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• W2793231214 abstract "During 2012, the Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America (SHEA) published a position paper highlighting the critical importance of infection preventionists (IPs) and health care epidemiologists (HEs) in effective antimicrobial stewardship (AS) programs.1Moody J. Cosgrove S.E. Olmstead R. Septimus E. Aureden K. Oriola S. et al.Antimicrobial stewardship: a collaborative partnership between infection preventionists and health care epidemiologists.Am J Infect Control. 2012; 40: 94-95Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar AS refers to collaborative, coordinated programs and interventions designed to improve antimicrobial prescribing (ie, right drug, dose, duration, and route of administration when antibiotics are needed) to optimize clinical outcomes while minimizing unintended consequences of antimicrobial agent use such as toxicity, selection of pathogenic organisms, and emergence of resistance.2Barlam T.F. Cosgrove S.E. Abbo L.M. MacDougall C. Schuetz A.N. Septimus E.J. et al.Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.Clin Infect Dis. 2016; 62: e51-e77Crossref PubMed Scopus (1557) Google Scholar, 3Dellit T.H. Owens R.C. McGowan J.E. Gerding D.N. Weinstein R.A. Burke J.P. et al.Infectious Disease Society of America and the Society for Healthcare Epidemiology of America guideline for developing an institutional program to enhance antimicrobial stewardship.Clin Infect Dis. 2007; 44: 159-177Crossref PubMed Scopus (2441) Google Scholar In the intervening 5 years, much has happened to garner national and regulatory attention to the growing problem of antimicrobial resistance (AMR) and the importance of AS and the concomitant stewardship of diagnostic testing as strategies to slow the emergence of resistant organisms while limiting unintended consequences such as selecting for resistant pathogens and the development of Clostridium difficile infection (CDI). This paper updates and reaffirms the critical role of IPs and HEs in the prevention and control of health care-associated infections (HAIs), particularly those caused by multidrug-resistant organisms (MDROs). The key supporting role of infection prevention and control (IPC) programs in advancing the synergistic strategy of AS alongside physician and pharmacist AS leaders is also highlighted. Three watershed events occurred in recent years to increase AMR and AS awareness among health care providers, policy makers, and the public. First, the human and economic cost of AMR in the United States was revealed in the Centers for Disease Control and Prevention (CDC) report, Antibiotic Resistance Threats in the United States, 2013.4Centers for Disease Control and Prevention (CDC) Antibiotic resistance threats in the United States 2013.http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdfDate: 2013Date accessed: August 11, 2017Google Scholar Using conservative estimates, the CDC determined that antibiotic-resistant organisms are responsible for more than 2 million infections and 23,000 deaths per year in the United States, at a direct cost of $20 billion.4Centers for Disease Control and Prevention (CDC) Antibiotic resistance threats in the United States 2013.http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdfDate: 2013Date accessed: August 11, 2017Google Scholar This report provided the first comprehensive snapshot of dangers posed by antibiotic-resistant organisms in the United States, categorizing these hazards as urgent, serious, or concerning. A subsequent, and perhaps more sobering 2014 report commissioned by the UK Prime Minister and the Wellcome Trust suggested that without global action, 10 million deaths from AMR infections will occur worldwide by 2050.5O'Neill J The review on antimicrobial resistance. Antimicrobial resistance: tackling a crises for the health and wealth of nations.http://amr-review.org/Date: 2014Date accessed: September 5, 2017Google Scholar Second, in response to this escalating problem, in 2014 President Obama implemented the National Strategy on Combating Antibiotic Resistant Bacteria through Executive Order 13676, followed in March 2015 by release of the National Action Plan for Combating Antibiotic-Resistant Bacteria,6The White House National action plan for combating antibiotic-resistant bacteria.https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdfDate: 2015Date accessed: August 11, 2017Google Scholar which outlines specific actions to be taken to implement the strategy. The action plan provides a 5-year roadmap outlining critical actions by key federal departments and agencies, as well as goals, milestones, and metrics for measuring progress. Of specific interest to IPs and HEs are actions for major reductions in the incidence of urgent and serious threats, including carbapenem-resistant Enterobacteriaceae, methicillin-resistant Staphylococcus aureus, and CDI; improved AS across all health care settings; and enhanced capacity to prevent the spread of resistant infections.6The White House National action plan for combating antibiotic-resistant