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June 12, 2015

Recommendation 1: Develop common structure and process indicators for hospital antimicrobial stewardship programs

The first TATFAR recommendation refers to appropriate use of antimicrobials in human medicine through hospital Antimicrobial Stewardship Programs (ASPs) and, specifically, to develop of common structure and process indicators for ASP. These indicators should  characterize programs and allow for comparisons among healthcare systems in EU and US.

A multidisciplinary expert panel, coordinated by the European Center for Disease Prevention and Control (ECDC) and US Centers for Disease Control and Prevention (CDC). The expert panel participated in a structured consensus process (modified Delphi method) to facilitate multinational collaboration and to ensure  equal involvement of all experts. The process was conducted between March and May 2014 and was concluded by a group consensus meeting in June 2014. An initial list of indicators was developed based on previous indicators, available guidance and a review of the literature, including published systematic reviews. Indicators within the following domains were assessed: Governance and Management; Human Resources; Laboratory; Information Technology; Education; Policies for Appropriate Use; Guidelines, Activities and Interventions; and Monitoring of Appropriate Use. Experts rated each indicator for feasibility, clinical importance and relevance to minimizing antimicrobial resistance. Three rounds of rating followed by the in-person meeting led to a final set of 33 indicators. Among them 17 indicators were considered essential to characterize an ASP and therefore were included in a core set of indicators. The remaining 16 indicators were considered optional indicators and included in a supplemental set.

Implementation of the TATFAR-developed core indicators in multiple nations would contribute to a comprehensive, comparative description of infrastructure, policies, and practices of ASPs internationally. These findings could, in turn, lead to an understanding of best practices of ASPs through further investigation into the relation of different ASP approaches to antimicrobial use and resistance. Current public health surveillance systems or special studies may be candidates for the addition of ASP questions to baseline surveys. Furthermore these indicators are envisaged as drivers for improvement and alignment of best practices. 

Final Set of Core and Supplemental Indicators for Hospital Antimicrobial Stewardship Programs

CORE INDICATORS
for hospital antimicrobial stewardship programs

Infrastructure

Core (C)
Indicator
Number
Essential Indicator to Characterize an ASP
C1Does your facility have a formal antimicrobial stewardship program accountable for ensuring appropriate antimicrobial use?
C2Does your facility have a formal organizational structure responsible for antimicrobial stewardship (e.g., a multidisciplinary committee focused on appropriate antimicrobial use, pharmacy committee, patient safety committee or other relevant structure)?
C3Is an antimicrobial stewardship team available at your facility (e.g., greater than one staff member supporting clinical decisions to ensure appropriate antimicrobial use)?
C4Is there a physician identified as a leader for antimicrobial stewardship activities at your facility?
C5Is there a pharmacist responsible for ensuring appropriate antimicrobial use at your facility?
C6Does your facility provide any salary support for dedicated time for antimicrobial stewardship activities (e.g., percentage of full-time equivalent (FTE) for ensuring appropriate antimicrobial use)? 
C7Does your facility have the IT capability to support the needs of the antimicrobial stewardship activities?

Policy and Practice

Core (C)
Indicator
Number
Essential Indicator to Characterize an ASP
C8Does your facility have facility-specific treatment recommendations based on local antimicrobial susceptibility to assist with antimicrobial selection for common clinical conditions?
C9Does your facility monitor if the indication is captured in the medical record for all antimicrobial prescriptions?
C10Does your facility audit or review surgical antimicrobial prophylaxis choice and duration?
C11Are results of antimicrobial audits or reviews communicated directly with prescribers?

Monitoring and Feedback

Core (C)
Indicator
Number
Essential Indicator to Characterize an ASP
C12Has your facility produced a cumulative antimicrobial susceptibility report in the past year?
C13Does your facility monitor if the indication is captured in the medical record for all antimicrobial prescriptions?
C14Does your facility audit or review surgical antimicrobial prophylaxis choice and duration?
C15Are results of antimicrobial audits or reviews communicated directly with prescribers?
C16Has an annual report focused on antimicrobial stewardship (summary antimicrobial use and/or practices improvement initiatives) been produced for your facility in the past year?
C17Does your facility provide any salary support for dedicated time for antimicrobial stewardship activities (e.g., percentage of full-time equivalent (FTE) for ensuring appropriate antimicrobial use)? 

C = Core Indicator

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SUPPLEMENTAL INDICATORS
for hospital antimicrobial stewardship programs

Infrastructure

Related Core (C) IndicatorSupplemental (S) Indicator
Number
Optional Indicator to Characterize an ASP
NAS1Does your facility have a named senior executive officer with accountability for antimicrobial leadership?
C3: Is an antimicrobial stewardship team available at your facility?
 S2If YES, Is an infection preventionist or hospital epidemiologist involved in stewardship activities?
S3If YES, Is a microbiologist (laboratory staff) involved in stewardship activities?
S4Is clinical infectious disease (ID) consultation available at your facility?
C4: Is there a physician identified as a leader for antimicrobial stewardship activities at your facility?
 S5If YES, are stewardship duties included in the job description and/or annual review?
S6If YES, has this physician had specialized training in infectious diseases, clinical microbiology and/or antimicrobial stewardship?
C5: Is there a pharmacist responsible for ensuring appropriate antimicrobial use at your facility?
 S7If YES, has this pharmacist had specialized training in infectious disease management or stewardship?

