University of Miami: Florida Antimicrobial Stewardship Symposium 2013 (FASS)

MIAMI BEACH – Antimicrobial resistance to Staphylococcus aureus varies by patient age, agent, and geographic region, but overall resistance patterns have remained steady over 5 years, according to a Florida-based study of nearly 300,000 isolates.

The analysis of 289,584 patient isolates collected in the Sunshine State from 2006 through 2010, revealed S. aureus resistance to oxacillin is running steady at approximately 50% over 5 years. Oxacillin is important because laboratories typically use resistance to this agent as a measure of overall methicillin-resistant S. aureus (MRSA).

With the exception of penicillin, resistance also remains stable for most antibiotics commonly deployed to combat S. aureus. Resistance to penicillin increased slightly from 91% in 2006 to 95% in 2010, said Dr. Richard S. Hopkins, acting state epidemiologist based in Tallahassee.

Quest Laboratories in Tampa provides the health department with a quarterly report of every S. aureus isolate result. Most of the data come from outpatient testing, which "gives you an idea of what is going on in the community," he said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

Resistant strains run highest among young children ages 1 year to 4 years old, Resistance to oxacillin exceeds 60% in that age group compared with approximately 50% for infants younger than 1 year and patients older than 4 years. These toddlers also tend to have S. aureus with the highest resistance rates to amoxicillin-clavulanic acid, cefazolin, and erythromycin.

Regarding geographic patterns of resistance, the panhandle of Florida consistently features a higher proportion of resistant S. aureus isolates. In contrast, the proportion tends to be lowest in south Florida. "We don’t know why the pattern is this way," said Dr. Hopkins, who studied geographical distribution along with his colleague, Catherine Lesko, an epidemiologist at the Florida Department of Health.

Although a few isolated S. aureus cases that demonstrate intermediate resistance to vancomycin are reported each year, the state health department has yet to see a strain completely resistant to vancomycin. "When we do, we will need to respond very strongly from a public health and clinical perspective," he said.

The intermediate resistant infections are almost always in hospitalized patients who have been treated with vancomycin, he said. "We think it’s evolution of vancomycin resistance right there in the patient under your care, rather than it is being spread from person to person in the hospital."

Dr. Hopkins is employed by the Florida Department of Health Bureau of Epidemiology.

MIAMI BEACH – Antimicrobial resistance to Staphylococcus aureus varies by patient age, agent, and geographic region, but overall resistance patterns have remained steady over 5 years, according to a Florida-based study of nearly 300,000 isolates.

The analysis of 289,584 patient isolates collected in the Sunshine State from 2006 through 2010, revealed S. aureus resistance to oxacillin is running steady at approximately 50% over 5 years. Oxacillin is important because laboratories typically use resistance to this agent as a measure of overall methicillin-resistant S. aureus (MRSA).

With the exception of penicillin, resistance also remains stable for most antibiotics commonly deployed to combat S. aureus. Resistance to penicillin increased slightly from 91% in 2006 to 95% in 2010, said Dr. Richard S. Hopkins, acting state epidemiologist based in Tallahassee.

Quest Laboratories in Tampa provides the health department with a quarterly report of every S. aureus isolate result. Most of the data come from outpatient testing, which "gives you an idea of what is going on in the community," he said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

Resistant strains run highest among young children ages 1 year to 4 years old, Resistance to oxacillin exceeds 60% in that age group compared with approximately 50% for infants younger than 1 year and patients older than 4 years. These toddlers also tend to have S. aureus with the highest resistance rates to amoxicillin-clavulanic acid, cefazolin, and erythromycin.

Regarding geographic patterns of resistance, the panhandle of Florida consistently features a higher proportion of resistant S. aureus isolates. In contrast, the proportion tends to be lowest in south Florida. "We don’t know why the pattern is this way," said Dr. Hopkins, who studied geographical distribution along with his colleague, Catherine Lesko, an epidemiologist at the Florida Department of Health.

Although a few isolated S. aureus cases that demonstrate intermediate resistance to vancomycin are reported each year, the state health department has yet to see a strain completely resistant to vancomycin. "When we do, we will need to respond very strongly from a public health and clinical perspective," he said.

The intermediate resistant infections are almost always in hospitalized patients who have been treated with vancomycin, he said. "We think it’s evolution of vancomycin resistance right there in the patient under your care, rather than it is being spread from person to person in the hospital."

Dr. Hopkins is employed by the Florida Department of Health Bureau of Epidemiology.

MIAMI BEACH – Antimicrobial resistance to Staphylococcus aureus varies by patient age, agent, and geographic region, but overall resistance patterns have remained steady over 5 years, according to a Florida-based study of nearly 300,000 isolates.

The analysis of 289,584 patient isolates collected in the Sunshine State from 2006 through 2010, revealed S. aureus resistance to oxacillin is running steady at approximately 50% over 5 years. Oxacillin is important because laboratories typically use resistance to this agent as a measure of overall methicillin-resistant S. aureus (MRSA).