bacteria.https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdfDate: 2015Date accessed: August 11, 2017Google Scholar Third, following release of the action plan, the White House convened the first-ever Forum on Antibiotic Stewardship and established the Presidential Advisory Council on Combating Antibiotic Resistant Bacteria. The Forum brought together 150 key human and animal health constituencies involved in AS, providing participants the opportunity to exchange ideas on ways public and private sectors can work together to improve responsible use of antibiotics, as well as commit to action.7The White House Briefing Room Fact sheet: over 150 animal and health stakeholders join white house efforts to combat antibiotic resistance.https://www.whitehouse.gov/the-press-office/2015/06/02/fact-sheet-over-150-animal-and-health-stakeholders-join-white-house-effoDate: 2015Date accessed: August 11, 2017Google Scholar The Advisory Council provides advice, information, and recommendations to the Secretary of Health and Human Services regarding programs and policies intended to support and evaluate the implementation of federal activities related to combating antibiotic-resistant bacteria.8Presidential Advisory Council on Combating Antibiotic Resistant Bacteria (PACCARB) https://www.hhs.gov/ash/advisory-committees/paccarb/index.htmlDate accessed: November 1, 2017Google Scholar Of note, the 2015 APIC, SHEA, and Society of Infectious Diseases Pharmacists (SIDP) presidents participated in the Forum on Antibiotic Stewardship and the 2017 APIC and SHEA presidents gave presentations during the Advisory Council meeting for nonfederal stakeholders during January 2017. These 3 events directly influenced the development of subsequent reports and recent regulatory mandates that highlight the key supporting role of IPC programs in advancing successful AS interventions across the entire continuum of patient care, including:•CDC Core Elements of Hospital Antibiotic Stewardship Programs,9Centers for Disease Control and Prevention (CDC) Core elements of hospital antibiotic stewardship programs.http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdfDate: 2014Date accessed: August 11, 2017Google Scholar CDC Core Elements of Antibiotic Stewardship for Nursing Homes,10Centers for Disease Control and Prevention (CDC) Core elements of antibiotic stewardship programs for nursing homes.https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.htmlDate: 2015Date accessed: August 11, 2017Google Scholar CDC Core Elements of Outpatient Antibiotic Stewardship,11Centers for Disease Control and Prevention (CDC) Core elements of outpatient antibiotic stewardship.https://www.cdc.gov/getsmart/community/pdfs/16_268900-a_coreelementsoutpatient_508.pdfDate: 2016Date accessed: August 11, 2017Google Scholar and Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals.12Centers for Disease Control and Prevention (CDC) Implementation of antibiotic stewardship core elements at small and critical access hospitals.https://www.cdc.gov/getsmart/healthcare/implementation/core-elements-small-critical.htmlDate: 2017Date accessed: August 11, 2017Google Scholar Each document identifies key structural and functional aspects of effective programs, and indicates that the work of physician and pharmacist AS program leaders is greatly enhanced by the support of other key groups, including IPC programs.•National Quality Partners Playbook: Antibiotic Stewardship in Acute Care.13National Quality Forum Antibiotic stewardship in acute care: a practical playbook.http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=82501Date: 2016Date accessed: August 11, 2017Google Scholar This comprehensive tool uses the CDC core elements as a framework and provides concrete strategies and practical suggestions to guide hospitals in strengthening existing AS initiatives or creating successful AS programs from the ground up.•The Centers for Medicare and Medicaid Services new requirements for participation rule, effective in 2016, requires long-term care (LTC) facilities to update their IPC program, including requiring an IPC officer in 2019, and an AS program that includes antibiotic use protocols and a system to monitor antibiotic use to be implemented in 2017.14Centers for Medicare and Medicaid Services CMS finalizes improvements in care, safety, and consumer protections for long-term care facility residents.https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-09-28.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descendingDate: 2016Date accessed: November 12, 2017Google Scholar The Centers for Medicare and Medicaid Services proposed infection control conditions-of-participation rule that requires AS programs in all acute care and critical access hospitals is among the pending regulations awaiting approval.