In February 2010, the CDPH HAI Program developed the only statewide antimicrobial stewardship program initiative in order to strengthen and promote optimization of antimicrobial utilization in California health care facilities. The purpose of an antimicrobial stewardship program is to measure and promote the appropriate use of antimicrobials by selecting the appropriate agent, dose, duration and route of administration in order to improve patient outcomes, while minimizing toxicity and the emergence of antimicrobial resistance (1). Antimicrobial stewardship has been shown to be essential in the control of Clostridium difficile infections and the emergence of multidrug resistant organisms (MDROs) (1) Although guidelines exist for developing antimicrobial stewardship programs, there is limited information on practical implementation of these guidelines, particularly in resource-limited settings.
The Department of Health and Human Services (DHHS) with the Healthcare Infection Control Practices Advisory Committee enumerates antimicrobial stewardship as one of the top five messages for healthcare worker and consumer awareness in 2010 (2). DHHS, with the Center for Medicare and Medicaid Services, stipulates that long-term care facilities should use antibiotics appropriately, encouraging utilization of a consulting pharmacist to provide oversight (3). California Senate Bill 739 mandated that, by January 1, 2008, CDPH require general acute care hospitals to monitor and evaluate the utilization of antibiotics and charge a quality improvement committee with the responsibility for oversight of the judicious use of these medications (4). California is the only state with this type of mandate. Citing California as an example, the Infectious Diseases Society of America, Society of Healthcare Epidemiology of America and Pediatric Infectious Disease Society issued a policy statement in April 2012 for the mandatory implementation of antimicrobial stewardship programs throughout health care (5). In addition, the Initiative was involved with helping to better delineate the role of infection preventionists in antimicrobial stewardship programs on a position paper with the Society of Healthcare Epidemiology of America and the Association for Professionals in Infection Control and Epidemiology, Inc. (6). The initiative also documented the first statewide assessment of antimicrobial stewardship programs and the questionnaire used in April 2013. The State of Antimicrobial Stewardship in California (7)
CDPH has many partners in this statewide initiative including, but not limited to: Division of Healthcare Quality and Promotion at Centers for Disease Control and Prevention (CDC), Infectious Disease Association of California, and Society of Healthcare Epidemiology of America.
Current program activities include:
Regional collaborations among hospitals with similar difficulties and/or healthcare systems so that facilities can learn from one another on successful and unsuccessful strategies.
Utilization of a statewide assessment of antimicrobial stewardship programs present in California healthcare facilities (May 2010 - March 2011) to develop evidence-based recommendations on how to implement or strengthen antimicrobial stewardship programs given available resources and facility attributes.
Consultative advice and practical evidence to facilities in order to gain administrative, pharmacy and provider buy-in.
Developing recommendations on internal and external outcome antimicrobial metrics with a group of antimicrobial stewardship experts across California and the Antimicrobial Stewardship Subcommittee of the California HAI Advisory Committee.
Educating long-term care facilities on the benefits of antimicrobial stewardship programs and conducting research to better study the efficacy of antimicrobial oversight in the long-term care setting.
Define regulation surrounding antimicrobial stewardship programs in California.
To read expert commentaries on antimicrobial stewardship and emergency departments as well as long-term care, please visit: http://www.medscape.com/partners/shea/public/shea. A one-time, free registration is required to access Medscape articles.
Additional articles of interest:
- Dellit, TH et al. Infectious Disease Society of American and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clin Infect Dis 2007;44:159-77.
- Department of Health and Human Services, Center for Medicare and Medicaid Services. “Interpretive Guidelines for Long-Term Care Facilities, Tag F441”, CMS Manual System Pub. 100-07 State Operations Provider Certification, Transmittal 51, July 30, 2009.
- Policy Statement on Antimicrobial Stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS) Infection Control and Hospital Epidemiology, Vol. 33, No. 4, Special Topic Issue: Antimicrobial Stewardship (April 2012), pp. 322-327 - - see recommendations
- Antimicrobial Stewardship: A Collaborative Partnership between Infection Preventionists and Health Care Epidemiologists. Julia Moody, Sara E. Cosgrove, Russell Olmsted, Edward Septimus, Kathy Aureden, Shannon Oriola, Gita Wasan Patel and Kavita K. Trivedi. Infection Control and Hospital Epidemiology , Vol. 33, No. 4, Special Topic Issue: Antimicrobial Stewardship (April 2012), pp. 328-330 - - see recommendations
- The State of Antimicrobial Stewardship in California
For additional information or comments, please contact: Kavita K. Trivedi, M.D. Public Health Medical Officer-California Department of Public Health