A trial demonstrated that antibiotic timeouts at 48-72 hours of therapy improved the appropriateness of antibiotic selection, but did not reduce overall antibiotic use (66). CDC Patient Safety Portal, VHA Directive 1031 Antimicrobial Stewardship Programs (ASP) [PDF 12 pages], Surveillance for Antimicrobial Use and Antimicrobial Resistance Options, Redefining the Antibiotic Stewardship Team: Recommendations from the American Nurses Association/Centers for Disease Control and Prevention Workgroup on the Role of Registered Nurses in Hospital Antibiotic Stewardship Practices, Five Ways Pharmacists Can Be Antibiotics Aware, Evaluation and Diagnosis of Penicillin Allergy for Healthcare Professionals, Implementation Resources for Antibiotic Stewardship, National Strategy for Combating Antibiotic-resistant Bacteria, AHRQ Safety Program for Improving Antibiotic Use, The Core Elements of Human Antibiotic Stewardship Programs in Resource-Limited Settings, Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP), Healthcare Professional Resources and Training, Educational Resources for Healthcare Professionals, Adult Outpatient Treatment Recommendations, Pediatric Outpatient Treatment Recommendations, Measuring Outpatient Antibiotic Prescribing, Tuberculosis (TB), Gonorrhea, and Valley Fever, Implementation Resources for Outpatient Facilities, Implementation Resources for Nursing Homes, U.S. Department of Health & Human Services. Handouts include Youve Been Prescribed an Antibiotic in the Hospital for an Infection pdf icon[PDF 2 pages]. Experts suggest that daily reviews of antibiotic selection, until a definitive diagnosis and treatment duration are established, can optimize treatment. United States hospitals have made considerable progress implementing the Core Elements. Help optimize empiric antibiotic prescribing by creating and interpreting a facility cumulative antibiotic resistance report or antibiogram. Can Be Antibiotics Aware Providing resources, including staffing, to operate the program effectively. There are a variety of health information technology companies that can facilitate the reporting of antibiotic use data to the AU Option (78). Hospitals can use local data and knowledge of practices to determine which antibiotics should be subject to prospective audit and feedback and/or preauthorization. Antibiotic stewardship programs can help clinicians improve clinical outcomes and minimize harms by improving antibiotic prescribing. Hospital leadership can play a critical role in helping the stewardship program get the resources needed to accomplish its goals. Like all medications, antibiotics have serious adverse effects, which occur in roughly 20% of hospitalized patients who receive them (4). Some hospitals have created a multidisciplinary stewardship subcommittee of the Pharmacy and Therapeutics Committee. Sepsis:Early administration of effective antibiotics is lifesaving in sepsis. They should also be educated about adverse effects and signs and symptoms that they should share with providers. Hospital antibiotic stewardship programs can increase infection cure rates while reducing (7-9): In Antibiotic Resistance Threats in the United States, 2019 ,CDC estimates that more than 2.8 million antibiotic-resistant infections occur in the United States each year, and more than 35,000 people die as a result. Monitoring resistance at the patient level (i.e. Optimizing the duration of treatment to ensure compliance with guidelines. The local or state health departments healthcare infection control and antibiotic resistance program is also an important resource for local information on antibiotic resistant threats (93). Nurses may be able to play an important role in improving penicillin allergy assessments (27). Improving antibiotic use is important to reduce antibiotic resistance and presents another option for measurement. C. difficile infection: Treatment guidelines recommend providers stop unnecessary antibiotics in all patients diagnosed withC. difficile infection. In 2014, CDC called on all hospitals in the United States to implement antibiotic stewardship programs and released the Core Elements of Hospital Antibiotic Stewardship Programs (Core Elements) to help hospitals achieve this goal. To further support the implementation of the Core Elements, CDC has: Partners across the country are using the Core Elements to guide antibiotic stewardship efforts in hospital settings. In 2019, CDC updated the hospital Core Elements to reflect both lessons learned from five years of experience as well as new evidence from the field of antibiotic stewardship. The NHSN AU Option is available to hospitals that have information system capability to submit electronic medication administration records (eMAR) and/or bar-coding medication administration records (BCMA) using an HL7 standardized clinical document architecture (20). Effective leadership, management and communication skills are essential for the leaders of a hospital antibiotic stewardship program (30). Two studies have compared these two interventions directly and found prospective audit and feedback to be more effective