•The Joint Commission Antimicrobial Stewardship Standard MM.09.01.01, effective January 1, 2017, requires hospitals, critical access hospitals, and nursing care centers have AS programs based on current scientific publications, and to have an AS multidisciplinary team that includes IPs.15The Joint Commission New antimicrobial stewardship standard.https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdfDate accessed: July 6, 2017Google Scholar The original standard contained 8 elements of performance (EPs)15The Joint Commission New antimicrobial stewardship standard.https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdfDate accessed: July 6, 2017Google Scholar; however, effective October 1, EP 3 (The [critical access] hospital educates patients, and their families as needed regarding the appropriate use of antimicrobial medications, including antibiotics) was deleted. This decision was based on feedback to The Joint Commission that education for patients regarding specific antimicrobial therapy they are receiving is already required under other medication management standards and that the value of general education on AS principles was unlikely to be retained by hospitalized patients and families and would be more appropriately delivered in outpatient settings.16The Joint Commission EP deletion: MM.09.01.01, EP 3 going away.https://www.jointcommission.org/issues/article.aspx?Article=YorQ4E0NZh1SOmOxW2H%2FtFFcVyCrphOFImQsZM%2BIvPc%3DDate accessed: November 11, 2017Google Scholar IPC and AS are bound by a strong esprit de corps and shared common goal—to keep patients safe and to improve patient outcomes, regardless of where care is delivered. The increasing incidence of MDRO infections has become a safety concern for patients across the continuum of patient care. MRDO infections are more difficult to treat, incur greater treatment costs, and have greater morbidity and mortality than infections caused by organisms susceptible to antibiotics. Antibiotic misuse and overuse facilitates the development of MDROs, as well as CDI infections – an antibiotic-associated adverse drug event – making AS an important synergistic HAI prevention and control strategy.17Septimus E. Weinstein R.A. Perl T. Goldmann D.A. Yokoe D.S. Approaches for preventing healthcare-associated infections: go long or go wide?.Infect Control Hosp Epidemiol. 2014; 35: 797-801Crossref PubMed Scopus (60) Google Scholar In fact, a recent meta-analysis showed AS programs reduced the incidence of infections and colonization with multidrug-resistant gram-negative bacteria, extended-spectrum β-lactamase-producing gram-negative bacteria, and methicillin-resistant S aureus, as well as the incidence of CDI infections.18Baur D. Gladstone B.P. Burkert F. Carrara E. Foschi F. Döbele S. et al.Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis.Lancet Infect Dis. 2017; 17: 990-1001Abstract Full Text Full Text PDF PubMed Scopus (389) Google Scholar Furthermore, AS programs, when implemented alongside IPC measures, especially hand-hygiene interventions, were more effective than implementation of AS alone—verifying that a well-functioning IPC program is fundamental to a successful organizational AS strategy.18Baur D. Gladstone B.P. Burkert F. Carrara E. Foschi F. Döbele S. et al.Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis.Lancet Infect Dis. 2017; 17: 990-1001Abstract Full Text Full Text PDF PubMed Scopus (389) Google Scholar Similar data have also shown that the addition of AS interventions can enhance results of robust IPC measures, particularly when addressing an outbreak.19Valiquette L. Cossette B. Garant M.-P. Diab H. Pepin J. Impact of a reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile–associated disease caused by the hypervirulent NAP1/027 strain.Clin Infect Dis. 2007; 45: S112-S121Crossref PubMed Scopus (261) Google Scholar AS programs have been shown to improve patient outcomes, reduce antimicrobial agent-related adverse events, and decrease AMR.18Baur D. Gladstone B.P. Burkert F. Carrara E. Foschi F. Döbele S. et al.Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis.Lancet Infect Dis. 2017; 17: 990-1001Abstract Full Text Full Text PDF PubMed Scopus (389) Google Scholar, 19Valiquette L. Cossette B. Garant M.-P. Diab H. Pepin J. Impact of a reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile–associated disease caused by the hypervirulent NAP1/027 strain.Clin Infect Dis. 2007; 45: S112-S121Crossref PubMed Scopus (261) Google Scholar, 20Dodds Ashley E.S. Keye K.S. DePestel D.D. Hermsen E.D. Antimicrobial stewardship: philosophy versus practice.Clin Infect Dis. 2014; 59: S112-S121Crossref PubMed Scopus (45) Google Scholar, 21Kelly A.A. Jones M.M. Echevarria K.L. Kralovic S.M. Samore M.H. Goetz M.B. et al.A report of the efforts of the Veterans Health Administration national antimicrobial stewardship initiative.Infect Control Hosp Epidemiol. 2017; 38: 513-520Crossref PubMed Scopus (54) Google Scholar To date, primary strategies include prescriber preauthorization and prospective audit and feedback, with supplemental strategies such as guidelines and clinical pathway development, intravenous-to-oral conversion protocols, limiting inappropriate culturing, and provider education.2Barlam T.F. Cosgrove S.E. Abbo L.M. MacDougall C. Schuetz A.N. Septimus E.J. et al.Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.Clin Infect Dis. 2016; 62: e51-e77Crossref PubMed Scopus (1557) Google Scholar, 9Centers for Disease Control and Prevention (CDC) Core elements of hospital antibiotic stewardship programs.http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdfDate: 2014Date accessed: August 11, 2017Google Scholar, 10Centers for Disease Control and Prevention (CDC) Core elements of antibiotic stewardship programs for nursing homes.https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.htmlDate: 2015Date accessed: August 11, 2017Google Scholar, 11Centers for Disease Control and Prevention (CDC) Core elements of outpatient antibiotic stewardship.https://www.cdc.gov/getsmart/community/pdfs/16_268900-a_coreelementsoutpatient_508.pdfDate: 2016Date accessed: August 11, 2017Google Scholar, 12Centers for Disease Control and Prevention (CDC) Implementation of antibiotic stewardship core elements at small and critical access hospitals.https://www.cdc.gov/getsmart/healthcare/implementation/core-elements-small-critical.htmlDate: 2017Date accessed: August 11, 2017Google Scholar Changing practices and prescribing patterns and learned behaviors of physicians, nurses, pharmacists, and other health care providers will take time and investment, but is critical to affecting a long-term solution to the rise of AMR and CDI infections. It is equally important that all clinicians depend on evidence-based IPC interventions to reduce demand for antimicrobial agents by preventing infections from occurring in the first place, and making every effort to prevent transmission when they do. IP and HE leaders are credible IPC subject-matter experts with additional social and behavioral skills to effectively engage the different professional disciplines to promote, implement, support, sustain, and evaluate IPC strategies across practice settings—many of the same skills needed by those leading AS programs. IPC and AS programs are intrinsically linked, making effective collaboration essential to ensure patient safety. The CDC identifies core elements associated with successful AS programs—7 elements for hospitals and LTC facilities9Centers for Disease Control and Prevention (CDC) Core elements of hospital antibiotic stewardship programs.http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdfDate: 2014Date accessed: August 11, 2017Google Scholar, 10Centers for Disease Control and Prevention (CDC) Core elements of antibiotic stewardship programs for nursing homes.https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.htmlDate: 2015Date accessed: August 11, 2017Google Scholar, 12Centers for Disease Control and Prevention (CDC) Implementation of antibiotic stewardship core elements at small and critical access hospitals.https://www.cdc.gov/getsmart/healthcare/implementation/core-elements-small-critical.htmlDate: 2017Date accessed: August 11, 2017Google Scholar and 4 elements for outpatient facilities11Centers for Disease Control and Prevention (CDC) Core elements of outpatient antibiotic stewardship.https://www.cdc.gov/getsmart/community/pdfs/16_268900-a_coreelementsoutpatient_508.pdfDate: 2016Date accessed: August 11, 2017Google Scholar—and provides a framework for implementation. Table 1, Table 2 provide a description of each element. APIC, SHEA, and SIDP support the CDC core elements as an AS framework and believe the following related to the synergy of IPC and AS:1.Leadership commitment. Health care system leaders must prioritize IPC and AS as part of wider patient safety strategies, creating an infrastructure to promote, sustain, and disseminate best practices across the continuum of patient care. IPC and AS program leaders must work together to align their programs, promoting communication and collaboration, and reducing the likelihood of redundant initiatives. Given the synergy between the programs, they should seize every opportunity to benefit from each other's expertise and organizational influence and partner when making the case for program support and necessary resource allocation to clinical and administrative leadership.2.Accountability. AS programs are best led by infectious disease (ID) physicians with clinical pharmacists with additional stewardship training.2Barlam T.F. Cosgrove S.E. Abbo L.M. MacDougall C. Schuetz A.N. Septimus E.J. et al.Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.Clin Infect Dis. 2016; 62: e51-e77Crossref PubMed Scopus (1557) Google Scholar, 3Dellit T.H. Owens R.C. McGowan J.E. Gerding D.N. Weinstein R.A. Burke J.P. et al.Infectious Disease Society of America and the Society for Healthcare Epidemiology of America guideline for developing an institutional program to enhance antimicrobial stewardship.Clin Infect Dis. 2007; 44: 159-177Crossref PubMed Scopus (2441) Google Scholar, 9Centers for Disease Control and Prevention (CDC) Core elements of hospital antibiotic stewardship programs.http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdfDate: 2014Date accessed: August 11, 2017Google Scholar Although this is the preferred approach, assuming this additional responsibility may exceed the capacity and/or capability of some ID physicians and/or clinical pharmacists and be impractical for community and critical access hospitals, as well as nonacute settings such as ambulatory and LTC facilities. As a result, in practice, AS programs are being led by a variety of health care professionals, in a variety of settings.22Cosgrove S.E. Hermsen E.D. Rybak M.J. File T.M. Parker S.K. Guidance for the knowledge and skills required for antimicrobial stewardship leaders.Infect Control Hosp Epidemiol. 