Antibiotic Stewardship Implementation Framework for Health Departments
Antibiotic resistance is an urgent public health problem that is responsible for over 2.8 million infections and more than 35,000 deaths annually in the United States1. The misuse of antibiotics has contributed to the growing problem of resistance and improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority2. Because antibiotics are a shared resource, the potential for spread of resistant organisms means that the misuse of antibiotics can adversely impact the health of patients, even those who are not directly exposed to them. Further, like all medications, antibiotics can have unintended consequences, including adverse drug reactions and Clostridioides difficile infection (CDI)2.
Antibiotic stewardship refers to coordinated interventions designed to improve the use of antibiotics. Antibiotic stewardship programs have been shown to increase optimal prescribing for therapy and prophylaxis, improve the quality of patient care, reduce adverse events associated with antibiotic use such as CDI and resistance, and offer cost savings to hospitals2. CDC recommends that antibiotic stewardship programs be implemented in all hospitals3.
State and local health departments play critical roles as partner and convener across the healthcare continuum and are positioned to promote appropriate antibiotic use and prevention strategies to limit the development of antimicrobial resistance4. In 2014, the Council of State and Territorial Epidemiologists (CSTE) submitted a policy position statement recommending that all state health departments evaluate and incorporate stewardship activities across healthcare settings into their healthcare-associated infection (HAI) programs5. The Association of State and Territorial Health Officials also advocates for state and local health departments to play coordinating and facilitating roles to address antimicrobial resistance by implementing stewardship activities across the healthcare continuum of care6. The National Association of County and City Health Officials also supports local health departments’ participation and engagement in antibiotic stewardship activities7.
What activities can state and local health departments do to implement antibiotic stewardship?
- Establish leadership in health departments by identifying a lead to evaluate and incorporate stewardship activities into the healthcare-associated infection (HAI) program; secure expertise knowledgeable on antibiotic stewardship activities and tools (e.g., from within agency and/or engagement with local/state based stewardship leaders); and identify staff available to evaluate antibiotic stewardship programs and antibiotic resistance patterns and trends.
- Conduct surveillance to understand current stewardship practices/needs across facilities. Surveillance should include tracking HAIs as well as some aspect of resistance patterns (e.g., antibiotic resistance associated with HAIs, single pathogens of concern, or cumulative susceptibility data), including outbreaks of antibiotic-resistant infections and evaluation of progress in stewardship implementation through ongoing assessment of stewardship activities and needs.
- Coordinate and integrate stewardship activities with ongoing quality improvement efforts both within own agency and by reaching out to Quality Improvement Organizations (e.g., Centers for Medicare & Medicaid Services Quality Innovation Network-Quality Improvement Organizations), Hospital Improvement and Innovation Networks, and Hospital Associations to synergize activities.
- Convene prevention collaboratives for facilities who commit to sharing tools and best practices; link facilities with each other to enhance antibiotic stewardship across a region; incorporate local surveillance data into collaborative actions; and share effective methods for stewardship implementation and promote guidance and best practices.
- Provide and develop education and tools on appropriate antibiotic prescribing for facilities and healthcare professionals; make stewardship resources available on website; support training of professionals and facilities on antibiotic stewardship through hosting online or in-person education.
- Develop a communications plan to reach and maintain relationships with facilities and organizations with similar goals and guide partners to appropriate stewardship resources; incorporate antibiotic stewardship into departmental reports and improvement plans; raise public awareness of antibiotic overuse and potential risks; and reach out to public regarding appropriate antibiotic use and issue of antibiotic resistance.
- Inform the legislative process to advance appropriate antibiotic use. Health department leadership have the opportunity to educate policymakers about the importance of appropriate antibiotic use. State and local health departments can provide recommendations for stewardship programs and work with health policy organizations, including health insurance providers, to initiate mandates such as tracking individual provider prescribing.
State Antibiotic Stewardship Implementation Resources
Leadership Letter of Commitment, AK pdf icon[PDF – 105 KB]
- Letter template addressed to a stewardship collaborative advisory committee from a healthcare organization Chief Executive Officer expressing a commitment to antibiotic stewardship activities and participation in a collaborative effort to improve patient care.
Call to Action Letter, CT pdf icon[PDF – 31 KB]
- Call to action letter from a Public Health Commissioner to healthcare providers expressing the importance of antibiotic stewardship and providing examples of ways for providers to take action to address the threat of antibiotic resistance.
Honor Roll for Antibiotic Stewardship, WA pdf icon[PDF – 344 KB]
- Honor roll program sponsored by a state health department to highlight hospitals implementing antibiotic stewardship programs. This document describes the requirements for recognition on the honor roll, a fillable application, and instructions for submission.
Work Plan for Healthcare-associated Infections and Antimicrobial Resistance Committee, LA County pdf icon[PDF – 103 KB]
- Work plan for a committee focused on leading activities for healthcare-associated infections and antibiotic stewardship in a local health department. This document provides the committee’s goals, objectives, and meeting schedule.
Summit on Antibiotic Stewardship, IL pdf icon[PDF – 799 KB]
- Agenda for a summit bringing together state health department and academic partners to provide education and training on antibiotic stewardship for providers, pharmacists, and administrators across the spectrum of healthcare.