than preauthorization (42,44). This Core Element was renamed Pharmacy Expertise to reflect the importance of pharmacy engagement for leading implementation efforts to improve antibiotic use. Financial Impact. community acquired pneumonia), urinary tract infection and skin and soft tissue infection (45). Supporting enrollment in and reporting to the. New CDC data states more than half of antibiotic prescribing for selected events in hospitals was not consistent with recommended prescribing practices. Sharing facility-specific information on antibiotic use is a tool to motivate improved prescribing, particularly if wide variations in the patterns of use exist among similar patient care locations (94). Giving stewardship program leader(s) time to manage the program and conduct daily stewardship interventions. Implementation of antibiotic stewardship programs requires flexibility due to the complexity of medical decision-making surrounding antibiotic use and the variability in the size and types of care among U.S. hospitals. Does this patient have an infection that will respond to antibiotics? Antibiotic prescribing was not supported in: 79% of patients with community-acquired pneumonia, 77% of patients with urinary tract infections, 47% of patients prescribed fluroquinolone treatment, and 27% of patients prescribed intravenous vancomycin antibiotic. imaging, procalcitonin). Guide the proper use of tests and the flow of results as part of diagnostic stewardship (. United States guidelines recommend the use of days of therapy rather than DDDs as the preferred numerator metric for hospital antibiotic use (16). This can be especially effective when the feedback is provided in person, for example through handshake stewardship. CDC will continue to use a variety of data sources, including the NHSN annual survey of hospital stewardship practices and AU Option, to find ways to optimize hospital antibiotic stewardship programs and practices. Review of planned outpatient parenteral antibiotic therapy (OPAT): In some cases, OPAT can be optimized or even avoided altogether following a review by the antibiotic stewardship program (65). The Core Elements of Hospital Antibiotic Stewardship Programs, 2019 pdf icon[PDF 40 pages], Antibiotic Stewardship Program Assessment Tool (Print Only) pdf icon[PDF 8 pages], New CDC data states more than half of antibiotic prescribing for selected events in hospitals was not consistent with recommended prescribing practices. Prospective audit and feedback is different from an antibiotic timeout because the stewardship program rather than the treating team conducts the audits. However, less than 1% of the US population has a serious penicillin allergy that would preclude treatment with a beta lactam antibiotic (69). Reporting stewardship activities and outcomes (including key success stories) to senior leadership and the hospital board on a regular basis (e.g. Appointing a senior executive leader to serve as a point of contact or champion for the stewardship program to help ensure that the program has resources and support to accomplish its mission. Findings from medication use evaluations along with summaries of key issues that arise during prospective audit and feedback reviews and preauthorization requests can be especially useful to share with prescribers. Use the shortest duration of antibiotic therapy that is clinically appropriate. Tracking: Monitor antibiotic prescribing, impact of interventions, and other important outcomes like C. difficile infection and resistance patterns. Avoid antibiotic therapy for asymptomatic bacteriuria except in certain clinical situations where treatment is indicated, such as for pregnant women and those undergoing an invasive genitourinary procedure. Develop diagnostic criteria to distinguish purulent and non-purulent infections and severity of illness (i.e., mild, moderate and severe) so that skin and soft tissue infections can be managed appropriately according to guidelines. More than half of all antibiotics given to treat active infections in hospitals are prescribed for three infections where there are important opportunities to improve use: lower respiratory tract infection (e.g. Optimizing testing, or diagnostic stewardship. Reviewing antibiotics in patients with new diagnoses ofC. difficile infection can identify opportunities to stop unnecessary antibiotics, which improves the clinical response of these infections to treatment and reduces the risk of recurrence (61-63). Expanding these rounds to include discussions with prescribers (also called handshake stewardship) has been shown to improve antibiotic use and is an effective way to enhance the visibility and support of the stewardship program (31, 32). This document details the methodology for the Simple Pneumonia with Hospitalization measure and should be reviewed along with the Simple Pneumonia with Hospitalization Measure Codes List file, which contains the medical codes used in constructing the measure. Regular stewardship rounds for the co-leaders, or the non-physician lead and the supporting physician can strengthen program leadership. Measurement