Community hospitals' antibiotic stewardship challenge: 4 thoughts from Intermountain's stewardship director

A recent study conducted by researchers from Intermountain Medical Center and the University of Utah School of Medicine, both in Salt Lake City, found the rates of antibiotic use in community hospitals to be on par with academic medical centers, even though the smaller hospitals tend to treat less complex patients.

In addition to the comparable rates of antibiotic use, most community hospitals examined in the study did not have antibiotic stewardship programs.

Eddie Stenehjem, MD, the antibiotic stewardship medical director with Intermountain Medical Center and the lead author of the study, recently took time to answer some questions on antibiotic stewardship in community hospitals via email.

Note: Responses have been lightly edited for length and clarity.

Question: What are the biggest challenges hindering the development of antibiotic stewardship programs in small community hospitals?

Dr. Eddie Stenenhjem: There are approximately 3,600 hospitals in the United States that have less than 200 beds, and the majority of those hospitals do not have antibiotic stewardship programs. However, all of those hospitals are required to have such programs in place by January 2017 to be in compliance with new Joint Commission and expected CMS guidelines.

The three biggest challenges those small community hospitals face are:

• Lack of trained infectious disease physicians and pharmacists to lead such programs
• Lack of a robust IT network that allows tracking of antibiotic use and resistance
• Lack of administrative support willing to allocate funding and resources for the development of these programs

Q: How can the infectious disease community do more to improve stewardship in small community hospitals?

ES: With so many hospitals in need of antibiotic stewardship programs, it is going to be a challenge. The possible solution lies in the development of new models that amplify the ability to reach the facilities in need.

One model that works here at Intermountain Healthcare is the centralization of these elements. We have a robust team of infectious disease physicians and pharmacists at Intermountain Medical Center that routinely consult with physicians at other smaller hospitals throughout our healthcare system via our TeleHealth program. This team also mentors the smaller hospitals in setting up their stewardship programs. We provide them the tools and data and support their efforts in an advisory role.

Other health systems are joining together with neighboring health systems to collaborate on antibiotic stewardship programs, thus sharing in the resources needed to effectively address antibiotic misuse.

Q: What are the dangers if this problem goes unresolved?

ES: Antibiotics have been misused for so many years that we are quickly approaching a post-antibiotic era. By working together to address the issue, we can improve our ability to fight life-threatening diseases like Clostridium difficile, reduce the number of superbugs that are immune to antibiotics, improve patient safety, reduce healthcare costs and improve overall quality in healthcare.

The CDC has been very keen on promoting antibiotic stewardship programs because letting it go unchecked is a major public health issue and threatens patient safety.

Q: What strategies/resources can small community hospitals take advantage of now to improve stewardship?

ES: There are a lot of things that have been done in terms of stewardship playbooks. For example, the CDC has put out their playbook and has the Core Elements of Hospital Antibiotic Stewardship Programs. I recently presented the results of a cluster-randomized controlled trial that examined the impact of antibiotic stewardship in 15 small community hospitals. The results: The hospitals assigned to higher levels of antibiotic stewardship programs saw a total reduction in the types of antibiotics used, along with the totals of prescriptions written for antibiotics.

Other organizations have resources and online trainings available, too:
• The National Quality Forum's playbook: Antibiotic Stewardship in Acute Care
• Stanford University's online class: Antimicrobial Stewardship: Optimization of Antibiotic Practices
• The PEW Charitable Trust's playbook: A Path to Better Antibiotic Stewardship in Inpatient Settings

Organizations like the Infectious Disease Society of America and the Society for Healthcare Epidemiology of America also provide training and resources at their conferences.

More articles on antibiotic stewardship:
Drug-resistant infections on the rise among US children  
Education essential to effective antibiotic stewardship 
Physicians prescribe wrong antibiotic half of the time

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