With the exception of penicillin, resistance also remains stable for most antibiotics commonly deployed to combat S. aureus. Resistance to penicillin increased slightly from 91% in 2006 to 95% in 2010, said Dr. Richard S. Hopkins, acting state epidemiologist based in Tallahassee.

Quest Laboratories in Tampa provides the health department with a quarterly report of every S. aureus isolate result. Most of the data come from outpatient testing, which "gives you an idea of what is going on in the community," he said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

Resistant strains run highest among young children ages 1 year to 4 years old, Resistance to oxacillin exceeds 60% in that age group compared with approximately 50% for infants younger than 1 year and patients older than 4 years. These toddlers also tend to have S. aureus with the highest resistance rates to amoxicillin-clavulanic acid, cefazolin, and erythromycin.

Regarding geographic patterns of resistance, the panhandle of Florida consistently features a higher proportion of resistant S. aureus isolates. In contrast, the proportion tends to be lowest in south Florida. "We don’t know why the pattern is this way," said Dr. Hopkins, who studied geographical distribution along with his colleague, Catherine Lesko, an epidemiologist at the Florida Department of Health.

Although a few isolated S. aureus cases that demonstrate intermediate resistance to vancomycin are reported each year, the state health department has yet to see a strain completely resistant to vancomycin. "When we do, we will need to respond very strongly from a public health and clinical perspective," he said.

The intermediate resistant infections are almost always in hospitalized patients who have been treated with vancomycin, he said. "We think it’s evolution of vancomycin resistance right there in the patient under your care, rather than it is being spread from person to person in the hospital."

Dr. Hopkins is employed by the Florida Department of Health Bureau of Epidemiology.

MIAMI BEACH – Think globally but track locally when it comes to antimicrobial resistance.

"We want to know what is going on nationally and worldwide in terms of resistance, but we really have to understand, and have down pat, what is going on in our own hospitals," said Aida E. Casiano-Colon, Ph.D., a microbiologist at a large regional laboratory in South Florida.

Awareness and collaboration among clinicians are particularly important when it comes to combating multidrug-resistant organisms (MDROs), Dr. Casiano-Colon said. "MDRO varies geographically and by health care setting. Larger hospitals usually have more resistance." Rates also vary by unit within a hospital, she said.

As clinical microbiology director at Integrated Regional Laboratories in Fort Lauderdale, Dr. Casiano-Colon has access to about 790,000 cultures each year from 13 hospitals and several nursing homes in South Florida, as well as from a national network of correctional facilities.

"We really have to understand, and have down pat, what is going on in our own hospitals."

"First the good news: The gram-positive organisms are actually showing a favorable trend. Antimicrobial resistance is very stable or improving," Dr. Casiano-Colon said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

In addition, the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) "is actually starting to drop." MRSA prevalence was 62% in 2011 (based on approximately 42,000 S. aureus isolates from 12 South Florida hospitals). This represents a 7.5% drop since 2006. Put another way, there was a 22% decline in MRSA rates per 1,000 adjusted patient-days, from 4.5 in 2006 to 3.5 in 2011 (based on almost 25,000 isolates). Compulsive hand hygiene, use of active surveillance cultures, barrier precautions, and other interventions continue to decrease the MRSA rate, she said.

Annual rates of MRSA bacteremia also continue to steadily decrease. The 2011 rate of 2.9/10,000 adjusted patient-days reveals a 34% drop in the last 5 years. However, MRSA "is still a very significant pathogen. All the other MDROs that cause bacteremia pale in comparison in terms of the rate of bloodstream infections," Dr. Casiano-Colon said.

"We are not really seeing a lot of vancomycin-resistant S. aureus, which is also very good news," she added.

The bad news is "we continue to detect escalating resistance in gram-negative organisms overall, especially ESBL [extended-spectrum beta-lactamase] bacteremia, carbapenem-resistant enterics, and Acinetobacter."

For example, the rate of ESBL bloodstream infections jumped "a very alarming" 333% from 0.6/10,000 patient days in 2008 to 2.6/10,000 in 2010.

Rates of all ESBL infections (including respiratory and urinary tract infections) are also showing an alarming increase, to a rate of 1.2/1,000 adjusted patient-days from 0.48/10,000 in 2007, Dr. Casiano-Colon said.

Resistant strains of carbapenem-resistant Enterobacteriaceae are another growing concern. Rates increased from 0.007 in 2008 to 0.03 in 2011. "These organisms cause severe infections among hospital patients and residents of long-term care facilities," she said.

MIAMI BEACH – Think globally but track locally when it comes to antimicrobial resistance.

"We want to know what is going on nationally and worldwide in terms of resistance, but we really have to understand, and have down pat, what is going on in our own hospitals," said Aida E. Casiano-Colon, Ph.D., a microbiologist at a large regional laboratory in South Florida.

Awareness and collaboration among clinicians are particularly important when it comes to combating multidrug-resistant organisms (MDROs), Dr. Casiano-Colon said. "MDRO varies geographically and by health care setting. Larger hospitals usually have more resistance." Rates also vary by unit within a hospital, she said.

