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Antimicrobial Resistance 2020

Updates to the Core Elements of Hospital Antibiotic Stewardship Programs

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Dr. Lauri Hicks

Director, CDC’s Office of Antibiotic Stewardship in the Division of Healthcare Quality Promotion

Optimising the use of antibiotics is critical to effectively treat infections, protect patients from harm caused by unnecessary antibiotic use, and combat antibiotic resistance.


Antibiotic stewardship programs can help clinicians improve clinical outcomes and minimise harm by improving the prescription of antibiotics.

In 2019, Centers for Disease Control and Prevention (CDC) updated the hospital Core Elements to reflect both lessons learned from five years of experience as well as new evidence from the field of antibiotic stewardship. Major updates to the hospital Core Elements include:

Hospital Leadership Commitment

Dedicate necessary human, financial and information technology resources:

  • The 2019 update has additional examples of hospital leadership, and the examples are stratified by “priority” and “other”.
  • Priority examples of hospital leadership commitment include: emphasis on the importance of leadership having dedicated time and resources to operate the antibiotic stewardship program effectively. It is also ensuring that the program’s leadership has regularly scheduled opportunities to report stewardship activities, resources and outcomes to senior executives and hospital board.

Accountability: Appoint a leader or co-leaders, such as a physician and pharmacist, responsible for program management and outcomes.

  • The 2019 update highlights the effectiveness of co-leadership between the physician and pharmacy, which was reported by 59% of the hospitals responding to the 2019 NHSN Annual Hospital Survey.

Pharmacy Expertise (previously “Drug Expertise”): Appoint a pharmacist, ideally as the co-leader of the stewardship program, to lead implementation efforts to improve antibiotic use.

  • This Core Element was renamed “Pharmacy Expertise” to reflect the importance of pharmacy engagement for leading implementation efforts to improve antibiotic use.

Action: Implement interventions, such as prospective audit and feedback or preauthorisation, to improve antibiotic use.

  • A new category of nursing-based actions was added to reflect the important role that nurses can play in hospital antibiotic stewardship efforts.

Tracking: Monitor antibiotic prescriptions, impact of interventions, and other important outcomes like C. difficile infection and resistance patterns.

  • It is important for hospitals to electronically submit antibiotic use data to the National Healthcare Safety Network (NHSN) Antimicrobial Use (AU) option for monitoring and benchmarking inpatient antibiotic use.
  • Antibiotic stewardship process measures were expanded and stratified into “priority” and “other”.
  • Priority process measures emphasise assessing the impact of the key interventions, including prospective audit and feedback, preauthorisation, and facility-specific treatment recommendations.

Reporting: Regularly report information on antibiotic use and resistance to prescribers, pharmacists, nurses, and hospital leadership.

  • The 2019 update points out the effectiveness of provider level data reporting, while acknowledging that this has not been well studied for hospital antibiotic use.

Education: Educate prescribers, pharmacists, and nurses about adverse reactions from antibiotics, antibiotic resistance and optimal prescribing.

  • The 2019 update highlights that case-based education through prospective audit and feedback and preauthorisation are effective methods to provide education on antibiotic use. This can be especially powerful when the case-based education is provided in person (e.g., handshake stewardship).
  • The 2019 update also suggests engaging nurses in patient education efforts.
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