2014; 35: 1444-1451Crossref PubMed Scopus (45) Google Scholar, 23Srinivasan A. Engaging hospitalists in antimicrobial stewardship: the CDC perspective.J Hosp Med. 2011; 6: S31-S33Crossref PubMed Scopus (24) Google Scholar, 24Scales K. Zimmerman S. Reed D. Beeber A.S. Kistler C.E. Preisser J.S. et al.Nurse and medical provider perspectives on antibiotic stewardship in nursing homes.J Am Geriatr Soc. 2016; 65: 165-171Crossref PubMed Scopus (19) Google Scholar, 25Manning M.L. Pogorzelska-Maziarz M. Healthcare system leaders' perspectives on infection preventionist and registered nurse engagement in antibiotic stewardship.Am J Infect Control. 2017; (accepted for publication 10/2017)Google Scholar Regardless of leadership model, it is imperative to engage interested, local, and respected physician, pharmacist, and nursing champions to help foster collaboration across specialty areas and to lend support for strong, empowered leadership at the front line of patient care. Those engaged in building, leading, and evaluating AS programs should seek to acquire the core skills as outlined in the SHEA white paper, Guidance for the Knowledge and Skills Required for Antimicrobial Stewardship Leaders as listed in Table 3.22Cosgrove S.E. Hermsen E.D. Rybak M.J. File T.M. Parker S.K. Guidance for the knowledge and skills required for antimicrobial stewardship leaders.Infect Control Hosp Epidemiol. 2014; 35: 1444-1451Crossref PubMed Scopus (45) Google Scholar3.Drug expertise. Most pharmacists are not formally trained in ID, and the majority of health care facilities do not have access to an ID pharmacist who is comfortable with AS.22Cosgrove S.E. Hermsen E.D. Rybak M.J. File T.M. Parker S.K. Guidance for the knowledge and skills required for antimicrobial stewardship leaders.Infect Control Hosp Epidemiol. 2014; 35: 1444-1451Crossref PubMed Scopus (45) Google Scholar, 26Heil E.L. Kuti J.L. Bearden D.T. Gallagher J.C. The essential role of pharmacists in antimicrobial stewardship.Infect Control Hosp Epidemiol. 2016; 37: 753-754Crossref PubMed Scopus (32) Google Scholar Health care facilities should consider appointing general clinical pharmacists to fill this role but should then require and fund additional training in AS from entities such as the SIDP Making a Difference in Infectious Diseases program, or SHEA.27MAD_ID, Making a difference in infectious diseases Antimicrobial stewardship training programs for pharmacist and physicians.http://mad-id.org/Date accessed: November 11, 2017Google Scholar, 28Society of Infectious Diseases Pharmacists Antimicrobial stewardship certificate program for pharmacist.https://www.sidp.org/Date accessed: November 11, 2017Google Scholar Alternative methods can also be used to gain access to ID physicians and pharmacists, including pooling resources, employing external stewardship consultants onsite or via telehealth, or seeking additional expertise by joining multihospital improvement collaboratives.12Centers for Disease Control and Prevention (CDC) Implementation of antibiotic stewardship core elements at small and critical access hospitals.https://www.cdc.gov/getsmart/healthcare/implementation/core-elements-small-critical.htmlDate: 2017Date accessed: August 11, 2017Google Scholar, 29Stenehjem E. Hyun D.Y. Septimus E. Yu K.C. Meyer M. Raj D. et al.Antibiotic stewardship in small hospitals: barriers and solutions.Clin Infect Dis. 2017; 65: 691-696Crossref PubMed Scopus (60) Google Scholar When remote expertise is used, it is important to have an AS program leader who is on staff at the hospital.12Centers for Disease Control and Prevention (CDC) Implementation of antibiotic stewardship core elements at small and critical access hospitals.https://www.cdc.gov/getsmart/healthcare/implementation/core-elements-small-critical.htmlDate: 2017Date accessed: August 11, 2017Google Scholar4.Action. Although IPs and HEs may not be involved in preauthorization or prospective audit and feedback interventions, they do engage a diverse range of clinical disciplines across practice settings in HAI prevention. IPs have substantial contact with bedside nurses, often together reviewing patients who develop HAIs as part of routine daily activities. They can leverage these strong collegial relationships to influence and facilitate nursing's supporting role in initiating antibiotic timeouts, performing antibiotic reconciliation during patient transitions of care, and educating patients and families about safe and appropriate antibiotic use.30Manning M.L. Pfeiffer J. Larson E.L. Combating antibiotic resistance: the role of nursing in antibiotic stewardship.Am J Infect Control. 