As clinical microbiology director at Integrated Regional Laboratories in Fort Lauderdale, Dr. Casiano-Colon has access to about 790,000 cultures each year from 13 hospitals and several nursing homes in South Florida, as well as from a national network of correctional facilities.

"We really have to understand, and have down pat, what is going on in our own hospitals."

"First the good news: The gram-positive organisms are actually showing a favorable trend. Antimicrobial resistance is very stable or improving," Dr. Casiano-Colon said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

In addition, the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) "is actually starting to drop." MRSA prevalence was 62% in 2011 (based on approximately 42,000 S. aureus isolates from 12 South Florida hospitals). This represents a 7.5% drop since 2006. Put another way, there was a 22% decline in MRSA rates per 1,000 adjusted patient-days, from 4.5 in 2006 to 3.5 in 2011 (based on almost 25,000 isolates). Compulsive hand hygiene, use of active surveillance cultures, barrier precautions, and other interventions continue to decrease the MRSA rate, she said.

Annual rates of MRSA bacteremia also continue to steadily decrease. The 2011 rate of 2.9/10,000 adjusted patient-days reveals a 34% drop in the last 5 years. However, MRSA "is still a very significant pathogen. All the other MDROs that cause bacteremia pale in comparison in terms of the rate of bloodstream infections," Dr. Casiano-Colon said.

"We are not really seeing a lot of vancomycin-resistant S. aureus, which is also very good news," she added.

The bad news is "we continue to detect escalating resistance in gram-negative organisms overall, especially ESBL [extended-spectrum beta-lactamase] bacteremia, carbapenem-resistant enterics, and Acinetobacter."

For example, the rate of ESBL bloodstream infections jumped "a very alarming" 333% from 0.6/10,000 patient days in 2008 to 2.6/10,000 in 2010.

Rates of all ESBL infections (including respiratory and urinary tract infections) are also showing an alarming increase, to a rate of 1.2/1,000 adjusted patient-days from 0.48/10,000 in 2007, Dr. Casiano-Colon said.

Resistant strains of carbapenem-resistant Enterobacteriaceae are another growing concern. Rates increased from 0.007 in 2008 to 0.03 in 2011. "These organisms cause severe infections among hospital patients and residents of long-term care facilities," she said.

MIAMI BEACH – Think globally but track locally when it comes to antimicrobial resistance.

"We want to know what is going on nationally and worldwide in terms of resistance, but we really have to understand, and have down pat, what is going on in our own hospitals," said Aida E. Casiano-Colon, Ph.D., a microbiologist at a large regional laboratory in South Florida.

Awareness and collaboration among clinicians are particularly important when it comes to combating multidrug-resistant organisms (MDROs), Dr. Casiano-Colon said. "MDRO varies geographically and by health care setting. Larger hospitals usually have more resistance." Rates also vary by unit within a hospital, she said.

As clinical microbiology director at Integrated Regional Laboratories in Fort Lauderdale, Dr. Casiano-Colon has access to about 790,000 cultures each year from 13 hospitals and several nursing homes in South Florida, as well as from a national network of correctional facilities.

"We really have to understand, and have down pat, what is going on in our own hospitals."

"First the good news: The gram-positive organisms are actually showing a favorable trend. Antimicrobial resistance is very stable or improving," Dr. Casiano-Colon said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

In addition, the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) "is actually starting to drop." MRSA prevalence was 62% in 2011 (based on approximately 42,000 S. aureus isolates from 12 South Florida hospitals). This represents a 7.5% drop since 2006. Put another way, there was a 22% decline in MRSA rates per 1,000 adjusted patient-days, from 4.5 in 2006 to 3.5 in 2011 (based on almost 25,000 isolates). Compulsive hand hygiene, use of active surveillance cultures, barrier precautions, and other interventions continue to decrease the MRSA rate, she said.

Annual rates of MRSA bacteremia also continue to steadily decrease. The 2011 rate of 2.9/10,000 adjusted patient-days reveals a 34% drop in the last 5 years. However, MRSA "is still a very significant pathogen. All the other MDROs that cause bacteremia pale in comparison in terms of the rate of bloodstream infections," Dr. Casiano-Colon said.

"We are not really seeing a lot of vancomycin-resistant S. aureus, which is also very good news," she added.

The bad news is "we continue to detect escalating resistance in gram-negative organisms overall, especially ESBL [extended-spectrum beta-lactamase] bacteremia, carbapenem-resistant enterics, and Acinetobacter."

For example, the rate of ESBL bloodstream infections jumped "a very alarming" 333% from 0.6/10,000 patient days in 2008 to 2.6/10,000 in 2010.

Rates of all ESBL infections (including respiratory and urinary tract infections) are also showing an alarming increase, to a rate of 1.2/1,000 adjusted patient-days from 0.48/10,000 in 2007, Dr. Casiano-Colon said.

Resistant strains of carbapenem-resistant Enterobacteriaceae are another growing concern. Rates increased from 0.007 in 2008 to 0.03 in 2011. "These organisms cause severe infections among hospital patients and residents of long-term care facilities," she said.

