1692. Stewardship in Community Hospitals – Optimizing Outcomes and Resources (SCORE): A Cluster-Randomized Controlled Trial Investigating the Impact of Antibiotic Stewardship in 15 Small, Community Hospitals
Session: Oral Abstract Session: SHEA Featured Oral Abstract
Friday, October 28, 2016: 4:15 PM
Room: La Nouvelle Orleans Ballroom


Small, community hospitals (SCH, < 200 beds) account for almost ¾ of US hospitals; most do not have antibiotic stewardship programs (ASPs).  Forthcoming federal regulations will require all SCHs to have ASPs.  Our objective was to compare the impact of 3 types of ASPs in a network of SCHs. 


Intermountain Healthcare has 15 SCHs within its network, all of which lacked ASPs prior to the study.   The 15 SCHs were randomized to 1 of 3 ASPs (table) with increasing infectious diseases (ID) support from a tertiary referral center.  Antibiotic use data was obtained via the NHSN AU option.  Adjusted antibiotic use rate ratios (RR) between the intervention period (15 mo) and the baseline (31 mo) trend were compared between Programs 2 and 3 vs. Program 1 (reference group) using negative binomial segmented regression. We used fixed effects models to draw conclusions for the 15 studied SCHs and mixed models with random hospital effects for generalizable inferences concerning the 3 ASPs.   


Adjusted RRs comparing intervention antibiotic use to baseline are shown in figure 1 (all antibiotics) and figure 2 (broad spectrum antibiotics).  Under fixed effects models, Program 2 SCHs did not significantly reduce total antibiotic use (RR 0.96, [0.83, 1.10]) while Program 3 SCHs reduced total use by 17% (RR 0.83 [0.72, 0.95]) compared to Program 1 SCHs.  Program 2 and 3 SCHs reduced broad spectrum use by 31% (RR 0.69 [0.53, 0.91]) and 27% (RR 0.73 [0.56, 0.95]), respectively, compared to  Program 1 SCHs. Similar trends but with wider confidence intervals including the null hypothesis were obtained under mixed models.


Within Intermountain hospitals, the 5 hospitals assigned to the Program 3 stewardship model exhibited reduced total and broad spectrum antibiotic use; whereas, the 5 Program 2 hospitals demonstrated only reduced broad spectrum use compared to Program 1 hospitals. 

Table:  ASPs in the SCORE study

Program 1

Program 2


Program 3


Antibiotic utilization report

48 hour antibiotic timeout

IV to PO conversion

Antibiotic indications

Access to ID phone consultation


Limited prospective audit and feedback

Expanded prospective audit and feedback


Antibiotic restrictions - local approval

Antibiotic restrictions - ID approval



ID physician review of culture results

Figure 1

Figure 2

Edward Stenehjem, MD, MSc1, Adam L. Hersh, MD, PhD2, Whitney R. Buckel, PharmD, BCPS3, Peter S. Jones, MSLS4, Xiaoming Sheng, PhD5, Josh Caraccio, PharmD6, Dustin Waters, PharmD, BCPS-AQ ID7, Jared Olson, PharmD8, Emily Thorell, MD, MSCI9, James Lloyd, BS10, R Evans, PhD10, Kristin Dascomb, MD, PhD11, Brandon Webb, MD12, John P. Burke, MD, FIDSA, FSHEA13, Bert K. Lopansri, MD4, Rajendu Srivastava, MD, MPH10, Tom Greene, PhD5 and Andrew Pavia, MD, FIDSA, FSHEA, FPIDS9, (1)Division of Infectious Diseases, Intermountain Medical Center, Murray, UT, (2)University of Utah School of Medicine, Salt Lake City, UT, (3)Infectious Diseases/Antimicrobial Stewardship, Intermountain Medical Center, Murray, UT, (4)Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, UT, (5)Medicine, University of Utah School of Medicine, Division of Epidemiology, Salt Lake City, UT, (6)Utah Valley Regional Medical Center, Provo, UT, (7)Pharmacy, Intermountain Healthcare McKay-Dee Hospital Center, Ogden, UT, (8)Primary Children's Hospital, Salt Lake City, UT, (9)Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, (10)Intermountain Healthcare, Salt Lake City, UT, (11)Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, (12)Clinical Epidemiology and Infectious Disease, Intermountain Healthcare, Murray, UT, (13)LDS Hospital, Salt Lake City, UT


E. Stenehjem, None

A. L. Hersh, Merck: Grant Investigator , Research grant

W. R. Buckel, None

P. S. Jones, None

X. Sheng, None

J. Caraccio, None

D. Waters, None

J. Olson, None

E. Thorell, None

J. Lloyd, None

R. Evans, None

K. Dascomb, None

B. Webb, None

J. P. Burke, None

B. K. Lopansri, None

R. Srivastava, None

T. Greene, None

A. Pavia, None

Findings in the abstracts are embargoed until 12:01 a.m. CDT, Wednesday Oct. 26th with the exception of research findings presented at the IDWeek press conferences.