ID RC Antimicrobial Stewardship Workbook 2022 FINAL T229141

ANTIMICROBIAL STEWARDSHIP
Jessica Robinson, Pharm.D., BCPS, BCIDP

Associate Professor
University of Charleston School of Pharmacy
Associate Director, Antimicrobial Stewardship
Charleston Area Medical Center
Charleston, WV
LEARNING OBJECTIVES:
At the end of the presentation and after reviewing the accompanying reading materials, the participant
should be able to:
1. Outline components of an effective stewardship program.

2. Select appropriate resources; relevant accreditation, legal, regulatory, and safety requirements;
and quality metrics related to infectious diseases.
3. Evaluate institutional treatment policies and pathways for compliance with antimicrobial
stewardship guidelines, surveillance data, and best available evidence.
4. Assess the effectiveness of infection prevention strategies.
5. Identify metrics for evaluating the value of infectious diseases pharmacy services.
©2022 American Society of Health-System Pharmacists, Inc. and American College of Clinical Pharmacy. All rights reserved. 1
SELF-ASSESSMENT QUESTIONS
Answer key is provided at the end of this chapter.
1. The establishment of an antimicrobial stewardship program in the outpatient setting is required by which
organization?
a. The Joint Commission (TJC)
b. Centers for Medicare and Medicaid Services (CMS)
c. National Healthcare Safety Network (NHSN)
d. The Leapfrog Group
2. Which of the following is a category of stewardship activities recognized in the Infectious Diseases Society of
America (IDSA) stewardship guidelines?
a. Antibiotic time-outs
b. Antibiotic de-escalation
c. Antibiotic metrics
d. Collaboration with infection prevention
3. Which of the following is NOT a limitation of developing a whole-hospital antibiogram based on CLSI M39
documents recommendations?
a. The ability to influence empiric therapy
b. The ability to evaluate E. coli resistance rates for isolates from urinary sources
c. The ability to evaluate antibiotic susceptibilities of combination therapy (i.e., combination

antibiogram)
d. The ability to track development of resistance
4. The stewardship program at your institution implements a guideline for procalcitonin testing and associated
antibiotic modifications. This type of stewardship activity is classified by the IDSA as:
a. Antibiotic intervention
b. Collaboration with laboratory
c. Antibiotic optimization
d. Special populations
5. Which organization is responsible for maintaining and updating definitions and methods for determining
Defined Daily Doses (DDD)?
a. The Centers for Disease Control and Prevention (CDC)
b. The Centers for Medicare and Medicaid Services (CMS)
c. The World Health Organization (WHO)
d. The Joint Commission (TJC)
STEWARDSHIP GUIDELINES
SEGMENT 1
Patient Case #1
TT is a 78-year-old male who presented to the ED with acute productive cough, chest pain, and shortness of
breath.
o PMH: Discharged 2 weeks ago following deep vein thrombosis diagnosis
o Allergies: Penicillin allergy (type of reaction is unknown)
o Vitals: RR 26 breaths/min, T 101.2 °F, HR 88 beats/min, O2 sat 86%
o PE: Notable for rales in right lower lung (RLL)
o Imaging: CXR with infiltrate in right lower lobe
o SH: resides in rehab facility since last hospital admission
Question 1: What stewardship intervention is strongly recommended by the IDSA/SHEA for guiding appropriate
therapy for this patient?
A. Use pre-authorization or prospective audit and feedback of antibiotic therapy.
B. Develop an institutional clinical practice guideline for treatment of pneumonia.
C. Develop computerized decision support alerts promoting appropriate antibiotic selection.
D. Provide didactic education to ED personnel detailing appropriate antibiotic management of
pneumonia.
I. IDSA/SHEA stewardship guidelines1
A. Categorized stewardship activities in 5 main categories:
1. Antimicrobial interventions
2. Antimicrobial optimization
3. Metrics
4. Collaboration with microbiology
5. Special populations
B. Each category has activities that are graded as strong recommendations, weak recommendations, or
good practice recommendations (see tables below)
Table 1: IDSA/SHEA Recommended Methods for Performing Stewardship Interventions1

Recommendation Strength of Recommendation
Preauthorization or prospective audit and feedback Strong
Reduce use of high-risk Clostridioides difficile antibiotics Strong
Didactic education Weak
Institutional clinical practice guidelines Weak
Syndrome-specific intervention Weak
Prescriber-led review of antibiotics Weak
Computerized decision support systems Weak
Antibiotic cycling Weak
Patient Case #1, continued:
Patient is started on:
o Cefepime 2 g IV every 8 hours
o Azithromycin 500 mg IV every 24 hours
o Tobramycin 180 mg IV every 12 hours
o Vancomycin 1.25 g every 24 hours
Question 2: Which stewardship interventions are strongly recommended by the IDSA/SHEA to optimize TT’s
antimicrobial regimen?
A. Recommend 7 days of antibiotic therapy and perform vancomycin therapeutic drug monitoring.
B. Change the azithromycin from IV to PO when clinically stable and perform tobramycin therapeutic drug
monitoring.
C. Perform penicillin skin testing and recommend 14 days of antibiotic therapy.
D. Change cefepime from 30-minute infusion to 4-hour infusion and perform vancomycin therapeutic drug
monitoring.
Table 2: IDSA/SHEA Recommended Methods for Antimicrobial Optimization1

PK monitoring of aminoglycosides Strong
PK monitoring of vancomycin Weak
Alternative dosing strategies based on PK principles Weak
IV-to-PO switch Strong
Beta-lactam allergy assessment Weak
Promote appropriate duration of therapy Strong
Patient Case #1, continued:
Question 3: What stewardship-microbiology collaborative activity is strongly recommended to help improve

TT’s antimicrobial regimen?
A. Implement Verigene for rapid organism identification and resistance testing from blood cultures and
provide treatment recommendations.
B. Build an antibiogram from last year’s susceptibility data and utilize it to select appropriate therapy.
C. Perform procalcitonin assay and discontinue therapy if concentration is <0.25 mcg/mL.
D. Implement cascade reporting of susceptibilities to only restricted broad-spectrum antibiotics when
there is documented resistance to narrow-spectrum antibiotics.
Table 3: IDSA/SHEA Recommended Stewardship Collaboration with Laboratory1

