Antibiotic Use in Hospitals, 2017

Antibiotic Use By Healthcare Setting

What Do We Know About Antibiotic Use In Hospitals?

In a 2016 study, CDC experts found that overall rates of antibiotic use in U.S. hospitals did not change from 2006-2012. More than half of patients received at least one antibiotic during their hospital stay.15 However, there were significant changes in the types of antibiotics prescribed with the most powerful antibiotics being used more often than others. There was a 37 percent rise in the use of carbapenems. Infections caused by bacteria that develop resistance to carbapenems can be especially hard to treat, and even deadly. There was also a 32 percent rise in the use of vancomycin, an important antibiotic used to treat common antibiotic-resistant infections caused by methicillin-resistant Staphyloccus aureus, or MRSA. Data from CDC’s National Healthcare Safety Network Antimicrobial Use Option show healthcare providers in some hospitals prescribe up to three times as many antibiotics as providers in similar areas of other hospitals. This variation suggests there are opportunities to improve prescribing practices.tibiotics in hospitals.

One-third of antibiotic prescriptions in hospitals involve potential prescribing problems such as giving an antibiotic without proper testing or evaluation, prescribing an antibiotic when it is not needed, or giving an antibiotic for too long.16 The National Action Plan for Combating Antibiotic-Resistant Bacteria pdf icon[218 KB] sets a goal that all hospitals have antibiotic stewardship programs to help reduce inappropriate antibiotic prescriptions by 20 percent by 2020.

Graph: Antibiotic Classes with the Largest Increases in Use, 2006–2012. Vancomycin: 32%; Beta-lactam/ inhibitor: 26%; 3rd/4th generation cephalosporins: 12%; and Carbapenems: 37%.

A national survey of antibiotic use done by CDC’s Emerging Infections Programs identified key opportunities to reduce inappropriate use. This study found that two out of three antibiotics in hospitals are given for three conditions: pneumonia, urinary tract infections (including bladder and kidney infections), and skin infections.17 There are data showing a variety of ways to improve antibiotic use in treating these conditions, so targeting them could have a large impact on improving appropriate antibiotic use. Likewise, studies have shown that there are many opportunities to improve the use of vancomycin and fluoroquinolones, two of the most commonly prescribed an

Graphic: Cover of The Core Elements of Hospital Antibiotic Stewardship Programs report produced by CDC.

Improving Antibiotic Use in Hospitals

Evidence demonstrates that hospital-based antibiotic stewardship programs improve the treatment of infections and reduce side effects associated with antibiotic use. They also significantly reduce hospital rates of C. difficile infection and antibiotic resistance. Moreover, these programs often achieve these benefits while saving hospitals money.

In 2014 CDC recommended that all acute care hospitals implement antibiotic stewardship programs. CDC’s Core Elements of Hospital Antibiotic Stewardship Programs provides a framework for establishing and improving antibiotic stewardship in hospitals. Since their adoption, the Core Elements have been used as an implementation framework by large health systems and have become part of The Joint Commission’s accreditation standard for antibiotic stewardship.


Core Elements of Antibiotic Stewardship For Hospitals
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Leadership Commitment

Dedicating necessary human, financial and information technology resources.

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Appointing a single leader responsible for program outcomes. Experience with successful programs show that a physician leader is effective.

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Drug Expertise

Appointing a single pharmacist leader responsible for working to improve antibiotic use.

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Implementing at least one recommended action, such as systemic evaluation of ongoing treatment need after a set period of initial treatment (i.e.“antibiotic time out” after 48 hours).

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Monitoring antibiotic prescribing and resistance patterns.

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Regular reporting information on antibiotic use and resistance to doctors, nurses and relevant staff.

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Educating clinicians about resistance and optimal prescribing.

Percent of Hospitals with Antibiotic Stewardship Programs by State, 2015
Graphic: Percent of Hospitals with Antibiotic Stewardship Programs by State, 2015. A hospital stewardship program is defined as a program following all 7 of CDC’s Core Elements of Hospital Antibiotic Stewardship Programs. Data Source: CDC’s National Healthcare Safety Network (NHSN) Survey. Nationally, 48.1% of all hospitals have stewardship programs (2,199 of 4,549); the national goal is 100% of hospitals by 2020. In 2015, states with the highest percentage of hospitals with antibiotic stewardship programs: California, Arizona, Utah, Florida, North and South Carolina, Virginia, Maryland, New Jersey, New York, Massachusetts, and Rhode Island. The lowest percent was found in: Montana, Colorado, North and South Dakota, Nebraska, Kansas, Minnesota, Iowa, Louisiana, Mississippi, New Hampshire, Vermont, and Puerto Rico.
Graph: Percentage of U.S. Acute Care Hospitals (n=4,569) Implementing All 7 Core Elements of Hospital Antibiotic Stewardship Programs: About 35% have less than 50 beds, 50% have 51–200 beds and About 60% have over 200 beds.

