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Invited Commentary
Infectious Diseases
February 26, 2021

Expanding Antimicrobial Stewardship Through Quality Improvement

Author Affiliations
  • 1Department of Pharmacy Practice, College of Pharmacy, Oregon State University, Portland
  • 2Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois
  • 3Division of Infectious Diseases, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
  • 4Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
  • 5Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
JAMA Netw Open. 2021;4(2):e211072. doi:10.1001/jamanetworkopen.2021.1072

Quality improvement, the systematic process to improve health care delivery, has become ubiquitous in health care. Quality improvement focuses on a modest concept: that we all have room for improvement as clinicians and health systems. The quality improvement literature emphasizes the use of simple interventions, such as checklists and performance reports, to improve health care. Entire departments now exist focused on quality or performance improvement to meet regulatory and accreditation standards with a goal to improve patient outcomes and safety. Quality improvement departments have robust infrastructure including information technology, data scientists, and improvement specialists. This infrastructure supports multiple interprofessional teams focused on improving care of a condition (eg, heart failure) and/or patient safety issue (eg, fall prevention). These teams adapt different approaches to identify strategies to support evidence-based health care and determine intervention effectiveness. Quality improvement departments are necessary to navigate the unique complexities of the facility’s implementation context to develop, deploy, and sustain successful interventions.

Antimicrobial stewardship is a set of strategies to improve and measure antibiotic prescribing by clinicians and antibiotic use by patients. Antimicrobial stewardship shares many common elements with quality improvement, including identifying what needs to be improved, implementing strategies to improve antibiotic prescribing, focusing on feasible and high-impact interventions, and measuring program outcomes. The ultimate goal of quality improvement and antimicrobial stewardship is also similar: to improve patient safety. Major long-term goals of antimicrobial stewardship are to decrease the development of Clostridioides difficile infection and antimicrobial resistance. Unfortunately, most health systems lack robust infrastructure to support antimicrobial stewardship, with few hospitals providing information technology personnel and salary support for infectious diseases pharmacists and physicians.1 Without this support, the work to develop, deploy, and determine the effectiveness of antimicrobial stewardship is shouldered by antimicrobial stewardship leaders, few of whom are specialty trained in infectious diseases or program evaluation.2

Antimicrobial stewardship programs first emerged among high-resource institutions, such as academic medical centers. However, as the importance of the work gained heightened awareness, the establishment of antimicrobial stewardship programs was encouraged or required through public health recommendations, state laws, accreditation requirements, and payor policies. In 2015, the US released the “National Action Plan for Combatting Antibiotic-Resistant Bacteria,” which called for all acute care hospitals to implement antimicrobial stewardship programs and prompted the release of the core elements of hospital antibiotic stewardship programs from the Centers for Disease Control and Prevention,1 as well as a joint guideline by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.3 These recommendations subsequently informed accreditation requirements implemented by The Joint Commission, the accrediting body for more than 22 000 US health systems.4 Currently, the National Quality Forum has endorsed Centers for Disease Control and Prevention antibiotic use metrics as quality improvement measures for antibiotic use and the Centers for Medicare & Medicaid Services has proposed a rule tying these measures to reimbursement policy.5 This evolution of regulations, requirements, and guidance has led to the expansion of antimicrobial stewardship programs to most hospitals in the US.6

Within this context of an increasing focus on antimicrobial stewardship implementation nationwide, it is particularly relevant to consider this study by Tamma et al2 that reports on the success of the largest pragmatic quality improvement antimicrobial stewardship program initiative in the US. As part of the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use, the investigators supported a cohort of 402 hospitals in developing sustainable antimicrobial stewardship programs and educating frontline clinical staff on incorporating antimicrobial stewardship into routine clinical care. Resources for implementing robust antimicrobial stewardship programs were limited at many hospitals; community and critical access hospitals composed most of the cohort, and nearly half of all hospitals did not have access to infectious diseases specialists. Through basic implementation strategies, including web-based and durable educational content, external facilitation from trained antimicrobial stewardship and quality improvement experts, team-based review of antibiotic prescribing, and quarterly feedback of antibiotic use data, the program demonstrated significant reductions in overall antibiotic use. Reductions specifically in fluoroquinolone use and hospital-onset C difficile rates were also observed. Lending support to the authors’ conclusion that the observed reductions appeared to result primarily from use of the Safety Program, antibiotic use did not change during the study period in a national database of hospitals that were similar to the study cohort. Likewise, hospitals more actively engaged in Safety Program activities experienced greater decreases in antibiotic use, further supporting the association between the Safety Program and the observed outcomes.