Policy and Practice

Related Core (C) IndicatorSupplemental (S) Indicator
Number
Optional Indicator to Characterize an ASP
C9: Does your facility have a written policy that requires prescribers to document an indication in the medical record or during order entry for all antimicrobial prescriptions?
 S8If YES, for surgical prophylaxis?
S9If YES, for community-acquired pneumonia?
S10If YES, for urinary tract infection?
S11If YES to any of the clinical conditions above, are these treatment recommendations easily accessible to prescribers on all wards (printed ‘pocket guide’ or electronic summaries atworkstations)?
NA Are any of the following actions implemented in your facility to improve antimicrobial prescribing?
 S12Standardized criteria for changing from intravenous to oral antimicrobial therapy in appropriate situations?
S13Dose optimization (pharmacokinetics/pharmacodynamics) to optimize the treatment of organisms with reduced susceptibility?
S14Discontinuation of specified antimicrobial prescriptions after a pre-defined duration?

Monitoring and Feedback

Related Core (C) IndicatorSupplemental (S) Indicator
Number
Optional Indicator to Characterize an ASP
NAS15Does your facility measure the percentage of antimicrobial prescriptions that are consistent with the local treatment recommendations for either UTI or CAP?
C15: Are results of antimicrobial audits or reviews communicated directly with prescribers?
 S16If YES, are antimicrobial prescriptions for surgical prophylaxis compliant with facility-specific guidelines in >80% of sampled cases in your facility?

C = Core Indicator
S = Supplemental Indicator
NA = Not applicable to a specific Core Indicator

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Expert Panel

The following individuals participated in the development of these Core and Supplemental Indicators for hospital antimicrobial stewardship programs.

NameInstitutionCity/Country
Anastasia AntoniadouUniversity Hospital AttikonAthens, Greece
Bojana BeovicUniversity Medical CenterLjubljana, Slovenia
Franky BuyleGhent University HospitalGhent, Belgium
Sara CosgroveJohns Hopkins Medical InstitutionsBaltimore (MD), USA
Peter DaveyMedical Research InstituteDundee, UK
Elizabeth S. Dodds AshleyUniversity of Rochester Medical CenterRochester (NY), USA
Catherine DumartinBordeaux University HospitalBordeaux, France 
Alison HolmesDepartment of Medicine, Imperial College LondonLondon, UK 
Winfried KernUniversity of Freiburg Medical CenterFreiburg, Germany
Maria Luisa MoroRegional Agency for Health and Social Care of Emilia-RomagnaBologna, Italy
Dilip NathwaniDepartment of Medicine, University of DundeeDundee, UK
Jeanne NegleyGeorgia Department of Public HealthAtlanta (GA), USA 
Melinda NeuhauserVHA Pharmacy Benefits Management ServicesHines (IL), USA 
Christopher A. OhlWake Forest University School of MedicineWinston-Salem (NC), USA 
Diamantis PlachourasEuropean Centre for Disease Prevention and Control (ECDC)Stockholm, Sweden
Lori A. PollackCenters for Disease Control and Prevention (CDC)Atlanta (GA), USA 
Jeroen SchoutenSenior Researcher, Scientific Institute for Quality of HealthcareNijmegen, Netherlands 
Ed SeptimusHCA Healthcare SystemHouston (TX), USA
Marc StruelensEuropean Centre for Disease Prevention and Control (ECDC)Stockholm, Sweden 
Agnes Wechsler- FördösDepartment of Antibiotic and Infection ControlWien, Austria

TATFAR Coordinators

Diamantis Plachouras

Expert in Antimicrobial Resistance and Healthcare Associated Infections
Surveillance and Response Support Unit
European Centre for Disease Prevention and Control (ECDC)
Stockholm, Sweden

Lori A. (Loria) Pollack

Medical Officer,  US Public Health Service
Centers for Disease Control and Prevention
Division of Healthcare Quality Promotion
National Center for Emerging and Zoonotic Infectious Diseases
Atlanta, GA

Senior Advisors

Dominique L. Monnet

Head, Antimicrobial Resistance and Healthcare-associated Infections (ARHAI) Programme
European Centre for Disease Prevention and Control (ECDC)
Stockholm, Sweden

J. Todd Weber

Chief, Prevention and Response Branch
Centers for Disease Control and Prevention
Division of Healthcare Quality Promotion
National Center for Emerging and Zoonotic Infectious Diseases
Atlanta, GA

For more information on the outcome of this recommendation, contact the TATFAR Secretariat at TATFAR_Secretariat@cdc.gov.

Summary of TATFAR Recommendation 1 [ PDF - 5 Pages ]

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