Identifying Main Types of Antimicrobial Stewardship Programs

In an effort to determine how to expand antimicrobial stewardship programs (ASP), a new study has identified 4 main types of programs and ways they can be implemented and expanded, according to information from a paper published in Clinical Infectious Diseases.

Investigators from Intermountain Healthcare in Utah evaluated the ASPs from 20 hospitals in order to describe the types of structures and functions of centralized stewardship programs taking place among health systems, while also highlighting common areas of emphasis and differences. After first completing a semi-structured questionnaire about the key aspects of their system’s structure and function, the ASP leaders participated in a webinar, a breakout focus group, and provided feedback on the discussions.

The sessions took place between March and April 2021. The largest 3 health systems (over 100 facilities) were grouped together, followed by the 2 consultative programs, and then the following systems were grouped in threes to ensure diversity in system size, the study authors explained. The ASP leaders included 1 pharmacist and 1 physician from each location.

The study authors reported that 100 percent of those invited responded to the questionnaire, but said that 36 of a possible 40 ASP leaders participated in the virtual breakout sessions; however, all 20 systems were represented.

After these discussions took place, 4 centralized ASPs structures emerged, the study authors found: collaborative, centrally coordinated, centrally led, and a collaborative, consultative network. The 20 health systems who participated fell into the following categories:

• 3 were collaborative
• 3 were centrally coordinated
• 3 were in between or in transition from centrally coordinated and centrally led
• 8 were centrally led
• 2 classified as collaborative, consultative work
• 1 organization considered itself to be hybrid

In the collaborative approach, there is no formal administrative or operational structure, but there is significant collaboration across sites informally, the study authors explained. In the centrally coordinated approach, the study authors wrote, there is a formal structure and an ASP is run through a task force or committee. In the centrally led approach, the study authors described a health system leader for the ASP where antimicrobial stewardship may be one of many responsibilities for this leader. The study authors explained that in the collaborative, consultative network model is a way for small community hospitals to enhance antimicrobial stewardship expertise locally but often these facilities lack adequate resources for a full ASP.

The 6 main pillars of ASPs identified through the discussions include:

• Building and leading stewardship
• Strategic planning and goal setting
• Developing validated data streams
• Developing and implementing ASPs
• Providing subject-matter expertise
• Serving as an information source for ASP efforts

A majority of these ASPs were co-led by physicians and pharmacists, but 2 programs were physician-led, the study authors found. Most of these programs named challenges due to inadequate resources at the local level (11 systems), system level (12 systems), or both (8 systems), the study authors added.

“During the discussions, 7 stewardship leads highlighted the value of alignment across disciplines whenever possible, such as Clostridioides difficile rates with infection preventionists, sepsis management and mortality with intensivists, and readmission rates with hospitalists,” the study authors noted. “These examples highlight that antimicrobial stewardship can assist with improving metrics prioritized and evaluated by other disciplines, creating win-win situations.”

There were some common barriers that came up in these discussions, the study authors wrote, most notably building out the necessary data infrastructure, obtaining adequate personnel funding, and securing participation at the facility level. The COVID-19 pandemic was also mentioned as an additional strain on the facilities’ ongoing and planned ASPs, the study authors said.

“Although there remains much to learn about the optimal structure and activities for centralized antimicrobial stewardship programs, there is immense potential to harness the power of health systems and networks to improve and expand antimicrobial stewardship within acute care hospitals and across novel settings,” the study authors concluded. “With increasing hospital mergers and acquisitions, health system antimicrobial stewardship is likely to expand in the coming decade.”