Develop antibiogram Strong
Selective or cascade reporting of susceptibility results Weak
Rapid viral testing to reduce inappropriate antibiotics Weak
Rapid diagnostic testing of blood Weak
Procalcitonin testing in ICU patients Weak
Fungal diagnostics in hematologic patients Weak
ANTIBIOGRAMS2
SEGMENT 2
I. Antibiograms
A. The purpose of an antibiogram is to assist with empiric selection of antibiotic therapy and evaluate
resistance trends over time
B. Different types of antibiograms
1. Inpatient vs. outpatient vs. emergency department
2. Source specific (e.g., urine-specific antibiogram – only pulling cultures from urinary cultures)
3. Dual-axis antibiogram (e.g., double-coverage of P. aeruginosa)
4. Unit- or service-specific antibiogram
C. The Clinical Laboratory Standards Institute (CLSI) provides recommendations for development and
analysis of an antibiogram in the M-39 document
Question 4: Which isolates should be used to develop an antibiogram per CLSI recommendations?
A. First isolate per patient per year
B. First isolate per patient per admission
C. First isolate per patient per month
D. First isolate per patient per source
Table 4: Antibiogram Dataset Example

Methicillin Vancomycin Linezolid Levofloxacin
S. aureus 55% (181/330) 100% (330/330) 91% (300/330) 60% (198/330)
S. lugdunensis 70% (34/49) 100% (49/49) 100% (1/1) 51% (25/49)
S. saprophyticus 100% (19/19) 100% (19/19) 67% (2/3) 84% (16/19)
S. epidermidis 71% (55/78) 89% (70/78) 97% (30/31) 50% (39/78)
Use Table 4 (above) for questions 5 and 6.
Question 5: Which Staphylococcus species should be included in an antibiogram per CLSI recommendations?
A. S. aureus, S. lugdunensis, S. saprophyticus, S. epidermidis
B. S. aureus, S. lugdunensis, S. saprophyticus
C. S. aureus, S. lugdunensis, S. epidermidis
D. S. aureus, S. saprophyticus, S. epidermidis
Question 6: Which of the following antibiotics should be excluded from the Staphylococcus species reported in
the antibiogram?
A. Methicillin
B. Vancomycin
C. Levofloxacin
D. Linezolid
II. Guidance for developing an annual antibiogram2
A. Include first isolate per patient per year
B. Include only organisms with at least 30 isolates
C. Include antibiotics that are routinely tested
D. Report percent susceptible (everything else is assumed to be intermediate or resistant)
E. Utilize confidence tables to determine if differences in susceptibilities are significant
F. Data should be shared with prescribers
III. CLSI antibiogram limitations
A. CLSI provides recommendations for developing antibiograms, but additional analyses may be needed
depending on institutional needs. Potential problems/limitations and suggestions for overcoming
each are listed in Table 5.
Table 5: CLSI Antibiogram Limitations

Problem/limitation Suggested additional analysis
Unable to detect differences in resistance among Floor or unit-specific antibiogram
different locations
Unable to differentiate sources of specific resistance Source-specific antibiogram
Unable to evaluate likelihood of susceptibility of Dual-axis antibiogram
combination therapy
Unable to track development of resistance over time ???
ANTIMICROBIAL STEWARDHIP CORE ELEMENTS IN ACUTE CARE HOSPITALS3,4,5
SEGMENT 3
Scenario #1
You are hired by an acute care hospital to help start an antimicrobial stewardship program. You have a meeting
scheduled with the directors of Pharmacy, Infectious Diseases, and Infection Prevention and have been tasked
with developing recommendations for establishing a successful stewardship program that meets accreditation
requirements.
Question 7: Which of the following organizations developed core elements of an antibiotic stewardship
program that facilitate compliance with accreditation requirements?
A. Centers for Disease Control and Prevention
B. Society of Infectious Diseases Pharmacists
C. American Society of Health-System Pharmacists
D. The Joint Commission
I. Brief history of stewardship from a regulatory and accreditation perspective3
A. The National Action Plan for Combating Antibiotic-Resistant Bacteria (CARB)
1. Released 2015, updated 2020
2. Maintains five original goals from 2015 plan, which address antibiotic resistance, data and
surveillance, development of new therapeutics and diagnostics and improved international
collaboration
a. Specific targets set for each objective and identifies responsible department or agency
b. Report annually on progress toward meeting target and challenges encountered
II. Centers for Disease Control and Prevention (CDC) core elements for acute care hospitals and critical
access hospitals4,5
A. Leadership commitment
B. Accountability
C. Pharmacy expertise
D. Action
E. Tracking
F. Reporting
G. Education
III. Leadership
A. Give stewardship program leader(s) time to manage the program and conduct daily stewardship
interventions
B. Provide resources, including staffing, to operate the program effectively
C. Have regular meetings with leaders of the stewardship program to assess the resources needed to
accomplish the hospital’s goals for improving antibiotic use
D. Appoint a senior executive leader to serve as a “champion” for the stewardship program to ensure
resource commitment
E. Report stewardship activities and outcomes to senior leadership on a regular basis
IV. Accountability and pharmacy expertise
A. Programs need dedicated leader or co-leaders
1. Most hospitals have co-leadership model with a physician and a pharmacist
2. If the program leader is a non-physician, a physician should be designated as support for issues
with medical staff
B. Replaced “drug expertise” with “pharmacy expertise”
C. Roles and expectations should be clearly defined
D. “Stewardship rounds” or “handshake rounds” may strengthen program
V. Action
A. Initial assessment of antimicrobial prescribing can help identify targets for interventions
B. CDC categories for stewardship interventions
1. Priority interventions
a. Prospective audit and feedback
1) Review by someone other than prescriber to determine if antibiotics are necessary, can
be de-escalated, correct dosing regimen, and/or correct duration
b. Preauthorization
1) Requires approval before dispensing an antibiotic
c. Facility-specific treatment guidelines
1) Reflect hospital-specific treatment recommendations based on formulary and local

susceptibility, should also include diagnostic recommendations
2. Infection-based interventions
a. More than half of antibiotics given in the hospital are prescribed for the following infections:
1) Community-acquired pneumonia (CAP)