MIAMI BEACH – More than half of acute care hospitals in Florida feature a formal antimicrobial stewardship program, and a sizable minority plans to launch one in the next year, according to a survey.

Antimicrobial resistance "is one of the most serious problems globally. Studies from acute and long-term care facilities have shown 30%-50% of antimicrobial use is inappropriate," Dr. Lilian M. Abbo said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

Many hospitals already employ components of antimicrobial stewardship, such as formulary restrictions; requiring prescription preauthorizations; or post-prescribing reviews with feedback to the clinician. However, proponents point to better patient outcomes, lower resistance rates, and overall cost savings for hospitals through formal programs.

The positive outcomes demonstrated by the Florida survey could be applied nationwide, said Dr. Abbo, a clinical faculty member in the division of infectious diseases at the University of Miami Hospital.

The electronic survey in Florida revealed that 55% of 85 acute care facility respondents have a stewardship program and another 21% plan to join their ranks soon. "Of the 24% who said ‘no,’ 80% agreed a program would be useful," said Dr. Abbo, who is also the medical director of the Antimicrobial Stewardship Program at University of Miami Hospital/Jackson Memorial Medical Center.

Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and multi-drug resistant gram-negative bacteria, in order, were the most troubling microbes reported. Specifically, when asked to identify their most challenging health care–associated infection, 33% of respondents cited C. difficile, 23% MRSA, and 19% the gram-negative bacteria.

So how are the facilities with formal stewardship programs combating this? The leading initiatives cited by 56 such hospitals including monitoring high-cost agents (52 hospitals or 93%), assessment of intravenous to oral conversions by 84%, and review of broad-spectrum agent use by 80%.

Specific agents under scrutiny through stewardship include linezolid (cited by 92% of respondents with a program), vancomycin (88%), and daptomycin (87%).

Outcomes associated with stewardship are one of the most difficult factors to measure, Dr. Abbo said. A total 70% of respondents with a program said they could demonstrate a decrease in drug purchasing costs, for example. Another 66% could show a reduction in antimicrobial resistance, and 66% a decrease in C. difficile infections. Other results show 64% can support lower antimicrobial consumption, 43% improved patient outcomes, 38% reduced length of stay, and 34% reduced adverse drug reactions associated with antibiotic use.

Stewardship programs that foster appropriate prescribing can save money. "That’s another important take-home message," Dr. Abbo said. "Cost savings are important. That is how you can negotiate with your CEO or CMO – that’s how you are going to save money for the hospital and more than pay for your salary."

In a practical move, the survey also examined barriers to implementation of stewardship programs. Of 76 responses, 66% cited personnel shortages, 64% cited time constraints, and 62% said funding is limited. Only 13% reported resistance from administration. "I was very impressed that most people do not feel their administrations are a barrier," Dr. Abbo said.

It takes a village to run an optimal stewardship program – another major theme from the results. "Stewardship cannot be done by one person alone," Dr. Abbo said. Efforts are multidisciplinary, with hospitalists involved in 23% of existing programs or those planned for the subsequent 12 months, the survey shows. Infectious disease physicians are involved in 55%, followed by clinical PharmDs (52%), infection control professionals (47%), and microbiologists (31%).

The majority of respondents, 62%, work at community hospitals. Another 10% each work at a city/county hospital or a nonuniversity teaching hospital. The remaining respondents hail from a university (adult or pediatric) hospital (6%), a community pediatric hospital (2%), a VA or military hospital (2%), or another acute care facility setting (8%).

A total 62% of facilities had between 100 and 500 beds. Only 11% had fewer than 100 beds, and 15% had more than 500 and up to 800 beds. The remaining 12% of facilities, the largest had more than 800 beds.

All 213 acute care facilities in the state were invited to participate in the survey, conducted from July to October 2011. Data are based on a 40% response rate.

A second survey was also e-mailed to nursing homes and skilled nursing facilities in the state to assess the scope of current and planned stewardship practices in those settings.

Dr. Abbo had no relevant financial disclosures. The survey was supported by a grant from the Florida Department of Health Bureau of Epidemiology.

MIAMI BEACH – More than half of acute care hospitals in Florida feature a formal antimicrobial stewardship program, and a sizable minority plans to launch one in the next year, according to a survey.

Antimicrobial resistance "is one of the most serious problems globally. Studies from acute and long-term care facilities have shown 30%-50% of antimicrobial use is inappropriate," Dr. Lilian M. Abbo said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

Many hospitals already employ components of antimicrobial stewardship, such as formulary restrictions; requiring prescription preauthorizations; or post-prescribing reviews with feedback to the clinician. However, proponents point to better patient outcomes, lower resistance rates, and overall cost savings for hospitals through formal programs.

The positive outcomes demonstrated by the Florida survey could be applied nationwide, said Dr. Abbo, a clinical faculty member in the division of infectious diseases at the University of Miami Hospital.

