National Antimicrobial Stewardship Practices - An Update

Background: There is a growing necessity in healthcare facilities to ensure the appropriate use of antimicrobials to improve patient outcomes and to reduce the likelihood of developing antimicrobial resistance. The healthcare community lacks metrics about stewardship practices including which methods are most successful and what proportion of hospitals have a formal program.

Objective: To assess stewardship methods used; barriers to successful implementation of an Antimicrobial Stewardship Program (ASP); and the perceptions of participants regarding the success of ASPs.

Methods: We conducted a web-based survey of providers about their experience with ASPs, targeting an expanded national population, and combined the results with our preliminary data collected one year ago from 127 institutions.

Results: Approximately 8,000 nationwide providers from a commercially available list were surveyed. 406 (5%) responded to our survey. 206 institutions (51%) had a formal ASP team, which was mostly comprised of Infectious Disease (ID) physicians, ID/clinical pharmacists, clinical microbiologists, and/or infection control professionals. ASP success was frequently measured by antimicrobial expenditures. Institutions with an ASP were more likely to have an antibiogram, ID consult service, and ID fellowship program (94% vs. 88%, 86% vs. 63%, and 15% vs. 8%, respectively). The mean yearly antimicrobial expenditure for antibacterials and antifungals was higher for institutions with an ASP ($1,800,000 vs. $836,000). The most common stewardship practices were automatic stop orders and/or a concurrent review approach, but institutions with an ASP also commonly utilized antimicrobial restriction approaches, including the requirement of ID consult and prior approval. Institutions with an ASP were significantly more likely to have formal antimicrobial prescription education (94% vs. 26%, p < 0.0001) and have an ID pharmacist (53% vs. 16%, p < 0.0001). Respondents from institutions with an ASP reported greater perceived physician agreement with antimicrobial policies (69% vs. 44%). Of institutions without an ASP, 63% had considered implementing a program but the most common barrier was staffing constraints.

Conclusions:   In this largest study of its kind to date, the results demonstrated that institutions with an ASP were larger, had proportionally higher antibiotic budgets, and were more likely to have an ID fellowship program. They were also significantly more likely to have a formal education program and/or an ID pharmacist. These hospitals had higher perceived acceptance of policies by other physicians at their institution. Hospitals must be made aware of the importance of the link between inappropriate antimicrobial prescription and resistance and poor patient outcomes. As with other efforts to improve patient safety, staff constraints should not impede the implementation of ASP programs.