2) Urinary tract infections (UTI)
3) Skin and soft tissue infections
b. Other potential targets include:
1) Sepsis
2) S. aureus infections
3) C. difficile infections
4) Culture proven invasive infections
5) Review of outpatient parenteral antibiotic therapy (OPAT)
3. Provider-based interventions
a. Antibiotic “timeouts”
1) Self-assessment by prescriber to determine if antibiotics are necessary, can be de-

escalated, correct dosing regimen and duration are used
b. Assessing penicillin allergy
1) Thorough history and physical, challenge doses and skin testing
4. Pharmacy-based interventions
a. Documentation of indications
b. IV-to-PO switch
c. Dose adjustments/optimization
d. Duplicative therapy alerts
e. Time-sensitive automatic stop orders
f. Detection and prevention of antibiotic-related drug-drug interactions
5. Microbiology-based interventions
a. Selective reporting of antimicrobial susceptibility testing results
b. Comments in microbiology reports
6. Nursing-based interventions
a. Optimizing microbiology cultures
b. Intravenous to oral transitions
c. Prompting antibiotic reviews (“timeouts”)
VI. Tracking and reporting
A. See Section 4
VII. Education
A. Key component of any antimicrobial stewardship program
1. Formal or informal
2. Education alone is NOT effective
3. Pair with interventions and measurement of outcomes
B. Case-based education is key
C. Most effective when tailored actions most relevant to group
VIII. Accreditation6,7
A. Joint Commission
1. Standard MM.09.01.01 (effective 1/1/17)
2. Applies to hospitals (including critical access hospitals)
3. Incorporates CDC core elements into standards
B. CMS
1. Sections § 482.42(b) and § 485.640(b) (effective 3/30/20)
2. Similar to Joint Commission requirements
Patient Case #2
A 57-year-old female presents to the ED with flank pain, fever, and nausea. Approximately 5 days ago, she had
urinary urgency and frequency that improved with over-the-counter phenazopyridine.
Vitals: Tmax 101.8, RR 16 , BP 108/76, HR 95

Labs: WBC 14.6, Scr 0.7 mg/dL
Ht: 62 inches; Wt: 85 kg
Allergies: penicillin (mild rash as a child)
Urinalysis: + bacteria, + WBC, + nitrite, + leukocyte esterase
PMH: HTN, depression. No history of urinary tract infections, colonization with multi-drug resistant organisms or
recent antimicrobial exposure.
ED physician diagnoses the patient with sepsis and starts all of the following:
• Piperacillin-tazobactam 3.375g IV q8h
• levofloxacin 750mg IV q24h
• vancomycin 1250mg IV q24h
Question 8: You are doing stewardship rounds and approach the team. Which of the following is a priority
intervention per the CDC core measures, and how is it classified?
A. Stop current antibiotics and start ceftriaxone; classified prospective audit and feedback.
B. Switch levofloxacin from IV to PO; classified as a pharmacy-driven IV to PO switch.
C. Perform a comprehensive allergy assessment; classified as assessing penicillin allergy.
D. Complete a renal dose adjustment for vancomycin; classified as dose adjustment
METRICS
SEGMENT 4
I. Tracking4
A. Antibiotic use measures
1. National Healthcare Safety Network (NHSN) Antimicrobial Use (AU) Option
B. Outcome measures
1. C. difficile infections
2. Antibiotic resistance
3. Financial impact
C. Process measures for quality improvement
1. Tracking types and acceptance of recommendations from prospective audit and feedback
2. Monitoring preauthorization interventions and ensuring it is not creating delays in therapy
3. Monitoring adherence to facility-specific treatment guidelines
II. Reporting
A. Antibiotic use and resistance information should be regularly reported to prescribers, pharmacists,
nurses, and leadership
B. Facility-specific information is key
1. Common issues observed through stewardship activities
2. Provider-specific reports with peer comparisons
Table 6: IDSA/SHEA Recommended Stewardship Metrics1

Monitor days of antimicrobial therapy (DOTs) Weak
Measure expenditures based on administration data Good practice
Measure syndrome-specific goals Good practice
III. Antibiotic utilization: days of therapy (DOT)8,9
A. A measurement of antibiotic exposure
B. A patient is classified as having 1 DOT per antibiotic per day, regardless of dose or frequency
C. Most accurate if calculated from medication administration record (vs. an order, purchasing data,
etc.)
D. Data are usually standardized per 1,000 patient days
E. Example: 1 patient in the 10-bed ICU is on antibiotics, which include ceftriaxone 2 g every 24 hours
and metronidazole 500mg IV every 8 hours:
1. The DOT for that day is 2 (does not matter how often you are giving these, if they are receiving
one dose, that counts as a DOT)
2. Total DOTs standardized for that day is 200 per 1,000 patient days, or also reported as
ceftriaxone and metronidazole, each as 100 DOTs/1,000 patient days
IV. Antibiotic utilization: defined daily dose (DDD)8,9
A. Measurement of antibiotic consumption (average dose a patient gets)
B. DDD is a standardized daily amount of antibiotic determined by the World Health Organization and
based on assumed average daily adult dose
C. Most accurate if calculated from medication administration record, and data is usually standardized
per 1,000 patient days
D. Example: 1 patient in the 10-bed ICU is on antibiotics, which include ceftriaxone 2 g IV every 24 hours
and metronidazole 500 mg IV every 8 hours:
1. The standardized DDD for ceftriaxone is 2 and metronidazole is 1.5
2. Ceftriaxone DDD is 1 (2 g order/ 2 DDD) and metronidazole is 1 (1.5 g order/ 1.5 DDD), and
standardized would be 100 DDDs/1,000 pt days
V. Other antibiotic utilization metrics8,9
A. Risk stratification by DOT or DDDs: risk stratification = evaluating and presenting data in different
ways in order to look at different populations
B. Compare individual units/wards
1. Example: bone marrow transplant units
C. Compare similar diagnoses
1. Example: patients with ICD10 for pneumonia
D. Compare utilization over time for specific subset of patients
1. Example: compare cefepime DOTs in NICU over 5 years
E. Antibiotic expenditure: how much hospital spends on antibiotics for a specified period of time
F. Scoring systems based on spectrum of activity
VI. Benchmarking antibiotic utilization10
A. Can be done through purchasing groups or hospital QI groups
B. CDC National Health and Safety Network (NHSN) Antibiotic Use and Resistance (AUR)
1. A national initiative to benchmark antibiotic use using DOTs/1,000 pt days
2. Data must be captured via medication administration records
3. Results are uploaded for entire hospital and each hospital unit/ward on a monthly basis
4. De-identified data and graphs can be downloaded and used to compare similar unit/wards
5. Many vendors of electronic health record or computerized decision support systems provide
interoperability
a. Standardized Antibiotic Administration Ratio (SAAR)
6. Values >1 indicate the institution is using more antibiotics than expected
Scenario #2
Your stewardship program revealed that patients admitted to the MICU with severe sepsis were frequently
receiving suboptimal cefepime regimens. Thus, you implemented an initiative to start all patients on cefepime 2
g IV every 8 hours (or an equivalent dosage based on renal impairment).
Question 9: What changes in DOTs and DDDs would you expect as a result of the cefepime dosing initiative?
I. Increase in DOTs and increase in DDDs
II. Increase in DOTs and no change in DDDs
III. No change in DOTs and increase in DDDs
IV. No change in DOTs and no change in DDDs
VII. Syndrome-specific metrics1

