5 Tips for Implementing Antimicrobial Stewardship in Small or Rural Hospitals


Antibiotic resistance has become one of the most serious emerging threats to public health.

Antibiotic resistance has become one of the most serious emerging threats to public health. The misuse of antibiotics and other medicines, known as antimicrobial agents, has contributed to a growing number of infections impervious to antibiotic treatments. According to the CDC, 20% to 50% of antibiotics prescribed in US acute care hospitals are either unnecessary or inappropriate.

Setting up an antimicrobial stewardship program (ASP) in a small or rural hospital can seem daunting, especially without the capabilities and resources that larger hospitals have. Linda M. Spooner, PharmD, BCPS (AQ-ID), FASHP, FCCP, led a session at the ASHP Midyear Clinical Meeting presenting a toolkit of steps for achieving quality antimicrobial stewardship in small and rural hospitals.

1. Plan, Do, Study, Act

It’s key to recognize, first and foremost, the primary drivers of antimicrobial stewardship. The goals of the program implementation include timely and appropriate initiation of antibiotics; appropriate administration and de-escalation; and monitoring, transparency, and stewardship infrastructure. Understanding that it is important to select specific interventions significant to the institution is a crucial first step to initiating implementation.

2. Gather Resources

Both the CDC and ASHP offer references significant to implementing ASPs, and formal educational training is often provided by numerous organizations, as well. Hospitals can utilize these resources to gain as much information and guidance as possible to steer them in the right direction.

3. Partnerships

Consider partnering with outside institutions to improve support and share experiences with peers facing similar challenges. Partnering with other smaller or rural hospitals can jumpstart positive collaboration efforts and idea sharing, whereas collaborating with larger hospitals can help provide perspective and access to educational sessions regarding creating and maintaining a successful ASP.

4. Committee Development

Spooner suggests using a pharmacy and therapeutics (P&T) committee throughout the development of antimicrobial stewardship. Committee purposes should include the review of the antibiotic formulary and its use, identification of core participants, collaboration, and determination of exact goals.

5. Determine Antibiotic Use Review

Smaller hospitals may need to consider a more targeted approach to reviewing all antibiotic orders and reports based on specific assessments within the hospital. Spooner suggests approaches such as empiric antibiotic selection guidelines, formulary restrictions, optimization of dosing, intravenous to oral switches, limitations on duration of use, and de-escalation or narrowing of the spectrum of antibiotics. Persistent documentation is crucial to maintaining a quality program and can help guide stewardship toward success.

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