The Core Elements were designed to be flexible enough to be adopted in hospitals of any size. In 2016, CDC partnered with the National Quality Partnership of the National Quality Forum, a not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in health care, to lead a team of experts in creating a practical guide to help hospitals implement the Core Elements. The Antibiotic Stewardship in Acute Care: A Practical Playbookexternal icon provides real-world strategies to help hospitals and health systems of all sizes implement and improve antibiotic stewardship programs.

CDC has been assessing the implementation of the Core Elements through the NHSN Annual Survey. In 2014, 41 percent of hospitals reported implementing all seven elements. By 2015, that had increased to 48 percent. However, there were important differences in implementation, with larger hospitals showing much more uptake: 66.1 percent of hospitals with over 200 beds reported all seven Core Elements, compared to 49.6 percent of hospitals with 51–200 beds and 31.1 percent of hospitals with 1–50 beds. Data from this survey indicate that there is much more to do, especially in smaller hospitals which face special challenges in implementing the Core Elements. CDC partnered with The Pew Charitable Trusts, the American Hospital Association and the Federal Office of Rural Health Policy to develop Implementation of Antimicrobial Stewardship Core Elements at Small and Critical Access Hospitals to support the implementation of stewardship programs in these hospitals.

CDC’s Standardized Antimicrobial Administration Ratio (SAAR): Assessment Tool Offers Step for Improvement

The NHSN Antimicrobial Use Option is available to hospitals currently using NHSN and allows hospitals to monitor antibiotic use. The centerpiece of the Antimicrobial Use Option is a risk-adjusted benchmarking measure of antibiotic use, the Standardized Antimicrobial Administration Ratio, or SAAR, which was endorsed by the National Quality Forum in 2016. The SAAR calculates the ratio of observed antibiotic use to predicted antibiotic use, based on modeled data from all reporting hospitals and allows hospitals to compare their antibiotic use with similar facilities. The SAAR offers a way to collect data for action by allowing facilities to not only compare their antibiotic use to others, but to monitor use over time. CDC is working with a variety of experts to further improve the SAAR. For example, experts suggested that a variety of different benchmarks would be most useful, so CDC has developed SAARs for five different antibiotic categories and several different hospital locations.

While the SAAR cannot be used to measure the appropriateness of antibiotic use in a hospital, it can be used to direct hospital antibiotic stewardship programs to areas where antibiotic use deviates from what is expected. A high SAAR signals a need for further review to see if there are opportunities to improve use. CDC collaborated with The Pew Charitable Trusts and a number of experts to develop an assessment tool to help hospitals find opportunities to improve use in locations with high SAARs. Though the tool is designed to be used in conjunction with the SAAR, it could be used to look for improvement opportunities in any location where stewardship programs believe use is higher than expected. For more information on the SAAR and strategies to assess antibiotic use in hospitals, visit Strategies to Assess Antibiotic Use to Drive Improvements In Hospitals pdf icon[PDF – 460 KB].

CDC collaborates with partners to implement appropriate antibiotic use efforts at a local level. CDC funds and supports many state and local health departments and other partners across the country to implement targeted antibiotic stewardship improvements in hospitals.

Ascension: Building the Infrastructure for Antibiotic Stewardship in a Large Health System

Ascension is the largest non-profit health system in the United States, with facilities in 25 states and the District of Columbia, including 141 hospitals and more than 21,000 acute care beds.

Ascension has made swift progress in its antibiotic stewardship efforts by implementing four strategies in support of full implementation of CDC’s Core Elements in all Ascension hospitals:

  • Making antibiotic stewardship a system priority with full leadership support.
  • Creating an infrastructure to promote and share best practices.
  • Promoting the careful use of narrow-spectrum antibiotics (antibiotics that are specifically effective against a limited number of bacteria).
  • Helping hospitals achieve their goals by investing in clinical decision support systems, strengthening local expertise, and tracking and evaluating antibiotic use data.

As a result of these efforts, Ascension has seen reductions in antibiotic use and 15.9 percent reduction in C. difficile infections. One 376-bed teaching hospital drove a 70 percent drop in the use of selected antibiotics over a six-month period.

Intermountain Healthcare: Using Data to Identify Opportunities for Improvement

Intermountain Healthcare is a not-for-profit health system based in Salt Lake City, Utah, with 22 hospitals, about 1,400 primary care and secondary care physicians at more than 185 clinics in the Intermountain Medical Group, and health insurance plans from SelectHealth. Intermountain Healthcare has been an early adopter of the NHSN Antimicrobial Use Option and has been using the data for action. For example, they identified one facility that had an overall antibiotic SAAR measure indicating use was as expected, but found one very high SAAR – for antibiotics used for surgical prophylaxis on adult surgical units—indicating higher use of these antibiotics than would be expected. This highlighted a specific area for further exploration and improvement.