of antibiotic stewardship interventions may involve evaluation of both processes and outcomes. Stewardship programs can work with their information technology staff to explore options for reporting data to the AU Option. Guide discussions on the potential implementation of rapid diagnostic tests and new antibacterial susceptibility test interpretive criteria (e.g., antibiotic breakpoints) that might impact antibiotic use. They should be engaged in developing educational materials and educating patients about appropriate antibiotic use. It is important for hospitals to monitor and benchmark antibiotic use by electronically reporting to the National Healthcare Safety Network (NHSN) Antimicrobial Use (AU) Option. Skin and soft tissue infection:Interventions have focused on ensuring patients with uncomplicated infections do not receive antibiotics with overly broad spectra (e.g. However, it is important to continue support for stewardship programs since costs can increase if programs are terminated (17). Decisions on which antibiotics to place under preauthorization should be made in consultation with providers to focus on opportunities to improve empiric use, rather than on drug costs (43). Developing antibiotic recommendations for sepsis that are based on local microbiology data. Culture proven invasive infection:Invasive infections (e.g. Making formal statements of support for efforts to improve and monitor antibiotic use. Priority examples of hospital leadership commitment emphasize the necessity of antibiotic stewardship programs leadership having dedicated time and resources to operate the program effectively, along with ensuring that program leadership has regularly scheduled opportunities to report stewardship activities, resources and outcomes to senior executives and hospital board. Antibiotic resistance information should be prepared in collaboration with the hospitals microbiology lab and infection control and healthcare epidemiology department. Patients should be alerted to side effects that may occur after they have been discharged and even after they have stopped taking antibiotics. Hospitalists have also proven to be effective physician leaders or supporters for efforts to improve antibiotic use, especially in smaller hospitals, given their increasing presence in inpatient care, the frequency with which they use antibiotics and their experience with leading hospital quality improvement projects (21, 22). Hospital prescribers and pharmacists can improve antibiotic prescribing by optimizing antibiotic selection, re-assessing antibiotic treatment when the results of diagnostic testing are available, and using the shortest effective duration of therapy. Optimizing the use of antibiotics is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance. Programs with co-leaders should have a clear delineation of responsibilities and expectations. Payment standardized costs remove the effect of differences in Medicare payment among health care providers that are the result of differences in regional health care provider expenses measured by hospital wage indexes and geographic price cost indexes (GPCIs) or other payment adjustments such as those for teaching hospitals. Staffing suggestions for hospital antibiotic stewardship programs are available from the Veterans Administration (. Saving Lives, Protecting People. 
blood stream infections) present opportunities for interventions to improve antibiotic use because they are easily identified from microbiology results and sub-optimal therapy often leads to worse outcomes. They can also support reporting to the NHSN AUR Module by updating monthly reporting plans, adding AUR users, and assisting with data upload. The development of treatment guidelines is a good way for the stewardship program to engage prescriber stakeholders to develop consensus on antibiotic use. Improving the evaluation of penicillin allergies. It can also prevent unnecessary initiation of antibiotics (42). The 2019 update has additional examples of hospital leadership, and the examples are stratified by priority and other. They are both strongly recommended in evidenced-based guidelines and can be considered foundational interventions for hospital stewardship programs. Other examples of leadership commitment include: Hospital leadership can help ensure that other groups and departments in the hospital are aware of stewardship efforts and collaborate with the stewardship program. Guidelines suggest that in adults, most cases of uncomplicated pneumonia can be treated for 5 days when a patient has a timely clinical response (, Implement criteria for ordering urine cultures to ensure that positive cultures are more likely to represent infection than bladder colonization (. The measure score is the clinicians risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. They also often have experience with quality improvement work (21, 22). Some hospitals review de-identified cases with providers to help identify changes in antibiotic therapy that could have been made. This can help optimize initial empiric therapy because it allows for expert