A. Most IDSA treatment guidelines list performance measures
B. Metrics will be different for each syndrome
C. Example: Staphylococcus aureus bacteremia performance measures
1. Source control
2. Repeat blood cultures every 2-4 days till clearance
3. Therapeutic vancomycin concentrations
4. Beta-lactam therapy for methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia
(nafcillin or cefazolin suggested)
5. Document antibiotic susceptibility for antibiotic therapy
D. Can link clinical outcomes to compliance with performance measures
E. Example: Stewardship-Led Comprehensive Collaborative Approach to Improving Outcomes with S.
aureus Bacteremia11
1. Stewardship teams can improve adherence to national guideline recommendations, which has
resulted in improved clinical outcomes.
Figure 1: Overall Bundle Compliance with Quality Performance Measures for S. aureus Bacteremia11
100
80
60 84.1
40 56.1
20
0
Intervention Control
Group Group
Table 7: Compliance with Individual Performance Measures for S. aureus Bacteremia11

Performance measure Historic Group Intervention Group P-value
Antibiotic initiation within 24 hr 97.5% 98.9% 0.612
Document clearance of cultures 85.0% 96.5% 0.013
Appropriate duration of therapy 86.4% 94.9% 0.088
IV Beta-lactam therapy for MSSA 86.8% 94.0% 0.321
Appropriate vancomycin trough 93% 97.6% 0.616
Echo for complicated bacteremia 96.2% 96.7% 0.999
Source control 78.6% 97.2% 0.037
* Bolded text indicates a statistically significant finding
Table 8: Clinical Outcomes Following Stewardship Syndrome-Specific Intervention for S. aureus Bacteremia11
Outcome Historic Group Intervention Group P-value
Mortality 19.5% 11.4% 0.200
Length of stay (days), from bacteremia (IQR) 9 (5-17) 9 (5-20) 0.474
30-Day readmission with S. aureus bacteremia 11.0% 1.1% 0.008
Persistent bacteremia 13.4% 9.1% 0.467
* Bolded text indicates a statistically significant finding
Table 9: Example Studies Showing Compliance with Syndrome-Specific Guidelines for Comprehensive
Management of S. aureus Bacteremia12-16
Author, year Intervention Clinical Outcomes
Lopez-Cortes, Multicenter pre-post study 14-day mortality: 17.8% pre vs. 11.3% post
2013 Develop guideline: ID consult and Adjusted 14-day mortality: OR 0.49 (0.28-
(n=508) compliance with 6 bundle process measures 0.87), p=0.016
Saunderson, Pediatric guideline, and intervention to Length of stay: 14 days vs. 16.5 days, NS
2014 promote compliance with 4 process 30-day mortality: 0% vs. 8.6%, NS
(n=66) measures
Borde, Develop guideline and promote In-hospital mortality: 43.6% vs. 10.0%,
2014 compliance with bundle process measures p=0.009
(n=59)
Nagao, 2017 Single center retrospective analysis of Adherence to ≥four measures: increased from
(n=477) compliance with 5 bundle endpoints 47.5 % in 2006 to 79.3 % in 2014 (P = 0.001);
the 30-day mortality decreased from 10.0% to
3.4%
Wenzler, 2017 Automated pharmacist-driven intervention All-cause mortality: 15.6% vs. 2.6%, P=0.063
(n=89) to improve compliance with performance
measures
Scenario #3
The stewardship team collaborated with the quality-improvement group to improve outcomes for patients
admitted with sepsis. Part of the multifaceted approach includes having the stewardship team pharmacist
receive real-time notification of blood culture results and then perform a chart review to recommend
appropriate modifications in antibiotic therapy.
Question 10: What performance and outcome measures should the stewardship team use to assess the value of
this real-time culture review initiative?
A. All-cause mortality, length of hospitalization, hospital readmissions, and antibiotic expenditures
B. Time to culture review, time to antibiotic order entry, time to antibiotic administration, and antibiotic
expenditures
C. Time to appropriate antibiotic therapy, time to antibiotic de-escalation, development of C. difficile
colitis, and total hospital billing data
D. Time to appropriate antibiotic therapy, all-cause mortality, length of hospitalization, and total hospital
billing data
Scenario #4
You are part of a stewardship team that implemented a new process that requires prescribers to page a
member of the antimicrobial stewardship team for approval before the pharmacy will dispense meropenem.
After implementing the new prior-approval process, the stewardship team would like to evaluate results of the
intervention.
Question 11: What is the best method to evaluate the impact of the prior-approval process on meropenem
utilization?
A. Utilize a pre-post quasi-experimental study design and perform interrupted time series analysis to
evaluate the impact of prior authorization on meropenem days of therapy.
B. Utilize a retrospective cohort study design and perform Student’s t test to evaluate the impact of prior
authorization on number of new meropenem orders.
C. Utilize a pre-post quasi-experimental study design and perform Student’s t test to evaluate the impact
of prior authorization on meropenem days of therapy.
D. Utilize a retrospective cohort study design and perform a Chi-square test to evaluate the impact of
prior authorization on the percentage of appropriate meropenem orders.
XIII. Interrupted time series (ITS)17