2016; 44: 1454-1457Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 31American Nurses Association Redefining the antibiotic stewardship team: Recommendations from the American Nurses Association/Centers for Disease Control and Prevention workgroup on the role of registered nurses in hospital antibiotic stewardship practices.http://www.nursingworld.org/ANA-CDC-AntibioticStewardship-WhitePaperDate accessed: September 5, 2017Google Scholar, 32Olson C.A. Tooman T.R. Alvarado C.J. Knowledge systems, health care teams, and clinical practice: a study of successful change.Adv Health Sci Educ Theory Pract. 2010; 15: 491-516Crossref PubMed Scopus (29) Google Scholar, 33Pakyz A.L. Moczygemba L.R. VanderWielen L.M. Edmond M.B. Stevens M.P. Kuzel A.J. Facilitators and barriers to implementing antimicrobial stewardship strategies: results from a qualitative study.Am J Infect Control. 2014; 42: S257-S263Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar For example, a recent study found that nurse prompting of antimicrobial review during daily rounds can lead to significant reduction in antimicrobial agent use, providing another mechanism of sustaining antimicrobial awareness.34Raybardhan S. Chung B. Ferreira D. Britton M. Shin P. Kan T. et al.Nurse prompting for prescriber-led review of antimicrobial use in the critical care unit: A quality improvement intervention with controlled interrupted time series analysis.https://idsa.confex.com/idsa/2017/webprogram/Paper65336.htmlDate accessed: December 5, 2017Google Scholar Additionally, IPs and HEs often participate in unit-based safety teams (eg, the Comprehensive Unit-Based Safety Program) and can facilitate an interprofessional, unit-based discussion of AS needs by inviting relevant AS team members to join the meetings. Furthermore, collaborative efforts to have the stewardship team contact the IPC team when they identify and/or approve antibiotic therapy for patients with infections caused by certain MDROs, and IP assistance in training bedside nurses in appropriate culture techniques are examples of how IPs and stewards can expand the capacity of both teams. Similar to IPC interventions and actions, flexibility and tailoring AS approaches to local needs is essential.5.Tracking. Although not responsible for monitoring antibiotic prescribing, IPC programs do perform surveillance for emerging pathogens and resistance patterns, as well as rapid response to every possible transmission. Use of the CDC National Healthcare Safety Network Antimicrobial Use and Resistance module is highly effective because it provides a mechanism for facilities to report and analyze antimicrobial agent use as part of AS efforts at their facility.35Centers for Disease Control and Prevention Antimicrobial Use and Resistance (AUR) Module.https://www.cdc.gov/nhsn/pdfs/pscmanual/11pscaurcurrent.pdfDate: 2017Date accessed: November 11, 2017Google Scholar Standardized antimicrobial administration ratio values can serve as a starting point for medication use evaluations by AS programs. To successfully report to the Antimicrobial Use and Resistance module, stewardship teams will need to work closely with their IPC team to ensure that appropriate data structures are developed and kept in alignment for reporting. There are important implications for antimicrobial agent use based on how units are grouped, including standardized antimicrobial administration ratio values only being calculated for specific unit types. Therefore, to obtain the most value from these data, the stewardship and IPC teams need to be in constant contact regarding facility structure and other reporting considerations. These data will also benefit the IPC team because antibiotic use patterns are often a key element in outbreak investigations. Stewardship programs also have data sources beyond the National Healthcare Safety Network and can often provide electronic antibiotic use summaries on the patient level, aiding the work of IPs and HEs.6.Reporting. Although not responsible for reporting information on antibiotic use, IPC programs are responsible for HAI surveillance and providing feedback of infection rates (eg, MDRO and CDI) and audit data (eg, hand hygiene adherence) to clinicians and other stakeholders. CDI prevention is a high priority for IPC and AS programs, so sharing and disseminating antibiotic use and CDI infection rates is essential to prevention efforts.2Barlam T.F. Cosgrove S.E. Abbo L.M. MacDougall C. Schuetz A.N. Septimus E.J. et al.Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.Clin Infect Dis. 2016; 62: e51-e77Crossref PubMed Scopus (1557) Google Scholar Providing feedback that is timely, frequent, individualized, nonpunitive, and customized can be very influential in reducing HAIs and antimicrobial agent use.33Pakyz A.L. Moczygemba L.R. VanderWielen L.M. Edmond M.B. Stevens M.P. Kuzel A.J. Facilitators and barriers to implementing antimicrobial stewardship strategies: results from a qualitative study.Am J Infect Control. 