Core Elements of Antibiotic Stewardship for Health Departments
Ensuring appropriate use of antibiotics is one of CDC’s core strategies to combat the urgent threat of antimicrobial resistance and to provide the best, safe care. Antibiotic stewardship can optimize the treatment of infections and ensure equitable access to high quality health care. State and local health department antibiotic stewardship programs (SLHD-ASP) play an important role in guiding antibiotic stewardship efforts in various healthcare settings and promoting appropriate antibiotic use for all patients in their communities.
The Centers for Disease Control and Prevention (CDC) released the Core Elements of Antibiotic Stewardship for healthcare settings outlining structural and procedural components that are associated with successful antibiotic stewardship programs. This document adapts the Core Elements framework to outline the structure of a SLHD-ASP and provides recommended stewardship implementation activities based on experiences of successful SLHD-ASPs (Figure 1). State and local health departments vary by their capacity, resources, and governance. [1] SLHD-ASPs need to select and adapt stewardship strategies to best meet local healthcare needs. Smaller local health departments, U.S. territories, and Affiliated Pacific Islands can select specific implementation strategies based on their priorities and available resources. [2]
SLHD-ASP’s unique positions allow them to guide and support stewardship activities and collaboratives with a variety of partners including integrated health systems, payers, professional organizations, academic partners, quality improvement organizations, licensing and regulatory agencies, and others. SLHD-ASPs can work together as part of regional and national collaboratives to engage with different healthcare settings including acute care (e.g., hospitals, critical access hospitals, long-term acute care hospitals), outpatient care (e.g., ambulatory care, urgent care, dialysis, dental), and long-term care settings (e.g., nursing homes, skilled-nursing, ventilator skilled-nursing and assisted living facilities). [3, 4]
Measurement is critical to identify opportunities for improving prescribing practices and to assess the impact of stewardship interventions. SLHD-ASP should monitor stewardship activities and antibiotic use data across the spectrum of health care.
- Tracking stewardship activities by assessing the uptake of the Core Elements can help identify facilities and settings that need the most support. [18-20]
- Tracking antibiotic use across different healthcare settings will identify where stewardship interventions are most needed and monitor their effectiveness. For settings with limited access to antibiotic use data, SLHD-ASP can leverage stewardship collaboratives to track data at the local level, specifically emphasizing electronic tracking to minimize burden, ensure sustainability, and allow for data validation.
SLHD-ASP programs can choose different data sources to track stewardship activities and antibiotic use:
Tracking data on stewardship activities and Core Elements uptake
- Track the uptake of the Core Elements (including Priorities for Hospital Core Element Implementation) through NHSN group function and compare to national or regional distributions available on the Antibiotic Resistance & Patient Safety Portal (ARPSP).
- Engage with healthcare facilities and health systems to track and validate nationally reported Core Elements data.
- Review completed Infection Control Assessment Tools and other surveys [21] to identify healthcare facilities that need stewardship technical assistance.
- Engage with state survey or agencies and review Centers for Medicare and Medicaid Services (CMS) long-term care stewardship citations to help long-term care facilities address gaps in their stewardship programs.
- Conduct a survey of outpatient facilities [22] to assess engagement in antibiotic stewardship and uptake of the Core Elements.
- Evaluate stewardship programs through setting-specific assessment tools based on the implementation of activities outlined in the Core Elements to inform facility certificates (e.g., honor roll).
Tracking antibiotic use data
- Analyze data sources to track antibiotic use across different healthcare settings directly or through a stewardship collaborative. Antibiotic use data can be stratified by practice setting, prescriber specialty, drug or class of interest, appropriateness of prescribing [15, 23]. Antibiotic use data can be compared to national or regional distributions available on the ARPSP. Examples of data sources by setting include:
- Inpatient data sources (e.g., NHSN Antimicrobial Use and Resistance Module Standardized Antimicrobial Administration Ratio (SAAR) risk-adjusted summary measure through NHSN group function [13])
- Outpatient data sources (e.g., Medicaid [24], All-Payer Claims Databases, [25] CMS Part D Public Use Files, electronic health records, proprietary data)
- Long-term care data sources (e.g., long-term care pharmacy transactions, electronic health record antibiotic orders/administrations)
- Assess data sources for availability of health equity-related variables that may identify disparities in antibiotic prescribing. When feasible, incorporate health equity-related variables in surveillance and data analyses at the patient, facility, and community levels.
Public health engagement in implementation of sustainable antibiotic stewardship activities is critical to support national and local efforts to improve antibiotic use and combat antimicrobial resistance. Antibiotic stewardship is integral to healthcare quality improvement and ensures that patients receive the best treatment for infections while minimizing the risk of adverse events. SLHD-ASPs play an important role in providing access to stewardship expertise and supporting stewardship collaboratives in their jurisdictions. [3, 4] The implementation of the Core Elements of Antibiotic Stewardship should be a dynamic process. Ensuring Leadership support, Accountability and Expertise is central to developing an effective SLHD-ASP. Tracking of stewardship activities and antibiotic use data and Reporting these data to relevant partners can inform stewardship Education & Actions (Figure 2). Continuous evaluation is important to assess progress and identify new stewardship activities. The expansion of SLHD-ASP will allow the identification of priority implementation strategies to inform future stewardship initiatives.