A. Quasi-experimental study design that evaluates longitudinal effects through regression modeling
B. Used to evaluate intervention effect when specific time of intervention is known
C. Table 10 outlines basic advantages and disadvantages of ITS
Table 10: Advantages and Disadvantages of ITS

Advantages Disadvantages
Often more feasible than randomized trials Not randomized
Pragmatic Various types of bias may be introduced
Good for retrospective evaluation of effects of Retrospective data may be incomplete or difficult to
changes in policy obtain
Designs can be strengthened with control groups Advanced statistical analysis is needed if using a more
complex design
CDC CORE ELEMENTS FOR LTF AND OUTPATIENT ANTIMICROBIAL STEWARDSHIP
SEGMENT 5
I. CDC core elements for antibiotic stewardship in nursing homes18
A. Published in 2015
B. Seven core elements:
1. Leadership Support
a. Written statements of support
b. Include stewardship-related duties in position descriptions of medical director, nurse leads

and consultant pharmacists
c. Communicate expectations about antibiotic use and stewardship policies
d. Create a culture that promotes antibiotic stewardship
2. Accountability
a. Identify individuals accountable for stewardship activities
1) Medical director
2) Director of nursing
3) Consultant pharmacist
b. Utilize existing resources to support stewardship efforts
1) Infection prevention
2) Laboratory
3) Local and state health departments
3. Drug Expertise
a. Work with consultant pharmacist with antimicrobial stewardship training
b. Partner with antibiotic stewardship program leaders at local hospitals
c. Develop relationships with infectious diseases consultants
4. Action
a. Policies that promote optimal antibiotic use
b. Interventions to improve antibiotic use:
1) Broad
a) Improve recognition of signs of infection, optimize diagnostic testing, antibiotic

“time-out”
2) Pharmacy
a) Assist with antibiotic dosing, review culture data, develop antibiotic monitoring
guidance
3) Infection- and syndrome-specific
a) Implement interventions on clinical syndromes that drive inappropriate use
5. Tracking and Reporting
a. Process measures
1) Appropriateness of antibiotics and compliance with use policies
b. Antibiotic use measures
1) Utilization tracking and impact of interventions
c. Antibiotic outcome measures
1) CDI rates, antibiotic resistance, and ADRs are examples
6. Education
a. Clinical interventions should target both providers and nursing staff
b. Tie education to feedback to increase likelihood of sustainability
C. Accreditation6
1. Joint Commission
a. Standard MM.09.01.01 (effective 1/1/17)
b. Applies to hospitals (including critical access hospitals)
c. Incorporates CDC core elements into standards
2. CMS
a. Section §483.80(a)(3) (effective 11/28/17)
b. Requires antibiotic stewardship program that includes antibiotic use protocols and a system
to monitor antibiotic use
II. CDC core elements on outpatient stewardship19
A. Published in 2016
B. Four core elements:
1. Commitment
a. Public commitment in support of antibiotic stewardship
b. Identify leader
c. Include antibiotic stewardship related duties in position descriptions
d. Communicate with clinic staff
2. Action for policy and practice
a. Use evidence-based diagnostic criteria and treatment recommendations

b. Use delayed prescribing or watchful waiting, if appropriate
c. Provide communication training for providers
d. Require justification for antibiotic prescribing
e. Provide clinical decision support
f. Utilize resources to prevent unnecessary patient visits
3. Tracking and reporting
a. Clinicians
1) Self-evaluate prescribing practices
2) Participate in activities to track and improve prescribing practices
b. Health-system leaders
3) Implement antibiotic prescribing and tracking system
4) Assess and share performance on quality improvement measures
4. Education and expertise
a. Patients
1) Use effective strategies to educate patients about appropriate antibiotic use, including
potential harms
2) Provide education materials
b. Providers
1) Provide face-to-face education training
2) Provide continuing education
3) Ensure access to experts
C. Accreditation20
1. Joint Commission
a. Standard MM.09.01.03 (effective 1/1/20)
b. Excludes ambulatory surgery centers and office-based surgery centers
c. Incorporates CDC core elements into standards
INFECTION PREVENTION
SEGMENT 6
I. Stewardship and infection prevention collaboration
A. Stewardship is essential for minimizing risk for development of multidrug-resistant organisms

(MDRO)
B. Infection prevention is essential in minimizing risk for spreading MDRO
C. Important to understand and promote compliance with infection prevention strategies
D. Stewardship programs can help improve reportable infection prevention metrics (e.g., healthcare-
associated C. difficile rates)
Table 11: Infection Prevention Precautions21

Precaution Purpose Common Diseases Private Gloves Gown Mask Hand Equipment
Room Hygiene
Droplet Prevent spread Rubella, pertussis, +/- + + + + +
of airborne meningococcal
droplets with meningitis, influenza,
pathogens RSV, HMV
Contact Prevent surface- Shingles, lice, +/- + + - + +
to-surface scabies, VRE, MDRO
spread GNR
Contact- Prevent surface- C. difficile, norovirus, + + + - + +
Diarrhea to-surface rotavirus, hepatitis A
spread
Respiratory Prevent airborne Chickenpox, measles, + - - + + -
spread of tuberculosis
pathogens
II. Reportable healthcare-associated infections (HAIs) to NHSN22
A. Most states are required to report
B. Infections required for reporting:
1. Catheter-associated urinary tract infections
2. Catheter-associated blood stream infections
3. Healthcare-acquired C. difficile infection
4. Select surgical site infections

5. Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
III. Publicly reported data22,23
A. Hospitals required to report data:
1. State HAIs performance compared to national average
2. HAIs for individual hospitals
B. Hospitals that complete an annual CDC/NHSN survey on antibiotic stewardship and infection
prevention practices
1. Compliance with stewardship core elements and infection prevention practices
2. The Leapfrog Group is a patient advocacy group that publicly ranks hospitals based on survey
results and HAI data
IV. 2021 Stewardship questions from CDC-NHSN survey24
A. Is there a committee responsible for antibiotic stewardship?
B. Is there a physician and/or pharmacist leader for your stewardship program, what is their training,
and how much time per week is allocated to stewardship activities?
C. Does the facility have key priority antibiotic stewardship interventions?
D. Does the facility have a policy or formal procedure for other interventions to ensure optimal use of
antibiotics?
E. Does the facility have specific “pharmacy-based” interventions in place?
F. Has the stewardship program engaged bedside nurses in actions to optimize antibiotic use?
G. Are metrics currently monitored to track antibiotic resistance and antimicrobial utilization?
H. Does the stewardship program provide reports on antibiotic use to prescribers, and in what form?
I. Does the facility distribute an antibiogram at least annually?
J. Do physicians, nurses, and/or pharmacy staff receive education on optimal prescribing, adverse
reactions from antibiotics, and antibiotic resistance at least annually?
K. Are patients provided education on important side effects of prescribed medications?
Scenario #5
You are the antimicrobial steward serving on the infection control committee for your hospital.
Question 12: Which of the following would be the most effective strategy to prevent the transmission of
influenza virus from infected patients admitted to your hospital to other hospital patients?
A. Prevent hand-to-surface spread of influenza virus through contact precautions.
B. Prevent the spread of airborne droplets with influenza virus through droplet precautions.
C. Prevent airborne spread of pathogens through respiratory precautions.
D. Prevent the spread of airborne droplets through contact precautions.
ANSWER KEY TO CASE QUESTIONS
1. Answer: A
All of these answers are recommended by the IDSA stewardship guideline, but Answer A is the only
intervention option that is “strongly recommended” by IDSA/SHEA. The other options have a lower-level
recommendation.
2. Answer: B
There are 6 interventions reviewed by the IDSA stewardship guidelines under the optimizing antibiotic therapy
recommendations, and 3 interventions are strongly recommended (IV-to-PO switch; promote appropriate
duration of therapy; and monitoring aminoglycoside kinetics). Therefore, the correct answer is B, as IV-to-PO
switch is the only option that is strongly recommended.
3. Answer: B
There is only one microbiology-stewardship collaboration intervention that is strongly recommended by IDSA,
which is the development of an antibiogram.
4. Answer: A
This recommendation is based on CLSI M39 document which provides guidance on developing an antibiogram.
Answer A allows the antibiogram to avoid being skewed by someone who has multiple cultures with resistant
bugs or persistent bacteremia. The other answers are not recommended by CLSI M39 document, as they
would potentially allow a patient to submit multiple isolates and skew antibiogram results.
5. Answer: C
The correct answer is to exclude S. saprophyticus from the antibiogram because when building an
antibiogram, the recommendation is to include only organisms with at least 30 isolates. S. saprophyticus has
19 isolates, and all other species in the table have at least 30 isolates. Therefore, the correct answer is C.
6. Answer: D
The correct answer is to only include antibiotics in the antibiogram that are routinely tested. Based on the
number of isolates displayed, linezolid is not routinely tested and should be excluded.
7. Answer: A
CDC developed core measures for acute care hospitals, ambulatory care clinics, and nursing homes. Current
acute care hospital Joint Commission standards are based on CDC core elements.
8. Answer: A
This patient has no history of urinary tract infections, recent antibiotic exposure, or history of infection with
multi-drug resistant organisms. Therefore, changing therapy from piperacillin-tazobactam, levofloxacin, and
vancomycin to ceftriaxone is appropriate, and would be classified as prospective audit and feedback. Other
priority interventions include pre-authorization and facility-specific treatment guidelines. All other
interventions may be reasonable but are not priority interventions per the CDC core elements.
9. Answer: C
DOT is a measure of exposure, and a patient receiving cefepime during an individual day will have a DOT of 1,
regardless of dose. DDD is sensitive to the amount given and will increase if the dose increases.
10. Answer: D
Answer D is correct as it links the direct measure of the intervention and associated clinical outcomes. By
performing real-time chart review following the alert, the stewardship team hopes to improve time to
effective therapy, which may improve outcomes. Thus, answer D is correct. Answer A does not include a
process measure, which is inappropriate. Answers B and C do not include clinical outcomes measures that are
appropriate for this scenario.
11. Answer: A
Answer A is correct. The best method to evaluate the impact of prior approval process on meropenem
utilization is to utilize a pre-post quasi-experimental study design and perform interrupted time series analysis
to evaluate the impact of prior authorization on meropenem days of therapy. A pre-post quasi experimental
study is likely the best option if the intervention is already implemented.
12. Answer: B
Answer B is correct. The influenza virus is spread through airborne transmission in non-respiratory aerosol
droplets, so droplet precautions should be used for suspected or documented influenza infected patients.
Influenza is not spread through the airborne route (without respiratory droplets), nor is it spread through
contact with surfaces, so A, C, and D are all incorrect.
ANSWER KEY TO SELF-ASSESSMENT QUESTIONS (from front of the chapter)
1. Answer: A
The only correct answer is A. While antimicrobial stewardship programs are required for accreditation by both
TJC and CMS for acute care hospitals and long-term care facilities, outpatient stewardship is currently required
only by TJC.
2. Answer: C
Antibiotic metrics is a category of stewardship intervention in the IDSA guidelines. The other categories
include antibiotic interventions, antibiotic optimization, collaboration with microbiology, and special
populations
3. Answer: A
The purpose of the CLSI antibiogram is to influence empiric antibiotic therapy. The other options are incorrect
as the antibiogram includes all sources (thus answer B is incorrect), evaluates single drug-pathogen
sensitivities (thus answer C is incorrect), and excludes repeat cultures (thus answer D is incorrect).
Additional antibiograms are recommended to address these limitations.
4. Answer: B
The IDSA guidelines provide categories of stewardship activities, which specially classify procalcitonin into the
category of “collaboration with laboratory.”
5. Answer: C
The World Health Organization maintains the standards for determining defined daily dose (DDD), which is the
correct answer. See the link below to WHO definitions for DDDs, which will be helpful for evaluating antibiotic
use at your institution: https://www.whocc.no/atc_ddd_indexupdates_included_in_the_atc_ddd_index/.
REFERENCES FOR FURTHER STUDY
General Antibiotic Stewardship Practice:
1. Barlam TF, Cosgrove SE, Abbo LM et al. Implementing an antibiotic stewardship program: guidelines by
the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin
Infect Dis. 2016;62(10):e51-e77. https://academic.oup.com/cid/article/62/10/e51/2462846 (accessed
2021 Sep 15).
2. Centers for Disease Control and Prevention (CDC). Core elements of hospital antibiotic stewardship
programs. https://www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html (accessed
2022 Feb 10).
Regulatory, Accreditation and Hospital Ranking:
1. Centers for Disease Control and Prevention (CDC). Core elements of hospital antibiotic stewardship
programs. https://www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html (accessed
2022 Feb 10).
2. Sanchez GV, Fleming-Dutra KE, Roberts RM et al. The core elements of outpatient antibiotic stewardship.
MMWR Recomm Rep. 2016;65(No. RR-6):1-12. https://www.cdc.gov/antibiotic-
use/community/pdfs/16_268900-A_CoreElementsOutpatient_508.pdf (accessed 2021 Sep 15).).
3. Centers for Disease Control and Prevention (CDC). Implementation of antibiotic stewardship core
elements at small and critical access hospitals. https://www.cdc.gov/antibiotic-
use/healthcare/implementation/core-elements-small-critical.html (accessed 2021 Sep 15).
4. Centers for Disease Control and Prevention (CDC). Core elements of antibiotic stewardship for nursing
homes. https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html (accessed 2021 Sep
15).
5. The Joint Commission. New antimicrobial stewardship standard.