2014; 42: S257-S263Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 36Hysong S.J. Meta-analysis: audit and feedback features impact effectiveness on quality of care.Med Care. 2009; 47: 356-363Crossref PubMed Scopus (215) Google Scholar, 37Solomon D.H. Van Houten L. Glynn R.J. Baden L. Curtis K. Schrager H. et al.Academic detailing to improve use of broad-spectrum antibiotics at an academic medical center.Arch Intern Med. 2001; 161: 1897-1902Crossref PubMed Scopus (211) Google Scholar, 38Lesprit P. Landelle C. Brun-Buisson C. Clinical impact of unsolicited post-prescription antibiotic review in surgical and medical wards: a randomized controlled trial.Clin Microbiol Infect. 2013; 19: E91-E97Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar As more robust antibiotic use benchmarking tools are more fully developed, there is a vital role of IPC programs to help educate and guide local reporting patterns. Similar to HAI data, data on stewardship efforts should be reported not just to providers, but also to appropriate facility committees, such as the IPC, patient safety, and medical executive committees, as well as the board of directors.7.Education. Health care provider engagement is an essential component for successful IPC and antibiotic resistance prevention work. Creating educational strategies to address each discipline's clinical interests and make the case for why IPC and AS is of value to them and their patients is essential.39Fakih M.G. Krein S.L. Edson B. Watson S.R. Battles J.B. Saint S. Engaging health care workers to prevent catheter-associated urinary tract infection and avert patient harm.Am J Infect Control. 2014; 42: S223-S229Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Education should be team oriented and problem based, and are most effective when they include workshops, bedside teaching, and simulation-based training.40Zingg W. Holmes A. Dettenkofer M. Goetting T. Secci F. Clack L. et al.Hospital organization, management, and structure for prevention of health-care-associated infection: a systematic review and expert consensus.Lancet Infect Dis. 2015; 15: 212-224Abstract Full Text Full Text PDF PubMed Scopus (269) Google Scholar We encourage the participation of IPs and HEs in designing and delivering AS-related education to health care providers as well as to patients and their families. This can often be done in collaboration with the AS team to reach a broader and more diverse audience with a single consistent message of preventing infection and reducing MDROs. A logical area for IPC education participation is to ensure that front-line physicians and nurses are aware of the indications for testing as well as the risks associated with inappropriate testing. Some specific examples include indications for obtaining and appropriate collection of urine cultures, indications for obtaining culture from endotracheal tubes, and indications for testing for CDI infections.Table 1The Centers for Disease Control and Prevention core elements of antimicrobial stewardship for hospitals and long-term care facilities9Centers for Disease Control and Prevention (CDC) Core elements of hospital antibiotic stewardship programs.http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdfDate: 2014Date accessed: August 11, 2017Google Scholar, 10Centers for Disease Control and Prevention (CDC) Core elements of antibiotic stewardship programs for nursing homes.https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.htmlDate: 2015Date accessed: August 11, 2017Google Scholar, 12Centers for Disease Control and Prevention (CDC) Implementation of antibiotic stewardship core elements at small and critical access hospitals.https://www.cdc.gov/getsmart/healthcare/implementation/core-elements-small-critical.htmlDate: 2017Date accessed: August 11, 2017Google ScholarElementDescriptionLeadership commitmentDedicating necessary human, financial, and information technology resourcesAccountabilityAppointing a single leader responsible for program outcomesDrug expertiseAppointing a single pharmacist leader responsible for working to improve antibiotic agent useActionImplementing at least 1 recommended action with the goal of improving antimicrobial agent useTrackingMonitoring antibiotic prescribing and resistance patternsReportingRegular reporting of information on antibiotic agent use and resistance to doctors, nurses, and relevant staffEducationEducating clinicians about resistance and optimal prescribing Open table in a new tab Table 2The Centers for Disease Control and Prevention core elements of outpatient antimicrobial stewardship11Centers for Disease Control and Prevention (CDC) Core elements of outpatient antibiotic stewardship.https://www.cdc.gov/getsmart/community/pdfs/16_268900-a_coreelementsoutpatient_508.pdfDate: 2016Date accessed: August 11, 2017Google ScholarElementDescriptionCommitmentDemonstrate dedication to and accountability for optimizing antibiotic prescribing and patientAction for policy and practiceImplement at least one policy or practice to improve antibiotic prescribing, assess whether it is working, and modify as neededTracking and reportingMonitoring antibiotic prescribing practices and offer regular feedback to clinicians, or have clinicians assess their own antibiotic prescribing practices themselvesEducation and expertiseProvide educational resources to clinicians and patients on antibiotic prescribing, and ensure access to needed expertise on optimizing antibiotic prescribing Open table in a new tab Table 3Categories of knowledge and skills required for antimicrobial stewardship leaders22Cosgrove S.E. Hermsen E.D. Rybak M.J. File T.M. Parker S.K. Guidance for the knowledge and skills required for antimicrobial stewardship leaders.Infect Control Hosp Epidemiol. 