The California Antimicrobial Stewardship Program Initiative

The CDPH HAI Program has developed a statewide antimicrobial stewardship program initiative in order to strengthen and promote optimization of antibiotic utilization in California health care facilities. The purpose of an antimicrobial stewardship program is to measure and promote the appropriate use of antimicrobials by selecting the appropriate agent, dose, duration and route of administration in order to improve patient outcomes, while minimizing toxicity and the emergence of antimicrobial resistance (1). Antibiotic stewardship has been shown to be essential in the control of Clostridium difficile infections and the emergence of multidrug resistant organisms (1). Although guidelines exist for developing antimicrobial stewardship programs, there is limited information on practical implementation of these guidelines, particularly in resource-limited settings.

The Department of Health and Human Services (DHHS) with the Healthcare Infection Control Practices Advisory Committee enumerates antimicrobial stewardship as one of the top five messages for healthcare worker and consumer awareness in 2010 (2). DHHS, with the Center for Medicare and Medicaid Services, stipulates that long-term care facilities should use antibiotics appropriately, encouraging utilization of a consulting pharmacist to provide oversight (3). California Senate Bill 739 mandated that, by January 1, 2008, CDPH require general acute care hospitals to monitor and evaluate the utilization of antibiotics and charge a quality improvement committee with the responsibility for oversight of the judicious use of these medications (4). While hospitals are presumably aware of this mandate, guidance on implementation has been lacking. In December 2009, the HAI Program was created and by February 2010 a physician was identified to spearhead this initiative.

CDPH has many partners in this statewide initiative including, but not limited to: The Division of Healthcare Quality and Promotion at Centers for Disease Control and Prevention, The Infectious Disease Association of California, The Infectious Diseases Society of American, and

The Society of Healthcare Epidemiology of America.

Current program activities include:

Assessment of antimicrobial stewardship programs in place in California healthcare facilities in order to identify barriers to success and methods to overcome them: a) Information collected via word-of-mouth and a voluntary web-based surveillance tool released on May 1, 2010 (5); b) Developing evidence-based recommendations on how to implement or strengthen antimicrobial stewardship programs given available resources and facility attributes.
Consultative advice and practical evidence to facilities in order to gain administrative and pharmacy buy-in.

Regional collaborations among hospitals with similar difficulties and/or healthcare systems so that facilities can learn from one another on successful and unsuccessful strategies.

A committee of experts in antimicrobial stewardship across California assembled and charged with recommending internal and external outcome antimicrobial metrics.

Educating long-term care facilities on the benefits of antimicrobial stewardship programs and working on research proposals to better study the efficacy of antimicrobial oversight in the long-term care setting.

Working with the Antimicrobial Stewardship Subcommittee of the HAI Advisory Committee to consider educational opportunities for California facilities to learn and expand on their antimicrobial stewardship programs; expand current legislation to include long-term care facilities; and specify characteristics of an antimicrobial stewardship program required in California facilities.

For more information on Preventing Infections in Healthcare Settings, see Preventing Infections in Healthcare Settings

References:

Dellit, TH et al. Infectious Disease Society of American and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clin Infect Dis 2007;44:159-77.
http://www.hhs.gov/ash/initiatives/hai/9-hai-plan-outreach.pdf
Department of Health and Human Services, Center for Medicare and Medicaid Services. “Interpretive Guidelines for Long-Term Care Facilities, Tag F441”, CMS Manual System Pub. 100-07 State Operations Provider Certification, Transmittal 51, July 30, 2009.
http://www.dhcs.ca.gov/provgovpart/initiatives/nqi/Documents/SB739.pdf