https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf (accessed
2021 Sep 15).
6. The Leapfrog Group. https://www.leapfroggroup.org/ (accessed 2022 March 15).
Antimicrobial Utilization Metrics:
1. Centers for Disease Control and Prevention (CDC). Antimicrobial use and antimicrobial resistance (UAR)
options. https://www.cdc.gov/nhsn/acute-care-hospital/aur/index.html (accessed 2022 Feb 10).
2. Centers for Disease Control and Prevention (CDC), National Healthcare Safety Network. The NHSN
standardized antimicrobial administration ratio (SAAR): a guide to the SAAR.
https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/aur/au-saar-guide-508.pdf (accessed 2021 Nov 3).
3. Ibrahim OM, Polk RE. Antimicrobial use metrics and benchmarking to improve stewardship outcomes:
methodology, opportunities, and challenges. Infect Dis Clin North Am. 2014 Jun;28(2):195-214. doi:
10.1016/j.idc.2014.01.006.
Antibiogram:
1. Clinical Laboratory Standards Institute (CLSI). Analysis and presentation of cumulative antimicrobial
susceptibility test data, 5th Edition. CLSI guideline M39. Clinical Laboratory Standards Institute. 2022.
Infection Prevention:
1. The Joint Commission. Antimicrobial stewardship. https://www.jointcommission.org/resources/patient-

safety-topics/infection-prevention-and-control/antimicrobial-stewardship/ (accessed 2022 Mar 15).
MODULE REFERENCES
1. Barlam TF, Cosgrove SE, Abbo LM et al. Implementing an antibiotic stewardship program: guidelines by
the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin
Infect Dis. 2016;62(10):e51-e77. https://academic.oup.com/cid/article/62/10/e51/2462846 (accessed
2021 Sep 15).
2. Clinical Laboratory Standards Institute. Analysis and presentation of cumulative antimicrobial

susceptibility test data; approved guideline – 4th Edition. CLSI document M39-A4. Wayne, PA: Clinical
Laboratory Standards Institute. 2014.
3. Centers for Disease Control and Prevention (CDC), Federal Task Force on Combating Antibiotic-Resistant
Bacteria. National action plan for combating antibiotic-resistant bacteria, 2020-2025.
https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//196436/CARB-National-Action-Plan-2020-
2025.pdf (accessed 2021 September 15).
4. Centers for Disease Control and Prevention. Core elements of hospital antibiotic stewardship programs.
https://www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html (accessed 2021 Sep
15).
5. Centers for Disease Control and Prevention (CDC). Implementation of antibiotic stewardship core
elements at small and critical access hospitals. https://www.cdc.gov/antibiotic-use/core-elements/small-
critical.html (accessed 2021 Sep 15).
6. The Joint Commission. Approved: new antimicrobial stewardship standard.

https://www.jointcommission.org/-/media/enterprise/tjc/imported-resource-
assets/documents/new_antimicrobial_stewardship_standardpdf.pdf (accessed 2021 Oct 20).
7. Centers for Medicare and Medicaid Services (CMS). Medicare and Medicaid programs; regulatory
provisions to promote program efficiency, transparency, and burden reduction; first safety requirements
for certain dialysis facilities; hospital and critical access hospital (CAH) changes to promote innovation,
flexibility, and improvement in patient care.
https://www.federalregister.gov/documents/2019/09/30/2019-20736/medicare-and-medicaid-programs-
regulatory-provisions-to-promote-program-efficiency-transparency-and (accessed 2021 Oct 20).
8. Ibrahim OM, Polk RE. Antimicrobial use metrics and benchmarking to improve stewardship outcomes:
methodology, opportunities, and challenges. Infect Dis Clin North Am. 2014 Jun;28(2):195-214. doi:
10.1016/j.idc.2014.01.006.
9. Bennett N, Schultz L, Boyd S et al. Understanding inpatient antimicrobial stewardship metrics. Am J