2014; 35: 1444-1451Crossref PubMed Scopus (45) Google Scholar1.General principles of antimicrobial stewardship2.Approaches to stewardship interventions3.Microbiology and laboratory diagnostics4.Common infectious syndromes5.Measurement and analysis6.Informatics/information technology7.Program building and leadership8.Special populations and nonacute hospital settings9.Infection control Open table in a new tab In addition to the CDC core elements, APIC, SHEA, and SIDP further believe that microbiology laboratory staff members and clinical microbiologists play an essential role in successful IPC and AS programs, including:•Diagnosis. The accurate and timely services provided by a microbiology laboratory supports the application of medical knowledge and judgment to achieve the best outcomes for patients with an ID. The lab provides information to help determine whether a patient is infected, what the pathogen is, and in most cases the susceptibility of the organism. The laboratory provides interpretation and translation of the results into the day-to-day infection management.41Dik J. Poelman R. Friedrich A.W. Panday P.N. Lo-Ten-Foe J.R. van Assen S. et al.An integrated stewardship model: antimicrobial, infection prevention and diagnostic (AID).Future Microbiol. 2015; 11: 93-102Crossref PubMed Scopus (51) Google Scholar Recent advances in molecular diagnostic technologies have significantly reduced the delay in ID diagnosis, can identify and precisely characterize emerging pathogens, and trace the source of outbreaks in a manner of days.42Das S. Shibib D.R. Vernon M.O. The new frontier of diagnostics: molecular assays and their role in infection prevention and control.Am J Infect Control. 2017; 45: 158-169Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar It is essential for IPs, HEs, and the AS team to understand the scope of these rapid diagnostic tests and work together to develop processes and interventions to assist clinicians in interpreting and responding appropriately to results.2Barlam T.F. Cosgrove S.E. Abbo L.M. MacDougall C. Schuetz A.N. Septimus E.J. et al.Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.Clin Infect Dis. 2016; 62: e51-e77Crossref PubMed Scopus (1557) Google Scholar•Guidance. To achieve the best results, microbiology cultures should have an appropriate indication (right test at the right time), be properly collected, and transported to a laboratory in a timely manner before antibiotic agents are administered. The influence of proper specimen collection is key in providing clinicians accurate information to improve patient outcomes. A clinician needs to have confidence that the results are accurate, clinically relevant, and significant.43Morency-Potvin P. Schwartz D.N. Weinstein R.A. Antimicrobial stewardship: how the right microbiology laboratory can right the ship.Clin Microbiol Rev. 2017; 30: 381-407Crossref PubMed Scopus (113) Google Scholar, 44Mullin K.M. Kovacs C.S. Fatica C. Einloth C. Neuner E.A. Guzman J.A. et al.A multifaceted approach to reduction of catheter-associated urinary tract infections in the intensive care unit with an emphasis on “stewardship of culturing.”.Infect Control Hosp Epidemiol. 2017; 38: 186-188Crossref PubMed Scopus (39) Google Scholar•Advisement. To effectively use molecular diagnostic technology for enhancement of IPC practices, it is important to understand the scope of these rapid diagnostic tests and to appreciate the need for judicious interpretation in collaboration with a clinical microbiologist.42Das S. Shibib D.R. Vernon M.O. The new frontier of diagnostics: molecular assays and their role in infection prevention and control.Am J Infect Control. 2017; 45: 158-169Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar The issues surrounding the prevention and control of infections are intrinsically linked with the issues associated with the use of antimicrobial agents and the proliferation and spread of MDROs. The vital work of IPC and AS programs cannot be performed independently and requires interdependent and coordinated action across multiple and overlapping disciplines and clinical settings. Deliberate strategic relationship-building actions will be required of IPC and AS program leaders to bring groups together to achieve the larger purpose of keeping patients safe from infection and ensuring that effective antibiotic therapy is available for future generations. The authors thank Arjun Srinivasan, MD, of the Healthcare Associated Infection Prevention Programs, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, for his thoughtful review of this article." @default.
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• W2793231214 title "Antimicrobial stewardship and infection prevention—leveraging the synergy: A position paper update" @default.
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