Much of the evidence surrounding antimicrobial stewardship in acute care settings comes from smaller, single-center studies that have limited generalizability to different hospital types. However, system-wide reductions in antibiotic use with coordinated implementation of antimicrobial stewardship programs across a large cohort of US hospitals has been reported previously within the Veterans Health Administration (VHA).7 In 2010, the VHA began a national antimicrobial stewardship initiative that eventually mandated antimicrobial stewardship programs in all VHA medical facilities and provided resources for implementation similar to those of the Agency for Healthcare Research and Quality Safety Program. Like the present study, the VHA Antimicrobial Stewardship Initiative led to an increase in the number of VHA facilities with stewardship programs (from 41% in 2011 to 89% in 2015) and a 12% overall reduction in antibiotic use.7 Veterans Health Administration medical facilities benefit from shared leadership, policies, and information technology, including a national electronic health record, which sets a strong foundation for success in implementing a national, coordinated stewardship initiative. Tamma et al2 noted that a similar intervention composed primarily of web-based education, online antimicrobial stewardship resources, and access to remote expert advice can significantly improve antibiotic use in diverse hospitals from disparate health care systems. Furthermore, this study reports a direct association of antimicrobial stewardship with rates of hospital-onset C difficile, an increasingly critical patient safety measure. We now have a practical framework for even small and low-resource hospitals to see a tangible and timely result from creation of an antimicrobial stewardship program and engagement in a handful of straightforward interventions. Given the lack of long-term follow-up, the sustainability of this program has yet to be confirmed; however, the program’s emphasis on easily accessible resources targeting frontline clinical staff without specific infectious diseases training may optimize its enduring effect.

To further advance the evidence-based implementation of effective antimicrobial stewardship, future work should focus on implementation strategies that support widespread uptake of interventions and ensure sustainability. More data are needed to identify effective antimicrobial stewardship interventions for outpatient and long-term care settings. To ensure sustainability, antimicrobial stewardship efforts must be integrated and supported by the robust quality improvement infrastructure of acute care facilities. Tamma et al2 observed that standardizing training and evaluation metrics improved antimicrobial stewardship implementation and decreased antibiotic prescribing. Standardizing the process for selecting and implementing antimicrobial stewardship strategies in hospitals through a robust quality improvement framework is the next step in expanding antimicrobial stewardship and improving antibiotic prescribing. Longitudinal data are needed to measure long-term outcomes of antimicrobial stewardship implementation strategies in the absence of added infrastructure afforded by research investigators and support the translation of proven stewardship strategies into practice. Because, after all, we all have room for improvement.

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Article Information

Published: February 26, 2021. doi:10.1001/jamanetworkopen.2021.1072

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 McGregor JC et al. JAMA Network Open.

Corresponding Author: Katie J. Suda, PharmD MS, Division of General Internal Medicine, School of Medicine, University of Pittsburgh, 3609 Forbes Ave, Ste 2, Pittsburgh, PA 15213 (ksuda@pitt.edu).

Conflict of Interest Disclosures: None reported.

Disclaimer: The opinions expressed are those of the authors and do not represent those of the US Department of Veterans Affairs or the US government.

Pollack  LA, Srinivasan  A.  Core elements of hospital antibiotic stewardship programs from the Centers for Disease Control and Prevention.   Clin Infect Dis. 2014;59(suppl 3):S97-S100. doi:10.1093/cid/ciu542PubMedGoogle ScholarCrossref
Tamma  PD, Miller  MA, Dullabh  P,  et al.  Association of a safety program for improving antibiotic use with antibiotic use and hospital-onset Clostridioides difficile infection rates among US hospitals.  JAMA Netw Open. 2021;4(2):e210235. doi:10.1001/jamanetworkopen.2021.0235Google Scholar
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. doi:10.1093/cid/ciw118PubMedGoogle ScholarCrossref
The Joint Commission. Facts about the Joint Commission. Accessed January 18, 2021. https://www.jointcommission.org/about-us/facts-about-the-joint-commission/
The National Quality Forum. National Quality Partners Playbook: Antibiotic Stewardship in Acute Care. Published July 2018. Accessed July 14, 2018. https://store.qualityforum.org/collections/antibiotic-stewardship/products/national-quality-partners-playbook%E2%84%A2-antibiotic-stewardship-in-post-acute-and-long-term-care-1
Centers for Disease Control and Prevention. Antibiotic resistance & patient safety portal. Accessed January 18, 2021. https://arpsp.cdc.gov/profile/stewardship
Kelly  AA, Jones  MM, Echevarria  KL,  et al.  A report of the efforts of the Veterans Health Administration national antimicrobial stewardship initiative.   Infect Control Hosp Epidemiol. 2017;38(5):513-520. doi:10.1017/ice.2016.328PubMedGoogle ScholarCrossref
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