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Breaking down barriers to antimicrobial stewardship in small hospitals

Study, commentary published in Clinical Infectious Diseases

Owing to their success in promoting patient safety at larger institutions, various national regulatory and accreditation agencies have mandated that all hospitals, regardless of size, implement antimicrobial stewardship programs (ASPs).

In 2015, 73% of U.S. hospitals had fewer than 200 beds, and 10% had fewer than 25 beds, many of which hold critical access hospital (CAH) designation, according to a recent study in Clinical Infectious Diseases. With 20%–50% of antibiotic use being unnecessary or inappropriate, and with similar usage rates, spectrums of antibiotics, and rates of drug-resistant bacteria compared with larger facilities, smaller hospitals may encounter barriers concerning resources while executing ASP initiatives.

“Antimicrobial resistance is one of the most problematic issues facing modern medicine,” explained Michael Klepser, PharmD, FCCP, FIDP, professor of pharmacy practice at Ferris State University College of Pharmacy in Big Rapids, MI. “Additionally, antibiotic-related adverse events are the most common cause of drug-related emergency room visits. These are not just big hospital problems. Furthermore, the specter of resistance results in increased drug costs, length of stay, and diagnostic testing costs.”

Smaller hospitals are less likely to have an active ASP with pharmacy support and, in 2015, CDC found that just 49% of hospitals servicing fewer than 200 beds and only 31% of CAHs met all seven of its “core elements” of antibiotic stewardship. Comparing this with 66% adherence at larger hospitals, clinicians might require creative solutions to address such challenges at smaller institutions.

Having scant personnel to perform stewardship has been identified as one of the most significant obstacles for smaller hospitals building ASPs, according to a recent commentary in Clinical Infectious Diseases. In Klepser’s experience, “The expertise and leadership necessary to develop and lead an antimicrobial stewardship team may be lacking. In some institutions, there may only be one to two pharmacists and the pharmacy may not be open at all hours.”

While the Infectious Diseases Society of America (IDSA)/Society for Healthcare Epidemiology of America (SHEA) guidelines recommend that ASPs be led by infectious disease (ID) physicians with advanced stewardship training or codirected by an ID physician and a clinical pharmacist with advanced ID training, smaller hospitals often lack dedicated ID-trained staff to support such programs.

To mitigate ID-specialized staffing setbacks, institutions may employ part-time ID support and contract personnel from surrounding facilities. Other hospitals utilize health care system assets, sometimes benefiting from local or commercial telehealth resources to deliver antibiotic stewardship.

Recruits can receive training through state health departments, many of which provide education, expertise, and assistance to hospitals on stewardship. The Society for Infectious Disease Pharmacists (SIDP) and Making a Difference in Infectious Diseases (MAD-ID) offer pharmacy-based training programs. An annual conference presented by SHEA focuses on training stewardship providers, and the annual Best Practices for ASPs workshop, held at IDWeek, provides instruction for non-ID physicians and pharmacists. In addition, antibiotic stewardship online courses are available through SHEA and Coursera.

Another common barrier to implementation cited by all sizes of ASP is lack of financial support. In both large and small hospitals, a detailed business case should be presented to administration to address funding ASP training, contracting IT vendors, and allocation of employees’ time. In doing so, attention to factors like differences in payer mix, reducing antibiotic consumption, and investment in human resources should be addressed in a manner that speaks to the hospital’s individual needs and goals.

Although ASP implementation presents clinical and administrative challenges, the benefits can be outstanding. By working with personnel to develop creative solutions to ID staffing needs, time constrains, and cost, smaller hospitals can implement successful ASPs that not only meet regulatory and accreditation standards but also parallel the institution’s pre-existing patient safety and financial objectives.

For the full article, please visit for the upcoming November 2017 issue of Pharmacy Today.


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