Map of County-level Prescribing Rates, NY pdf icon[PDF – 133 KB]external icon
- County-level analysis of rates of avoidable outpatient antibiotic prescriptions for acute upper respiratory infections using state Medicaid data.
Provider Outreach Letter, NY pdf icon[PDF – 95 KB]
- Outreach letter targeting prescribers practicing in counties reporting high rates of avoidable outpatient antibiotic prescribing. The letter contains an explanation of the problem and offers educational materials.
Antimicrobial Use and Informatics Capabilities Survey, CA pdf icon[PDF – 107 KB]
- Survey to assess how hospitals are measuring antibiotic use and facility capabilities regarding submitting data to the National Healthcare Safety Network (NHSN).
Stewardship Assessment Tool, LA pdf icon[PDF – 195 KB]
- Tool to collect information on hospitals and their antibiotic stewardship programs.
Agenda for Meeting Hosted by Pharmacist-Led Collaborative for Antimicrobial Stewardship, AR pdf icon[PDF – 499 KB]external icon
- Agenda for a meeting hosted by an antibiotic stewardship collaborative offering education on implementation and examples of programs implemented in hospitals.
Logic Model, GA pdf icon[PDF – 45 KB]
- Logic model providing a framework for antibiotic stewardship activities and a plan for implementing stewardship statewide across the continuum of healthcare.
Antibiotic Stewardship Program Collaborative Invitation, CA pdf icon[PDF – 243 KB]external icon
- Invitation for acute care facilities to participate in an antibiotic stewardship program collaborative, a description of the program including an explanation of the motivation behind forming the collaborative, examples of activities hosted by the collaborative, and instructions for how facilities can enroll.
Collaborative Charter, IL pdf icon[PDF – 297 KB]
- Charter for an antibiotic stewardship collaborative comprised of acute care hospitals including an outline of the goals, structure, and activities of the collaborative.
Stewardship in Small, Rural Hospitals Workbook, WA pdf icon[PDF – 440 KB]
- Toolkit providing baseline assessments and resources for how to implement antibiotic stewardship in small, rural hospitals.
Antibiotic Stewardship in Long-term Care Toolkit, MNexternal icon
- Toolkit providing baseline assessments and resources for how to implement antibiotic stewardship in long-term care facilities.
Educational Curriculum, ORexternal icon
- Educational curricula for the public, kindergarten through 3rd grade, 4th through 6th grade, and high school students about antibiotic resistance and appropriate antibiotic use.
Training Day on Stewardship in Long-term Care, WA pdf icon[PDF – 460 KB]
- Agenda for a training on implementing an antibiotic stewardship program in long-term care settings.
Communication Campaign Implementation Guide, IL pdf icon[PDF – 57 KB]external icon
- Communications campaign and the guide provided to outpatient clinicians and facilities with information and resources on how to implement the campaign in their facilities.
Get Smart Week Activities Summary, MN pdf icon[PDF – 739 KB]
- Summary of activities the state participated in during Get Smart About Antibiotics Week 2015 and the analytics for website views and social media impressions.
Get Smart Week Letter, AZ pdf icon[PDF – 185 KB]
- Letter template to partners providing a summary of Get Smart About Antibiotics Week activities and ways that individuals can participate.
Communication from Director about Antibiotic Resistance Threat and the Importance of Stewardship, AR pdf icon[PDF – 103 KB]
- Communication from a health department director providing a description of the issue of antibiotic resistance and the importance of antibiotic stewardship.
Website for Communications Campaign, ILexternal icon
- Website describing a communications campaign promoting appropriate use of antibiotics in the outpatient setting, the partners involved in the campaign, and links to resources.
Senate Bill 739, CA pdf icon[PDF -57 KB]external icon
- Link to the Senate Bill passed in California in 2006 requiring acute care hospitals to have a process for evaluating antibiotic use.
Senate Bill 1311, CAexternal icon
- Link to the Senate Bill passed in California in 2014 requiring all acute care hospitals in CA to have an antibiotic stewardship program following federal guidelines.
Gubernatorial Proclamation for Get Smart Week, MN pdf icon[PDF – 460 KB]external icon
- Gubernatorial proclamation for Get Smart Week in Minnesota to increase awareness about the issue and participation in the activities.
- Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2019. Atlanta, GA: US Department of Health and Human Services, CDC; 2019.
- Centers for Disease Control and Prevention. Core elements of hospital antibiotic stewardship programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014.
- Fridkin SK, Baggs J, Fagan R, et al. Vital signs: Improving antibiotic use among hospitalized patients. MMWR 2014;63:194-200.
- Trivedi KK, Pollack LA. The role of public health in antimicrobial stewardship in healthcare. Clin Infect Dis 2014;59:101-3.
- Council of State and Territorial Epidemiologists. CSTE Position Statement 14-ID-01. Recommendations for strengthening antimicrobial stewardship in the United States, including the role of the state and local health departments pdf icon[PDF – 223 KB]external icon. 2014.
- Association of State and Territorial Health Officials. Combating antibiotic resistance: Policies to promote antimicrobial stewardship programsexternal icon. 2015.
- National Association of County and City Health Officials. Antimicrobial resistance and stewardship: Local efforts on a global issue pdf icon[PDF – 228 KB]external icon. 2015.