Antimicrobial stewardship guidelines: the CDC Core Elements in practice

The best known antimicrobial stewardship guidelines for hospitals are the Core Elements published by the United States Centers for Disease Control and Prevention: leadership commitment, accountability, pharmacy expertise, action, tracking, reporting and education. They describe a program, not a protocol, and most of the difficulty is in evidencing them.

Leadership commitment

This is the element that quietly decides the others: dedicated time, budget and a mandate. In a smaller facility it usually comes down to whether the pharmacist has protected hours or is doing stewardship after the dispensing is finished. If nothing else in the program is written down, the time allocation should be.

Accountability and pharmacy expertise

One named person leads the program and is answerable for outcomes; one named pharmacist leads on improving use. In practice this is often the same two people who have always done it, and the value of naming them is that the responsibility survives their absence.

Action, which is where the clinical work sits

The fourth item is the one that connects this list to resistance data. An empiric guideline that is not built on local susceptibility is a textbook, and a textbook cannot tell your emergency department which agent covers most of the organisms it actually sees.

• Prospective audit with feedback to the prescriber, the intervention with the best evidence behind it
• Preauthorisation for restricted agents
• A documented antibiotic time out at 48 to 72 hours, when culture results are usually available
• Facility-specific empiric guidelines for the common syndromes, built on the local antibiogram
• Intravenous to oral conversion where the agent has good oral availability

Tracking and reporting, the two most often deferred

Tracking means measuring antibiotic use and resistance. Reporting means getting that information to the people who prescribe, in a form they will read. These are the elements a small program defers, because the data assembly is expensive and the audience is busy.

The resistance half is the part a tool can genuinely make cheap. A cumulative antibiogram cut by unit, with the isolate counts visible and the rules stated, is a report a committee can act on. The consumption half needs administration data and belongs in a different system.

Education, and the format that works

The Core Elements ask for education of prescribers, and the honest observation from most programs is that a lecture changes little on its own. What changes practice is feedback attached to a specific case, and a pocket guideline that reflects local data closely enough that clinicians stop overriding it.

A realistic first year for a small program

• Produce a current antibiogram with its rules stated, and the intensive care cut alongside it
• Rewrite one empiric guideline, for the syndrome you treat most, using that data
• Start a weekly audit on two target agents rather than everything at once
• Report use and resistance to the committee quarterly, in the same format each time
• Write down who owns the program, and how many hours they have

What guidelines do not say

No guideline tells you which antibiotic to start in your hospital. They describe a structure for making that decision well and revisiting it. The local data is the input the structure needs, and producing it should not be the hardest part of running a program.

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Related on this site: accreditation reporting, empiric guidelines from local data.