Graph: Ratio of observed to expected antibiotic use Standardized Antimicrobial Administration Ratio (SAAR) by category and unit type in one Intermountain Healthcare facility, Quarter 1, 2016. A SAAR value of less than 1 indicates less than expected antibiotic use, and a value greater than 1 indicates higher than expected antibiotic use. Higher than expected antibiotic use occurred overall, With Broad-spectrum antibiotics in adult ICUs and in adult medical/surgery, and also with anti-MRSA antibiotics in adult medical/surgery. Significantly higher than expected use was found with antibiotics for surgical prophylaxis in adult surgical units. Lower than expected use was only found with Anti-MRSA antibiotics in adult medical/surgery.

Southwest Health System: Pharmacist-led Antibiotic Stewardship in a Small Health System

Southwest Health System (SHS) serves about 50,000 people in rural southwest Colorado, and in parts of Utah, Arizona, and New Mexico, and the Ute Mountain and Navajo reservations. SHS has 25 inpatient beds and 8 clinics. SHS has made antibiotic stewardship a priority through a variety of strategies while implementing CDC’s Core Elements:

  • Creating a stewardship team of hospital leaders, including laboratory professionals, physicians, pharmacists, infection preventionists, nurse educators, and a wound care specialist.
  • Using pharmacists to lead the antibiotic stewardship program. Pharmacists also work to decrease risk of C. difficile by adjusting medications.
  • Educating hospital staff and providing feedback through active daily rounding where staff discuss medications, antibiotic choice, duration of therapy, and discharge medications.
  • Collaborating with partners in a state-wide antibiotic stewardship collaborative (including implementation of a urinary tract infection (UTI)/upper respiratory infection (URI) stewardship program in SHS’ eight clinics) and seeking efforts to expand stewardship to local long-term care organizations and dentists.

The Richard L. Roudebush Indianapolis Veterans Affairs Medical Center: Using NHSN Data to Evaluate a Stewardship Activity

The Richard L. Roudebush VA Medical Center located in Indianapolis, Indiana, is a general medical and surgical hospital and teaching hospital with 150 beds. The organization used CDC’s NHSN Antimicrobial Use Option to evaluate their hospital stewardship program. Infectious disease physicians and clinical pharmacists tracked and reviewed antibiotic usage in their hospital and gave feedback to providers. They used NHSN data to track antibiotic use before and after the intervention and identified a hospital-wide decrease in antibiotic use, as reflected in lower SAAR values, especially in anti-MRSA agents and antibiotics used for
hospital onset infections, which were targets of their reviews.

State Policies to Improve Antibiotic Use in Hospitals

  • California: California Senate Bills 739 and 1311 require hospitals to develop a process for monitoring antibiotic use and implementing antibiotic stewardship. California was the first state to enact legislation to improve antibiotic use.
  • Missouri: In addition to requiring all Missouri hospitals to create antibiotic stewardship programs, Missouri Senate Bill 579 (passed in 2016), requires that all non-psychiatric hospitals must begin reporting antibiotic use to CDC’s NHSN by August 2017.
Photo: Physician in a hospital reviewing a patient’s antibiotic therapy 2–3 days after it is started based on the patient’s clinical condition and microbiology culture results.

Healthcare Providers, Patients, and Families Play a Critical Role In Supporting Optimal Antibiotic Use and Preventing Infections In Hospitals.

What can healthcare providers do to support appropriate antibiotic use and prevent infections in hospitals?

  • Follow clinical guidelines when prescribing antibiotics.
    • Use the right antibiotic, at the right dose, for the right duration, and at the right time.
  • Review antibiotic therapy 2–3 days after it is started based on the patient’s clinical condition and microbiology culture results.
  • Talk to patients and families about when antibiotics are and are not needed, and discuss possible harms such as allergic reactions, C. difficile and antibiotic-resistant infections.
    • Ask patients if they have ever had a C. difficile infection, and tailor antibiotic treatment accordingly.
  • Be aware of antibiotic resistance patterns in your facility and community; use the data to inform prescribing decisions.
  • Follow hand hygiene and other infection prevention measures with every patient.

What can patients and families do to support appropriate antibiotic use and prevent infections in hospitals?

  • Talk to your healthcare provider about when antibiotics will and won’t help, and ask about antibiotic resistance.
  • Ask what infection an antibiotic is treating, how long antibiotics are needed, and what side effects might happen.
  • Tell your healthcare provider if you have been hospitalized in another facility or have recently taken antibiotics.
  • If you have a urinary catheter, ask daily if it’s necessary.
  • Ask what your hospital is doing to protect you and your family from antibiotic-resistant and C. difficile infections.
  • Insist that everyone cleans their hands before touching you.
  • Get vaccinated for flu and pneumonia, and encourage others to stay up-to-date on vaccines.