What Antimicrobial Stewardship Interventions Are We Focusing on? The Experience of a Large Healthcare System

Background:  The CDC core elements for inpatient antimicrobial stewardship (AS) programs recommend implementing at least one intervention to improve antimicrobial use. As part of a health system’s effort, all hospital AS programs were asked to implement two interventions at their facility to improve antimicrobial use. 

Methods: Each hospital AS team chose interventions based on perceived local needs and available resources and expertise.  The intervention recommendations were grouped into 5 main categories: prospective monitoring of broad spectrum gram-negative agents, prospective monitoring of anti-Methicillin-resistant Staphylococcus aureus (MRSA) agents, order set standardization for Infectious Diseases treatment, order set standardization of surgical antimicrobial prophylaxis, and establishing appropriate indications for all antimicrobials.  We compared the results for all facilities, as well as based on hospital bed size (small <100 beds, medium 100-300 beds, large >300 beds).

Results:  Of 108 hospitals, 50 (46.3%) were small, 30 (27.8%) medium, and 28 (25.9%) large. Prospective monitoring of broad-spectrum, anti-gram-negative agents was implemented in the vast majority of hospitals (n=92, 85%), followed by prospective monitoring of anti-MRSA agents (n= 67, 62%), order set standardization for Infectious Diseases treatment (n= 30, 28%), order set standardization for surgical site infection prophylaxis (n= 27, 25%), and establishing appropriate indications for all antimicrobials (n= 2, 2%). Small hospitals focused more on prospective monitoring of gram-negative antimicrobials and anti-MRSA agents; medium-sized hospitals chose, more than others, to address order set standardization for Infectious Diseases treatment; large hospitals evaluated antibiotics used for surgical prophylaxis more often (Figure).

Conclusion: The focused interventions to improve antimicrobial use varied slightly based on institutional size. Our findings indicate that prospective monitoring of antimicrobials covering broad-spectrum, gram-negative organisms, and anti-MRSA agents are highest priority initiatives for all hospitals regardless of size.