The electronic survey in Florida revealed that 55% of 85 acute care facility respondents have a stewardship program and another 21% plan to join their ranks soon. "Of the 24% who said ‘no,’ 80% agreed a program would be useful," said Dr. Abbo, who is also the medical director of the Antimicrobial Stewardship Program at University of Miami Hospital/Jackson Memorial Medical Center.

Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and multi-drug resistant gram-negative bacteria, in order, were the most troubling microbes reported. Specifically, when asked to identify their most challenging health care–associated infection, 33% of respondents cited C. difficile, 23% MRSA, and 19% the gram-negative bacteria.

So how are the facilities with formal stewardship programs combating this? The leading initiatives cited by 56 such hospitals including monitoring high-cost agents (52 hospitals or 93%), assessment of intravenous to oral conversions by 84%, and review of broad-spectrum agent use by 80%.

Specific agents under scrutiny through stewardship include linezolid (cited by 92% of respondents with a program), vancomycin (88%), and daptomycin (87%).

Outcomes associated with stewardship are one of the most difficult factors to measure, Dr. Abbo said. A total 70% of respondents with a program said they could demonstrate a decrease in drug purchasing costs, for example. Another 66% could show a reduction in antimicrobial resistance, and 66% a decrease in C. difficile infections. Other results show 64% can support lower antimicrobial consumption, 43% improved patient outcomes, 38% reduced length of stay, and 34% reduced adverse drug reactions associated with antibiotic use.

Stewardship programs that foster appropriate prescribing can save money. "That’s another important take-home message," Dr. Abbo said. "Cost savings are important. That is how you can negotiate with your CEO or CMO – that’s how you are going to save money for the hospital and more than pay for your salary."

In a practical move, the survey also examined barriers to implementation of stewardship programs. Of 76 responses, 66% cited personnel shortages, 64% cited time constraints, and 62% said funding is limited. Only 13% reported resistance from administration. "I was very impressed that most people do not feel their administrations are a barrier," Dr. Abbo said.

It takes a village to run an optimal stewardship program – another major theme from the results. "Stewardship cannot be done by one person alone," Dr. Abbo said. Efforts are multidisciplinary, with hospitalists involved in 23% of existing programs or those planned for the subsequent 12 months, the survey shows. Infectious disease physicians are involved in 55%, followed by clinical PharmDs (52%), infection control professionals (47%), and microbiologists (31%).

The majority of respondents, 62%, work at community hospitals. Another 10% each work at a city/county hospital or a nonuniversity teaching hospital. The remaining respondents hail from a university (adult or pediatric) hospital (6%), a community pediatric hospital (2%), a VA or military hospital (2%), or another acute care facility setting (8%).

A total 62% of facilities had between 100 and 500 beds. Only 11% had fewer than 100 beds, and 15% had more than 500 and up to 800 beds. The remaining 12% of facilities, the largest had more than 800 beds.

All 213 acute care facilities in the state were invited to participate in the survey, conducted from July to October 2011. Data are based on a 40% response rate.

A second survey was also e-mailed to nursing homes and skilled nursing facilities in the state to assess the scope of current and planned stewardship practices in those settings.

Dr. Abbo had no relevant financial disclosures. The survey was supported by a grant from the Florida Department of Health Bureau of Epidemiology.

MIAMI BEACH – More than half of acute care hospitals in Florida feature a formal antimicrobial stewardship program, and a sizable minority plans to launch one in the next year, according to a survey.

Antimicrobial resistance "is one of the most serious problems globally. Studies from acute and long-term care facilities have shown 30%-50% of antimicrobial use is inappropriate," Dr. Lilian M. Abbo said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

Many hospitals already employ components of antimicrobial stewardship, such as formulary restrictions; requiring prescription preauthorizations; or post-prescribing reviews with feedback to the clinician. However, proponents point to better patient outcomes, lower resistance rates, and overall cost savings for hospitals through formal programs.

The positive outcomes demonstrated by the Florida survey could be applied nationwide, said Dr. Abbo, a clinical faculty member in the division of infectious diseases at the University of Miami Hospital.

The electronic survey in Florida revealed that 55% of 85 acute care facility respondents have a stewardship program and another 21% plan to join their ranks soon. "Of the 24% who said ‘no,’ 80% agreed a program would be useful," said Dr. Abbo, who is also the medical director of the Antimicrobial Stewardship Program at University of Miami Hospital/Jackson Memorial Medical Center.

Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and multi-drug resistant gram-negative bacteria, in order, were the most troubling microbes reported. Specifically, when asked to identify their most challenging health care–associated infection, 33% of respondents cited C. difficile, 23% MRSA, and 19% the gram-negative bacteria.

So how are the facilities with formal stewardship programs combating this? The leading initiatives cited by 56 such hospitals including monitoring high-cost agents (52 hospitals or 93%), assessment of intravenous to oral conversions by 84%, and review of broad-spectrum agent use by 80%.

Specific agents under scrutiny through stewardship include linezolid (cited by 92% of respondents with a program), vancomycin (88%), and daptomycin (87%).

