What are the expectations for a hospital's antibiotic stewardship program?

Organizational Support (EP 10)
Dedicating the financial resources necessary for staffing and information technology to support the antibiotic stewardship program is essential to demonstrate the hospital's commitment to improving antibiotic prescribing practices. Hospital leaders should be prepared to discuss how antibiotic stewardship has been established as a patient safety priority, and the resources that have been allocated to the antibiotic stewardship program to support its activities. 

Program Leadership (EPs 11, 12)
Qualifications: Hospitals are required to appoint a physician and/or pharmacist who is qualified through education, training, or experience in infectious diseases and/or antibiotic stewardship as the leader(s) of the program. Organizations may determine whether to appoint a physician or pharmacist to lead the antibiotic stewardship program, or to have a physician and pharmacist co-lead the program, depending on the organization's size, structure, and complexity. The antibiotic stewardship program leader(s) may be assigned at the corporate or system level, as long as the leader is able to coordinate and implement antibiotic stewardship activities at each location. While documentation of the governing body's appointment of the antibiotic stewardship program leader(s) is not required, hospitals are expected to discuss how the governing body is involved in decisions about the program's leader(s).

Responsibilities: The appointed leader(s) of the program is responsible for the development and implementation of a hospital-wide antibiotic stewardship program that is based on national recognized guidelines. The program leader(s) is also responsible for documenting antibiotic stewardship activities, communicating and collaborating with individuals across the organization on antibiotic use issues, and providing competency-based training and education for staff. These expectations align with the Centers for Medicare and Medicaid Services Conditions of Participation for antibiotic stewardship (see §482.42 for hospitals and §485.640 for critical access hospitals for additional information).

When developing competency-based training and education for staff, it is important to note that The Joint Commission describes competency as a combination of observable and measurable knowledge, skills, and abilities. Competence assessment lets the hospital know whether its staff have the ability to use specific skills and to employ the knowledge necessary to perform their jobs. Organizations have the flexibility to define the competencies associated with the practical applications of their antibiotic stewardship guidelines, policies, and procedures. Examples of competency-based training and education may include a combination of observable and measurable methods, such as use of a written test or demonstrate accurate completion of procedure/process. The competency-based training and education should be provided to staff with responsibilities related to antibiotic stewardship. 

Multidisciplinary Committee (EP 13)
It is important for hospitals to establish a multidisciplinary committee to oversee the antibiotic stewardship program. The composition of the committee is determined by the hospital and may include part-time or consultant staff that are on site or they may participate in committee activities remotely. Examples of committee representation may include medical staff, pharmacy services, the infection prevention and control program, nursing services, microbiology, information technology, and the quality assessment and performance improvement program. 

Program Coordination (EPs 14, 15)
The antibiotic stewardship program is expected to have a process in place that demonstrates coordination among all components of the hospital responsible for antibiotic use and resistance including, but not limited to, the infection prevention and control program the quality assessment and performance improvement program, the medical staff, nursing services, and pharmacy services. Additionally, the antibiotic stewardship program is responsible for documenting the evidence-based use of antibiotics in all departments and services of the hospital. The goal of this requirement is for the antibiotic stewardship program to document that all departments and services of the hospital are using antibiotics in a manner supported by evidence as determined by the hospital. Hospitals should be prepared to verify that the hospital's antibiotic use is consistent with the documented evidence-based antibiotic stewardship program recommendations. These expectations align with the Centers for Medicare and Medicaid Services Conditions of Participation for antibiotic stewardship (see §482.42 for hospitals and §485.640 for critical access hospitals for additional information).

Monitor Antibiotic Use (EP 16)
Measuring the hospital's antibiotic use is a critical first step to identifying improvement opportunities for antibiotic prescribing and can also help an organization determine whether its antibiotic stewardship activities are effective. Hospitals may monitor antibiotic use by analyzing days of therapy per 1000 days present or 1000 patient days or by reporting to the National Healthcare Safety Network Antimicrobial Use Option. While hospitals are encouraged to electronically submit data to the NHSN AU option so that they may benchmark their rates comparatively to national data, it is not required. For hospitals contracting with external pharmacy management organizations that may be unable to calculate days of therapy directly, an estimated metric for days of therapy may be used to identify opportunities to improve antibiotic prescribing practices.

Optimize Prescribing (EP 17)
The antibiotic stewardship program is required to implement strategies to optimize antibiotic prescribing practices. Organizations may determine how the strategies are implemented based on the antibiotic stewardship program's expertise and the organization's complexity. Organizations may choose to implement preauthorization for specific antibiotics that includes an internal review and approval process prior to use. Alternatively, organizations may implement prospective review and feedback regarding antibiotic prescribing practices, including the treatment of positive blood cultures. While the prospective review must be performed by a member of the antibiotic stewardship team, organizations should consider multiple pharmacists on the antibiotic stewardship team to minimize potential delays in patient care.

Implement Evidence-Based Guidelines (EPs 18, 19)
Hospitals are required to implement at least two evidence-based guidelines to improve antibiotic use for the most common indications. The two evidence-based guidelines implemented may be selected by the organization based on national guidelines and must also reflect local susceptibilities, formulary options, and the patient population served. Examples include, but are not limited to, community-acquired pneumonia, urinary tract infections, skin and soft tissue infections, Clostridioides difficile colitis, asymptomatic bacteriuria, plan for parenteral to oral antibiotic conversion, or use of surgical prophylactic antibiotics. Hospitals should be prepared to discuss how the evidence-based guidelines were selected and implemented.

The antibiotic stewardship program is required to evaluate adherence (including antibiotic selection, and duration of therapy, where applicable) to at least one of the evidence-based guidelines the hospital implements. Hospitals may measure adherence using a variety of methods, depending on the data and information technology resources available to the antibiotic stewardship program team. Organizations may evaluate adherence data at the group level (i.e., department, unit, clinician subgroup) or at the individual prescriber level. Adherence data may be obtained for a sample of patients from relevant clinical areas by analyzing the electronic health records or through chart review. 

Data Collection and Reporting (EP 20)
It is critical to collect, analyze, and report data about the antibiotic stewardship program to hospital leadership and prescribers. Antibiotic stewardship program data may include antibiotic resistance patterns, antibiotic prescribing practices, or an evaluation of the antibiotic stewardship program's activities. Reporting antibiotic stewardship program data to hospital leadership and prescribers allows organizations to review the program's activities and its impact on prescribing practices. 

Performance Improvement (EP 21)
When the antibiotic stewardship program identifies improvement opportunities, the hospital develops an action plan. The hospital should be prepared to discuss the actions taken to improve antibiotic prescribing practices. 

Additional Resources
Perspectives Newsletter July 2022  Volume 42  Number 7
Requirement, Rationale, Reference  (R3) Report