input on antibiotic selection and dosing, which can be lifesaving in serious infections, like sepsis. The misuse of antibiotics has also contributed to antibiotic resistance, a serious threat to public health (5). Recover it here, 2022 MIPS Promoting Interoperability Measures, MIPS Feedback Reports and Payment Adjustments. The misuse of antibiotics can adversely impact the health of patients who are not even exposed to them through the spread of resistant organisms and Clostridioides difficile (C. difficile) (6). The Simple Pneumonia with Hospitalization cost measure uses the following data sources: Methodologically, the Simple Pneumonia with Hospitalization cost measure can be triggered based on claims data from acute inpatient (IP) hospitals. unnecessary coverage for methicillin-resistantStaphylococcus aureus(MRSA) and gram-negative pathogens) and prescribing the correct route, dosage and duration of treatment (52, 53). MIPS Participation - Do I have to Report MIPS 2022? Whats New in the Core Elements of Hospital Antibiotic Stewardship Programs, 2019 [Video 5:24]. Ensuring protocols are in place to administer antibiotics quickly in cases of suspected sepsis. Highly effective hospital antibiotic stewardship programs have strong engagement of pharmacists, either as a leader or co-leader of the program (36, 37). attendance of stewardship training courses and meetings) and hospital staff. Prompt initiation of antibiotics to treat infections reduces morbidity and save lives, for example, in cases of sepsis (1). emergency department and observation units), and for the entire hospital. Antibiotic prescribing was not supported in: 79% of patients with community-acquired pneumonia, 77% of patients with urinary tract infections, 47% of patients prescribed fluroquinolone treatment, and 27% of patients prescribed intravenous vancomycin antibiotic. The Core Elements are intended to be an adaptable framework that hospitals can use to guide efforts to improve antibiotic prescribing. Priority interventions include prospective audit and feedback, preauthorization, and facility-specific treatment recommendations. There are also a variety of educational materials on hospital antibiotic use and stewardship available from the Agency for Healthcare Research and Qualitys Safety Program for Improving Antibiotic Use (97). Patient education is also an important focus for antibiotic stewardship programs. Find resources on how to improve hospital antibiotic use and help fight antibiotic resistance: Implementation Resources, Assessment of the Appropriateness of Antimicrobial Use in US Hospitalsexternal icon, 2020 Antimicrobial Use Option Data Report November 2021 pdf icon[PDF 13 pgs], 2020 Antimicrobial Use Option Report Data Tables November 2021 excel icon[XLS 331 KB]. CDCs national campaign, Be Antibiotics Aware, helps healthcare providers educate their patients about appropriate antibiotic use. misericordia incorporating stewardship into order sets and clinical pathways). Enrolling hospitals in the NHSN AU Option was a priority goal set forth in the National Strategy for Combating Antibiotic-Resistant Bacteria and by the Presidents Advisory Committee on Combating Antibiotic Resistant Bacteria (79). preauthorization through an electronic order entry system) to implement preauthorization based on program goals, available expertise, and resources in a way that does not delay therapy for serious infections. Pneumonia is a leading infectious cause of hospitalization and death among adults in the United States, and community-acquired pneumonia (CAP), which is akin to the patient population in the Simple Pneumonia with Hospitalization measure, is a major driver of Medicare morbidity and mortality rates. Prospective audit and feedback of new culture or rapid diagnostic results may be particularly beneficial to reduce the time needed to discontinue, narrow, or broaden antibiotic therapy as appropriate. Microbiology labs and stewardship programs can work together to optimize the use of such tests and the communication of results. Hospitals can also track antibiotic resistance though the NHSN Antimicrobial Resistance (AR) Option (20). Having regular meetings with leaders of the stewardship program to assess the resources needed to accomplish the hospitals goals for improving antibiotic use. Tracking the types and acceptance of recommendations from prospective audit and feedback interventions, which can identify areas where more education or additional focused interventions might be useful. Building upon the hospital Core Elements framework, CDC also developed guides for other healthcare settings: CDC has also published an implementation guide for the Core Elements in small and critical access hospitals, Implementation of Antibiotic Stewardship Core Elements in Small and Critical Access Hospitals (12). There are many options for providing education on antibiotic use such as didactic presentations, which can be done in formal and informal settings, messaging through posters, flyers and newsletters, or electronic communication to staff groups.
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