Outcomes associated with stewardship are one of the most difficult factors to measure, Dr. Abbo said. A total 70% of respondents with a program said they could demonstrate a decrease in drug purchasing costs, for example. Another 66% could show a reduction in antimicrobial resistance, and 66% a decrease in C. difficile infections. Other results show 64% can support lower antimicrobial consumption, 43% improved patient outcomes, 38% reduced length of stay, and 34% reduced adverse drug reactions associated with antibiotic use.

Stewardship programs that foster appropriate prescribing can save money. "That’s another important take-home message," Dr. Abbo said. "Cost savings are important. That is how you can negotiate with your CEO or CMO – that’s how you are going to save money for the hospital and more than pay for your salary."

In a practical move, the survey also examined barriers to implementation of stewardship programs. Of 76 responses, 66% cited personnel shortages, 64% cited time constraints, and 62% said funding is limited. Only 13% reported resistance from administration. "I was very impressed that most people do not feel their administrations are a barrier," Dr. Abbo said.

It takes a village to run an optimal stewardship program – another major theme from the results. "Stewardship cannot be done by one person alone," Dr. Abbo said. Efforts are multidisciplinary, with hospitalists involved in 23% of existing programs or those planned for the subsequent 12 months, the survey shows. Infectious disease physicians are involved in 55%, followed by clinical PharmDs (52%), infection control professionals (47%), and microbiologists (31%).

The majority of respondents, 62%, work at community hospitals. Another 10% each work at a city/county hospital or a nonuniversity teaching hospital. The remaining respondents hail from a university (adult or pediatric) hospital (6%), a community pediatric hospital (2%), a VA or military hospital (2%), or another acute care facility setting (8%).

A total 62% of facilities had between 100 and 500 beds. Only 11% had fewer than 100 beds, and 15% had more than 500 and up to 800 beds. The remaining 12% of facilities, the largest had more than 800 beds.

All 213 acute care facilities in the state were invited to participate in the survey, conducted from July to October 2011. Data are based on a 40% response rate.

A second survey was also e-mailed to nursing homes and skilled nursing facilities in the state to assess the scope of current and planned stewardship practices in those settings.

Dr. Abbo had no relevant financial disclosures. The survey was supported by a grant from the Florida Department of Health Bureau of Epidemiology.

MIAMI BEACH – In the 2 years since California mandated judicious antimicrobial use, more money has poured into antimicrobial stewardship programs to combat inappropriate use, increasing resistance, and the sometimes debilitating adverse effects of these agents.

It is unlikely that hospital administrators would have funded these initiatives to this extent, particularly during a time of constrained budgets, without the law, Dr. Kavita K. Trivedi said.

"California currently is the only state with legislation regarding antimicrobial use. We hope that other states will follow along, especially because we’ve had such a positive experience with our legislation," said Dr. Trivedi, public health medical officer for the California Department of Public Health in Richmond.

"We are seeing and entering now that postantibiotic era where we don’t have the right antibiotics out there to treat our patients."

Clinically speaking, the law could not have come at a more critical point, Dr. Trivedi said. "I personally hear about all the resistant organisms and infections we have in the State of California. And thus far, we have had about 15 infections where we had absolutely no antibiotics that we can treat these patients with. It’s very concerning."

Not only has inappropriate antimicrobial use caused the current problems, but "we don’t have any antibiotics coming down the line that will be able to help those 15 patients of mine in California," she said. There are only 15 or 16 antibiotics currently in development in the United States, and only 8 have any activity against gram-negative bacteria, where resistance patterns are particularly worrisome, she added.

"We are seeing and entering now that postantibiotic era where we don’t have the right antibiotics out there to treat our patients," Dr. Trivedi said at the symposium. "It’s very, very concerning."

The 425 general acute care hospitals in California had 2 years to comply with the law after Gov. Arnold Schwarzenegger signed Senate Bill 739 into law in January 2008. "In this very long Senate bill, there is one sentence that was snuck in at the last minute regarding antimicrobial use. I’m very happy that someone did this," Dr. Trivedi said. The law includes a requirement that "all general acute care hospitals develop a process for evaluating the judicious use of antibiotics, the results of which should be monitored jointly by appropriate representatives and committees involved in quality improvement activities."

"We, and by that I mean the California Department of Public Health, interpret this to mean each California acute care hospital should have an antimicrobial stewardship program," Dr. Trivedi said.

"If they do it appropriately, they are going to decrease health care costs, reduce resistance rates, and improve the number of resistant infections in patients, so overall it’s a ‘win-win.’ "

A meeting attendee questioned how the public health department can help hospitals develop effective programs and, at the same time, punish hospitals that do not comply. "Although this is punitive now, and we are citing hospitals for not having stewardship programs, it is really encouraging hospitals to do the right thing in terms of patient safety and quality. So we do believe in our legislation and are very proud of it," Dr. Trivedi said.

The director of the hospital medicine program at the University of Michigan, Ann Arbor, Dr. Scott A. Flanders, was not convinced about legislation. "I’m reluctant to say that states should mandate [these programs]," he asserted. More research is needed to define the most essential aspects of effective stewardship programs, he said when reached for comment.