Health-Syst Pharm. 2018;75:230-8. doi: 10.2146/ajhp160335.
10. Centers for Disease Control and Prevention (CDC), National Healthcare Safety Network. Antimicrobial use
and resistance module (AUR) – January 2022.
https://www.cdc.gov/nhsn/pdfs/pscmanual/11pscaurcurrent.pdf (accessed 2022 February 10).
11. Nguyen CT, Ghandi T, Chenoweth C et al. Impact of an antimicrobial stewardship-led intervention for
Staphylococcus aureus bacteraemia: a quasi-experimental study. J Antimicrob Chemother. 2015;70:3390-
6.
12. López-Cortés LE, Del Toro MD, Gálvez-Acebal J et al. Impact of an evidence-based bundle intervention in
the quality-of-care management and outcome of Staphylococcus aureus bacteremia. Clin Infect Dis.
2013;57(9):1225-33. doi: 10.1093/cid/cit449.
13. Saunderson RB, Gouliouris T, Cartwright EJ et al. Impact of infectious diseases consultation on the
management of Staphylococcus aureus bacteraemia in children. BML Open 2014;4:e004659. doi:
10.1136/bmjopen-2013-004659.
14. Borde JP, Batin N, Rieg S et al. Adherence to an antibiotic stewardship bundle targeting Staphylococcus
aureus blood stream infections at a 200-bed community hospital. Infect. 2014;42(4):713-9. doi:
10.1007/s15010-014-0633-1.
15. Nagao M, Tamamoto M, Matsumura Y et al. Complete adherence to evidence-based quality-of-care

indicators for Staphylococcus aureus bacteremia resulted in better prognosis. Infect. 2017;45(1):83-91.
doi: 10.1007/s15010-016-0946-3.
16. Wenzler E, Wang F, Goff DA et al. An automated, pharmacist-driven initiative improves quality of care for
Staphylococcus aureus bacteremia. Clin Infect Dis. 2017;65(2):194-200. doi: 10.1093/cid/cix315.
17. Schweizer ML, Braun BI, Milstone AM. Research methods in healthcare epidemiology and antimicrobial
stewardship – quasi-experimental designs. Infect Control Hosp Epidemiol. 2016;37(10):1135-40. doi:
10.1017/ice.2016.117.
18. Centers for Disease Control and Prevention (CDC). Core elements of antibiotic stewardship for nursing
homes. https://www.cdc.gov/antibiotic-use/core-elements/nursing-homes.html (accessed 2021 Sep 30).
19. Centers for Disease Control and Prevention (CDC). Core elements of outpatient antibiotic stewardship.
https://www.cdc.gov/antibiotic-use/core-elements/outpatient.html (accessed 2021 Sep 30).
20. The Joint Commission. R3 report issue 23: antimicrobial stewardship in ambulatory health care.
https://www.jointcommission.org/standards/r3-report/r3-report-issue-23-antimicrobial-stewardship-in-
ambulatory-health-care/ (accessed 21 Oct 14).
21. Centers for Disease Control and Prevention (CDC). Infection control: isolation precautions.
https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html (accessed 2021 Oct 25).
22. Centers for Disease Control and Prevention (CDC), National Healthcare Safety Network. CMS – acute care
hospitals (ACH). https://www.cdc.gov/nhsn/cms/ach.html (accessed 2022 Feb 10).
23. The Leapfrog Group. https://www.leapfroggroup.org/ (accessed 2022 March 15).
24. Centers for Disease Control and Prevention, National Healthcare Safety Network (NHSN). Patient safety
component – annual hospital survey. https://www.cdc.gov/nhsn/forms/57.103_pshospsurv_blank.pdf
(accessed 2022 Feb 8).

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ANTIMICROBIAL STEWARDSHIP

Jessica Robinson, Pharm.D., BCPS, BCIDP

1. Outline components of an effective stewardship program.

Answer key is provided at the end of this chapter.

a. The Joint Commission (TJC)

b. Centers for Medicare and Medicaid Services (CMS)

c. National Healthcare Safety Network (NHSN)

d. The Leapfrog Group

d. Collaboration with infection prevention

a. The ability to influence empiric therapy

c. The ability to evaluate antibiotic susceptibilities of combination therapy (i.e., combination

d. The ability to track development of resistance

b. Collaboration with laboratory

b. The Centers for Medicare and Medicaid Services (CMS)

c. The World Health Organization (WHO)

d. The Joint Commission (TJC)

I. IDSA/SHEA stewardship guidelines1

A. Categorized stewardship activities in 5 main categories:

4. Collaboration with microbiology

Table 1: IDSA/SHEA Recommended Methods for Performing Stewardship Interventions1

Patient Case #1, continued:

Table 2: IDSA/SHEA Recommended Methods for Antimicrobial Optimization1

Patient Case #1, continued:

Question 3: What stewardship-microbiology collaborative activity is strongly recommended to help improve

Table 3: IDSA/SHEA Recommended Stewardship Collaboration with Laboratory1

B. Different types of antibiograms

1. Inpatient vs. outpatient vs. emergency department

3. Dual-axis antibiogram (e.g., double-coverage of P. aeruginosa)

4. Unit- or service-specific antibiogram

Table 4: Antibiogram Dataset Example

Use Table 4 (above) for questions 5 and 6.

II. Guidance for developing an annual antibiogram2

A. Include first isolate per patient per year

C. Include antibiotics that are routinely tested

D. Report percent susceptible (everything else is assumed to be intermediate or resistant)

E. Utilize confidence tables to determine if differences in susceptibilities are significant

F. Data should be shared with prescribers

III. CLSI antibiogram limitations

Table 5: CLSI Antibiogram Limitations

I. Brief history of stewardship from a regulatory and accreditation perspective3

A. The National Action Plan for Combating Antibiotic-Resistant Bacteria (CARB)

1. Released 2015, updated 2020

b. Report annually on progress toward meeting target and challenges encountered

B. Provide resources, including staffing, to operate the program effectively

E. Report stewardship activities and outcomes to senior leadership on a regular basis

IV. Accountability and pharmacy expertise

A. Programs need dedicated leader or co-leaders

1. Most hospitals have co-leadership model with a physician and a pharmacist

B. Replaced “drug expertise” with “pharmacy expertise”

C. Roles and expectations should be clearly defined

D. “Stewardship rounds” or “handshake rounds” may strengthen program

B. CDC categories for stewardship interventions

a. Prospective audit and feedback

1) Requires approval before dispensing an antibiotic

c. Facility-specific treatment guidelines

1) Reflect hospital-specific treatment recommendations based on formulary and local

1) Community-acquired pneumonia (CAP)

3) Skin and soft tissue infections

4) Culture proven invasive infections

5) Review of outpatient parenteral antibiotic therapy (OPAT)

1) Self-assessment by prescriber to determine if antibiotics are necessary, can be de-

b. Assessing penicillin allergy

1) Thorough history and physical, challenge doses and skin testing

d. Duplicative therapy alerts