(4):299-309. g



Hosp Pharm 2010;45(11 Suppl 1):S19–S212010 � Thomas Land Publishers, Inc.www.thomasland.comdoi: 10.1310/hpj4511-S19

Continuing Education Posttest

Continuing education (CE) for this program is processedsolely through the ProCE online CE Center. To receiveCE credit, please complete the program posttest andevaluation by clicking on the ProCE link on the lowerleft-hand corner of the page at www.hospitalpharma-cyjournal.com. With a passing grade of 70% or greateron the posttest, you can print your CE statement ofcredit online.

1. Which of the following is not considered anESKAPE pathogen?a. Klebsiella pneumoniaeb. Acinetobacter baumaniic. Proteus mirabilisd. Enterococcus faecium

2. Which of the following methods is endorsed bythe Infectious Diseases Society of America (IDSA)as an element of an effective antimicrobial stew-ardship program?a. Prospective audit with intervention and feed-

backb. Formulary restriction and preauthorizationc. Initiation of antimicrobial therapy within 10

minutes of suspected infectiond. Both A and B

3. Passive clinical decision support systems requirethe user to query the database for possible inter-ventions.a. Trueb. False

4. The main goal of antimicrobial stewardship is tomake financial improvements to the hospital’s bot-tom line.a. Trueb. False

5. Which of the following is considered a goal ofa comprehensive antimicrobial stewardship pro-gram?a. Optimizing patient outcomesb. Minimizing unintended consequences of anti-

microbial therapyc. Decreasing the incidence of multidrug-resistant

pathogensd. All of the above

6. An antibiogram should always include which ofthe following items?a. Patient’s age and sex and the unit to which the

patient was admittedb. Number of isolates included in the calculation

and percent of isolates susceptiblec. Type of laboratory test used to determine the

minimum inhibitory concentrationd. Cost of each antibiotic and route of adminis-

tration

7. Which antibiotic susceptibility methods will notprovide a minimum inhibitory concentration?a. Disk diffusionb. MicroScanc. Etestd. VITEK

8. In which situation would a molecular assay beused to detect antibiotic resistance?a. To detect beta-lactamase in a Haemophilus in-

fluenzae isolate from an eye infectionb. To determine whether multiple Pseudomonas

isolates from an outbreak in a unit are relatedc. To determine whether gram-positive cocci in

clusters from a blood culture are resistant tomethicillin

d. To distinguish an isolate from the neonatal in-tensive care unit as Staphylococcus aureus orStaphylococcus epidermidis

9. Which of the following organizations providesspecific guidelines that should be used when de-signing and preparing an antibiogram?a. The Joint Commissionb. US Food and Drug Administrationc. Clinical Laboratory Improvement Consortiumd. Clinical Laboratory Standards Institute

10. How often should an antibiogram be developedand distributed throughout the hospital?a. Once a monthb. Twice a yearc. Once a yeard. When there are enough isolates


11. A small community hospital does not have aninfectious diseases–trained clinical pharmaciston staff, has only one part-time infectious dis-eases physician with privileges at the hospital,and outsources its microbiology processing toan outside laboratory. Which of the followingdescribes the best approach to antimicrobialstewardship for this institution?a. A program customized to the resources avail-

able to the hospital can be developed.b. A program should not be attempted in this

situation due to the lack of resources.c. A program is not necessary in community

hospitals due to the low level of antimicrobialuse.

d. A program can be established only if micro-biology testing becomes an internal process.

12. Which of the following can be done by pharma-cists who are not trained in infectious diseasepharmacotherapy to improve their competencyand comfort level in this area?a. Shadow other practitioners in the fieldb. Read key guidelines and review articlesc. Complete a stewardship certification pro-

gram once availabled. All of the above

13. Community Hospital X implemented an antimi-crobial stewardship program 6 months ago. Thebest metrics to include in the first program reportat the upcoming medical staff meeting include allof the following, except:a. Process measurements (eg, number of inter-

ventions performed)b. Cost savings/cost avoidancec. Ecologic measurements (eg, antimicrobial

resistance rates)d. Patient-level outcomes (eg, compliance with

guidelines)

14. Which of the following is a disadvantage of hav-ing housestaff as prescribers at a teaching insti-tution when implementing an antimicrobialstewardship program?a. Near-constant presence in the hospitalb. Willingness to learn about proper prescribingc. Hesitancy to follow recommendations with-

out approval of supervisory cliniciansd. Familiarity with newer antimicrobial agents

15. Which of the following would represent an intra-hospital comparison of antimicrobial steward-ship metric data for a hospital?a. Comparing the methicillin-resistant Staphylo-

coccus aureus (MRSA) rate at the targethospital to that of a similar hospital in thesame city

b. Comparing the target hospital’s quarterly useof carbapenems over the last 2 years

c. Comparing the target hospital’s compliancewith Surgical Care Improvement Project(SCIP) surgical prophylaxis guidelines to thehospital quality goal of 95%

d. Comparing the number of patients switchedfrom intravenous fluoroquinolones to oralfluoroquinolones at the target hospital towhat was reported in a recent journal article


Continuing Education

ACCREDITATION

This program is co-sponsored bythe Illinois Council of Health-SystemPharmacists and ProCE, Inc. TheIllinois Council of Health-SystemPharmacists is accredited by the Ac-creditation Council for PharmacyEducation as a provider of continuingpharmacy education. This program isequivalent to 1.5 contact hours or0.15 CEUs. This CE activity is pro-vided at no cost.

ACPE Universal Activity Number:121-999-10-073-H04-PActivity type: Knowledge-basedInitial Release Date: 11/01/2010Expiration Date: 11/01/2013

FUNDINGThis activity is supported by aneducational grant from Ortho-McNeil, Division of Ortho-

McNeil-Janssen Pharmaceuticals, Inc., administeredby Ortho-McNeil Janssen Scientific Affairs, LLC.

DISCLOSUREIt is the policy of the CE providers to require thedisclosure of the existence of any significant financialinterest or any other relationship a faculty member ora sponsor has with the manufacturer of any com-mercial product(s) discussed in an educational activity.The faculty members all report having no relevantaffiliations or financial/commercial relationships.

Please note: The opinions expressed in this journalsupplement should not be construed as those of theCE providers. The information and views are those ofthe faculty through clinical practice and knowledge ofthe professional literature. Portions of this activitymay include the use of drugs for unlabeled in-dications. Use of drugs outside of labeling should beconsidered experimental and participants are advisedto consult prescribing information and professionalliterature. g


Continuing Education

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How to Make Antimicrobial Stewardship Work: Practical Considerations for Hospitals of All Sizes

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