"While I applaud efforts to improve antimicrobial use – it’s critically important and hospitals need to prioritize it – I don’t know that legislation is always the best way to do that," Dr. Flanders said. "Many hospitals are resource constrained and are struggling with numerous legislative and nationally imposed mandates. Adding yet another on top of it is a challenge."

Arizona and Minnesota are among other states considering legislation to bolster antimicrobial stewardship, Dr. Trivedi said, but the proposals so far are not as strict as the law in California.

Because of the legislation, California launched its Antimicrobial Stewardship Program Initiative in February 2010. To initially assess the status of stewardship statewide, the health department conducted a web-based survey from May 2010 to March 2011. Responses came from 220 acute care hospitals, for a response rate of 52%. Of these, 167 were community hospitals. Almost half of these community hospitals, 45%, had a stewardship program, and another 31% were planning such an initiative. "A good chunk of our community hospitals ... already had these programs, even before our initiative started to help them," Dr. Trivedi said.

Nearly 128 hospitals, or a quarter of those in the state, said the law influenced them to start a stewardship program, Dr. Trivedi said. "Even though our legislation is very nonspecific, and does not even mention the words ‘stewardship program,’ it really did help the hospital administrations focus on these initiatives and allocate the funding for these programs."

The next step for the health department is to compile and release antimicrobial susceptibility data for 2008, 2009, and 2010, Dr. Trivedi said.

Dr. Trivedi and Dr. Flanders said they had no relevant financial disclosures.

MIAMI BEACH – In the 2 years since California mandated judicious antimicrobial use, more money has poured into antimicrobial stewardship programs to combat inappropriate use, increasing resistance, and the sometimes debilitating adverse effects of these agents.

It is unlikely that hospital administrators would have funded these initiatives to this extent, particularly during a time of constrained budgets, without the law, Dr. Kavita K. Trivedi said.

"California currently is the only state with legislation regarding antimicrobial use. We hope that other states will follow along, especially because we’ve had such a positive experience with our legislation," said Dr. Trivedi, public health medical officer for the California Department of Public Health in Richmond.

"We are seeing and entering now that postantibiotic era where we don’t have the right antibiotics out there to treat our patients."

Clinically speaking, the law could not have come at a more critical point, Dr. Trivedi said. "I personally hear about all the resistant organisms and infections we have in the State of California. And thus far, we have had about 15 infections where we had absolutely no antibiotics that we can treat these patients with. It’s very concerning."

Not only has inappropriate antimicrobial use caused the current problems, but "we don’t have any antibiotics coming down the line that will be able to help those 15 patients of mine in California," she said. There are only 15 or 16 antibiotics currently in development in the United States, and only 8 have any activity against gram-negative bacteria, where resistance patterns are particularly worrisome, she added.

"We are seeing and entering now that postantibiotic era where we don’t have the right antibiotics out there to treat our patients," Dr. Trivedi said at the symposium. "It’s very, very concerning."

The 425 general acute care hospitals in California had 2 years to comply with the law after Gov. Arnold Schwarzenegger signed Senate Bill 739 into law in January 2008. "In this very long Senate bill, there is one sentence that was snuck in at the last minute regarding antimicrobial use. I’m very happy that someone did this," Dr. Trivedi said. The law includes a requirement that "all general acute care hospitals develop a process for evaluating the judicious use of antibiotics, the results of which should be monitored jointly by appropriate representatives and committees involved in quality improvement activities."

"We, and by that I mean the California Department of Public Health, interpret this to mean each California acute care hospital should have an antimicrobial stewardship program," Dr. Trivedi said.

"If they do it appropriately, they are going to decrease health care costs, reduce resistance rates, and improve the number of resistant infections in patients, so overall it’s a ‘win-win.’ "

A meeting attendee questioned how the public health department can help hospitals develop effective programs and, at the same time, punish hospitals that do not comply. "Although this is punitive now, and we are citing hospitals for not having stewardship programs, it is really encouraging hospitals to do the right thing in terms of patient safety and quality. So we do believe in our legislation and are very proud of it," Dr. Trivedi said.

The director of the hospital medicine program at the University of Michigan, Ann Arbor, Dr. Scott A. Flanders, was not convinced about legislation. "I’m reluctant to say that states should mandate [these programs]," he asserted. More research is needed to define the most essential aspects of effective stewardship programs, he said when reached for comment.

"While I applaud efforts to improve antimicrobial use – it’s critically important and hospitals need to prioritize it – I don’t know that legislation is always the best way to do that," Dr. Flanders said. "Many hospitals are resource constrained and are struggling with numerous legislative and nationally imposed mandates. Adding yet another on top of it is a challenge."

Arizona and Minnesota are among other states considering legislation to bolster antimicrobial stewardship, Dr. Trivedi said, but the proposals so far are not as strict as the law in California.

Because of the legislation, California launched its Antimicrobial Stewardship Program Initiative in February 2010. To initially assess the status of stewardship statewide, the health department conducted a web-based survey from May 2010 to March 2011. Responses came from 220 acute care hospitals, for a response rate of 52%. Of these, 167 were community hospitals. Almost half of these community hospitals, 45%, had a stewardship program, and another 31% were planning such an initiative. "A good chunk of our community hospitals ... already had these programs, even before our initiative started to help them," Dr. Trivedi said.

