The State of Antimicrobial Stewardship Programs in California

Background: Antimicrobial use optimization is widely accepted to decrease antimicrobial resistance patterns, patient toxicities and healthcare costs. Antimicrobial stewardship programs (ASP) are intervention-based programs designed to improve and measure the appropriate use of antimicrobials.  California Senate Bill (SB) 739 mandated that, by January 2008, all general acute care hospitals develop processes for evaluating the judicious use of antibiotics and monitor results using appropriate quality improvement committees. Although the law neither specifies processes nor addresses noncompliance, it provides a statutory incentive to hospital administrators to establish active ASPs. California is the only state with this type of legislation. 

Objective: To assess current ASPs and strategies in place in California general acute care hospitals using a voluntary web-based survey implemented in May 2010.

Methods: Hospitals were encouraged to participate in the survey via emails, presentations to local health departments and professional societies, and word-of-mouth.  The survey collected hospital characteristics and ASP determinants including strategies utilized and outcomes measured.  Whether SB 739 influenced the development of the hospital’s ASP also was queried.  Information was collected on barriers in initiation for institutions that self-identified as not having a formal ASP.   

Results: By October 2010, 213 (~55%) of California’s acute care hospitals responded to the survey, representing all regions of California and sizes of hospitals.  Community hospitals represented 79% and city/county hospitals represented 9% of respondents.  Fifty-two percent of hospitals described an active ASP and 23% of these hospitals stated SB 739 had influenced the initiation of the ASP.  Of the hospitals with an ASP, formulary restriction (83%), pre-authorization (61%) and post-prescription audit with feedback (41%) were the most common strategies reported; outcomes measured included resistance patterns (76%), antimicrobial use (70%) and antimicrobial costs (67%).  Thirty percent of all hospitals described no ASP but were planning one and 17% described no ASP; barriers to developing an ASP included staffing constraints (69%) and lack of funding (46%).

Conclusions: Although many studies have been published describing hospital-specific ASPs, most have been in academic centers and there have been no assessments of current ASP strategies across a variety of hospital systems.  This study shows that many ASPs are currently active in California, particularly in community and resource-limited hospitals where previously a scarcity of antimicrobial restriction was thought to exist.  Additionally, although California law does not specifically mandate ASPs, SB 739 appears to have played a role in initiating many ASPs, supporting the adoption of similar legislation in other states and at the national level.