Antibiotic stewardship programs (ASPs) improve antibiotic prescribing. Seventy-three percent of US hospitals have <200 beds. Small hospitals (<200 beds) have similar rates of antibiotic prescribing compared to large hospitals, but the majority of small hospitals lack ASPs that satisfy the Centers for Disease Control and Prevention’s core elements. All hospitals, regardless of size, are now required to have ASPs by The Joint Commission, and the Centers for Medicare and Medicaid Services has proposed a similar requirement. Very few studies have described the successful implementation of ASPs in small hospitals. We describe barriers commonly encountered in small hospitals when constructing an antibiotic stewardship team, obtaining appropriate metrics of antibiotic prescribing, implementing antibiotic stewardship interventions, obtaining financial resources, and utilizing the microbiology laboratory. We propose potential solutions that tailor stewardship activities to the needs of the facility and the resources typically available.
Constructing the Antibiotic Stewardship Team
ID Physician and Pharmacy Leadership
1. Part-time ID support and pooling resources
2. Utilize healthcare system resources to provide antibiotic stewardship and ID support
3. Taking advantage of state-based efforts and collaboratives
4. Commercial Telehealth Support
Utilizing non-ID trained physicians and pharmacists
When no ID physician or pharmacist is available, as is almost always the case in CAHs, hospitalists and general pharmacists can effectively lead ASPs...
Allies to the Antibiotic Stewardship Team
Robust antibiotic stewardship teams often include representation from infection prevention, hospital administration, quality improvement, microbiology, information technology (IT), and nursing....
Measurement - Data Collection and Analysis
A complete discussion of the types of quality measures available for ASPs is outside the scope of this review but many excellent reviews are available.....
Days of therapy (DOT) per 1,000 patient days present has become the US’s antibiotic consumption metric of choice.....
Once a facility has developed an ASP, it must then decide on where best to focus efforts to improve antibiotic prescribing. A point prevalence survey and an antibiotic appropriateness evaluation can be accomplished in small hospitals and help guide efforts. A point prevalence survey assesses all patients on an antibiotic on a certain day or during a specific time interval. CAHs may need to assess antibiotic use for an entire month to obtain an appropriate sample. Patients on antibiotics are assessed for indication, antibiotic type, and route of delivery. In conjunction with the point prevalence survey, the ASP can assess for antibiotic prescribing appropriateness. The CDC has developed appropriateness surveys that can be used for specific antibiotics or specific syndromes.
Once an improvement opportunity has been identified, the intervention must be operationalized and integrated into clinical care. The type and scope of the intervention should be driven by the expertise and resources of the ASP. Basic interventions to improve antibiotic prescribing principles can be implemented in any hospital regardless of ID expertise availability. Creating clinical algorithms for common syndromes requiring antibiotics will typically direct prescribing for the majority of patients. Implementing an antibiotic time-out to reassess the continuing need and choice of antibiotics can be can be integrated into pharmacy or physician work flow, nursing, or care coordination conferences. Developing basic antibiotic education for providers can emphasize clinical algorithms, common errors in antibiotic prescribing, and clinical updates. Requiring every antibiotic order to have an indication will allow pharmacy staff to optimize drug selection and dose. Integrating principles of antibiotic stewardship into other quality improvement efforts will increase the scope of ASPs in small hospitals (e.g., improving compliance with sepsis measures).
Advanced stewardship interventions often require ID expertise and/or significant time and training. Implementing a post-prescription review system allows for a daily assessment of prescribing appropriateness, the intensity of which can be adjusted based on staffing at individual facilities. Restricting designated antibiotics, either by not having certain antibiotics on the formulary or by requiring approval from a member of the ASP, can be used to guide prescribers to make appropriate empiric antibiotic choices. Reviewing designated microbiology culture results and laboratory testing can be done as a patient safety measure to ensure an appropriate treatment plan is in place. Daily review of positive blood cultures should receive the highest priority. These reviews can be completed by any member of the ASP team, including IPs, and results flagged for review by the local physician champion.
To be successful, ASPs need clear support from hospital leadership. This support can come in many forms but dedicating the necessary human, financial, and/or IT resources is paramount......
An up-to-date antibiogram is essential for developing pre-prescription review policies, hospital specific guidelines, and in understanding local resistance patterns.....
ASPs are just as critical in small hospitals as they are in large hospitals, but there are unique challenges small hospitals face in in implementing ASPs. Utilizing a collaborative approach and tailoring ASPs activities to the needs of the facility and the resources available can lead to successful programs.