Nearly 128 hospitals, or a quarter of those in the state, said the law influenced them to start a stewardship program, Dr. Trivedi said. "Even though our legislation is very nonspecific, and does not even mention the words ‘stewardship program,’ it really did help the hospital administrations focus on these initiatives and allocate the funding for these programs."

The next step for the health department is to compile and release antimicrobial susceptibility data for 2008, 2009, and 2010, Dr. Trivedi said.

Dr. Trivedi and Dr. Flanders said they had no relevant financial disclosures.

MIAMI BEACH – In the 2 years since California mandated judicious antimicrobial use, more money has poured into antimicrobial stewardship programs to combat inappropriate use, increasing resistance, and the sometimes debilitating adverse effects of these agents.

It is unlikely that hospital administrators would have funded these initiatives to this extent, particularly during a time of constrained budgets, without the law, Dr. Kavita K. Trivedi said.

"California currently is the only state with legislation regarding antimicrobial use. We hope that other states will follow along, especially because we’ve had such a positive experience with our legislation," said Dr. Trivedi, public health medical officer for the California Department of Public Health in Richmond.

"We are seeing and entering now that postantibiotic era where we don’t have the right antibiotics out there to treat our patients."

Clinically speaking, the law could not have come at a more critical point, Dr. Trivedi said. "I personally hear about all the resistant organisms and infections we have in the State of California. And thus far, we have had about 15 infections where we had absolutely no antibiotics that we can treat these patients with. It’s very concerning."

Not only has inappropriate antimicrobial use caused the current problems, but "we don’t have any antibiotics coming down the line that will be able to help those 15 patients of mine in California," she said. There are only 15 or 16 antibiotics currently in development in the United States, and only 8 have any activity against gram-negative bacteria, where resistance patterns are particularly worrisome, she added.

"We are seeing and entering now that postantibiotic era where we don’t have the right antibiotics out there to treat our patients," Dr. Trivedi said at the symposium. "It’s very, very concerning."

The 425 general acute care hospitals in California had 2 years to comply with the law after Gov. Arnold Schwarzenegger signed Senate Bill 739 into law in January 2008. "In this very long Senate bill, there is one sentence that was snuck in at the last minute regarding antimicrobial use. I’m very happy that someone did this," Dr. Trivedi said. The law includes a requirement that "all general acute care hospitals develop a process for evaluating the judicious use of antibiotics, the results of which should be monitored jointly by appropriate representatives and committees involved in quality improvement activities."

"We, and by that I mean the California Department of Public Health, interpret this to mean each California acute care hospital should have an antimicrobial stewardship program," Dr. Trivedi said.

"If they do it appropriately, they are going to decrease health care costs, reduce resistance rates, and improve the number of resistant infections in patients, so overall it’s a ‘win-win.’ "

A meeting attendee questioned how the public health department can help hospitals develop effective programs and, at the same time, punish hospitals that do not comply. "Although this is punitive now, and we are citing hospitals for not having stewardship programs, it is really encouraging hospitals to do the right thing in terms of patient safety and quality. So we do believe in our legislation and are very proud of it," Dr. Trivedi said.

The director of the hospital medicine program at the University of Michigan, Ann Arbor, Dr. Scott A. Flanders, was not convinced about legislation. "I’m reluctant to say that states should mandate [these programs]," he asserted. More research is needed to define the most essential aspects of effective stewardship programs, he said when reached for comment.

"While I applaud efforts to improve antimicrobial use – it’s critically important and hospitals need to prioritize it – I don’t know that legislation is always the best way to do that," Dr. Flanders said. "Many hospitals are resource constrained and are struggling with numerous legislative and nationally imposed mandates. Adding yet another on top of it is a challenge."

Arizona and Minnesota are among other states considering legislation to bolster antimicrobial stewardship, Dr. Trivedi said, but the proposals so far are not as strict as the law in California.

Because of the legislation, California launched its Antimicrobial Stewardship Program Initiative in February 2010. To initially assess the status of stewardship statewide, the health department conducted a web-based survey from May 2010 to March 2011. Responses came from 220 acute care hospitals, for a response rate of 52%. Of these, 167 were community hospitals. Almost half of these community hospitals, 45%, had a stewardship program, and another 31% were planning such an initiative. "A good chunk of our community hospitals ... already had these programs, even before our initiative started to help them," Dr. Trivedi said.

Nearly 128 hospitals, or a quarter of those in the state, said the law influenced them to start a stewardship program, Dr. Trivedi said. "Even though our legislation is very nonspecific, and does not even mention the words ‘stewardship program,’ it really did help the hospital administrations focus on these initiatives and allocate the funding for these programs."

The next step for the health department is to compile and release antimicrobial susceptibility data for 2008, 2009, and 2010, Dr. Trivedi said.

Dr. Trivedi and Dr. Flanders said they had no relevant financial disclosures.