Small Hospitals Struggle to Field Antibiotic Stewardship Teams

Prodded by the Joint Commission, the number of hospitals in the United States with antibiotic stewardship programs nearly doubled in 4 years, from 52% in 2013 to 95% in 2017. The Joint Commission made the presence of the programs a condition of accreditation in 2017. But their effectiveness, especially in smaller hospitals, is uneven, according to a recent study in Infection Control & Hospital Epidemiology, which looked at how such programs fared against Clostridioides difficile infection (CDI). C. diff causes nearly 500,000 infections in the US annually and leads to about 15,000 deaths.

The study is part of an ongoing survey in which investigators ask infection preventionists every 4 years what practices their hospitals are using to prevent common hospital-acquired infections (HAIs) often caused by antibiotic overuse. Hospitals that didn’t employ an infection preventionist were asked to have the lead infection preventionist serve as the primary respondent, “though we encouraged consulting with others to complete the questionnaire.” 

Investigators with the US Department of Veterans Affairs and the University of Michigan concluded that “many hospitals, especially smaller hospitals, appear to struggle with access to ID [infectious disease] expertise and with deploying diagnostic stewardship strategies. CDI prevention could be enhanced through diagnostic stewardship and by emphasizing the role of non–ID-trained pharmacists and clinicians in antibiotic stewardship.” 

They surveyed 528 hospitals, placing them in 3 categories: less than 50 beds, 50 to 250 beds, and more than 250 beds. The hospitals that had antibiotic stewardship programs were asked if the following professionals were on the team: infection preventionist, infectious disease (ID) physician, hospitalist, other physician, pharmacist with ID training, pharmacist without ID training, nurse, or other. 

“Most stewardship teams had a pharmacist (99%), a physician (95%, including ID physician [69%], hospitalist [48%], or other physician [44%]), and/or an infection preventionist (91%),” the study stated. 

It’s not clear whether all US hospitals have been able to meet the Joint Commission’s goals. This led the US Centers for Disease Control and Prevention (CDC) to recommend that antibiotic stewardship programs at critical access hospitals with more than 25 beds include a pharmacist and a physician leader. Larger hospitals were more likely to meet both the Joint Commission and CDC’s recommendations. 

“Although nearly all hospitals now have an antibiotic stewardship program, team compositions differ by hospital size, and most hospitals do not meet ideal recommendations for multidisciplinary teams,” the study concluded. “Specifically, smaller hospitals appear to have limited ID expertise on their stewardship teams and to struggle with deploying diagnostic stewardship strategies.” 

Systematic changes to attract physicians and pharmacists with ID expertise might help, but it’s a long-term solution. Another option would be telestewardship in which antibiotic use is monitored remotely by ID physicians. 

“Unfortunately, many systems are prevented from using telestewardship due to medico-legal barriers and lack of financial reimbursement,” the study stated. In addition, investigators could not determine how well high-tech CDI prevention strategies have fared because the evidence is mixed and the cost is high. “Thus, small hospitals may be appropriately delaying purchasing expensive new technology until more evidence supports their use.”

Knowing when, and when not, to do certain tests could also help. One way would be to automatically deny testing for CDI patients with formed stools. In addition, “up to 40% of hospitalized patients treated with antibiotics for presumed urinary tract infection have asymptomatic bacteriuria. Antibiotic use in this group increases adverse events and prolongs hospitalization without improving outcomes.” 

Among the study’s limitations are that it depended on self-reporting, and hospitals that do not have good antibiotic stewardship programs may not have participated for that reason.