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Policy Innovation Profile

State Health Department Support Spurs Development of Many Antimicrobial Stewardship Programs After Passage of Legislative Mandate

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Antimicrobial Stewardship Remains Key Challenge for U.S. Hospitals

by Diane Jacobsen, MPH, CPHQ, Institute for Healthcare Improvement

Inappropriate use of antibiotics in U.S. hospitals needlessly increases the cost of care, leads to antibiotic-associated toxicity and other adverse events, promotes antibiotic resistance, and increases the risk of Clostridium difficile infection. Although the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America have issued comprehensive guidelines on developing hospital-based antimicrobial stewardship programs,1 adoption of these guidelines has been relatively slow and incomplete, despite emerging evidence that such programs can reduce hospital costs substantially, decrease the risk of C. difficile infection, and perhaps slow development of antibiotic resistance. California’s policy effort to support the development of antimicrobial stewardship programs throughout the state raises awareness and builds needed support within and across hospitals, as described in an innovation profile on the AHRQ Health Care Innovations Exchange. The education and guidance being provided by the California Department of Public Health to hospital and long-term care facilities enables organizations to learn from innovative ideas across organizations. The regional collaboratives developed in California provide a forum for health care facilities to easily learn from each other and from recognized experts to make improvements.2

It has been estimated that up to 50% of antibiotic use in hospitals is inappropriate, so there is considerable room for reducing waste, improving patient safety, and blunting the emergence of multiple drug-resistant organisms. Hospital-based antibiotic stewardship is a promising approach to addressing this urgent quality and safety issue.

In seeking to gain support from administrators and clinicians, the importance of presenting objective data on the expanding problem of antibiotic resistance and the need to use antibiotics appropriately cannot be overstated. The experience and conclusions described in this innovation profile provide important insights when considering legislation to drive further adoption of formal antimicrobial stewardship programs. Most notably, the profile shows the importance of ensuring that such programs provide flexibility that allows tailoring to the local environment and the resources available.

The challenge of incorporating process and outcomes measures to assess the impact of efforts to improve antibiotic selection, timing, de-escalation, etc. doesn’t need to be made any more complex than initially capturing data at the level of patient care during regular patient rounding. Obtaining process data is proving challenging on the local, regional, and national level and will require innovative approaches within individual organizations prior to the use of such data for comparative benchmarking across institutions.


1Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44:159-77. [PubMed]

2The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. Available at:

About the Author

Diane Jacobsen, MPH, CPHQ, is a director at the Institute for Healthcare Improvement (IHI), an independent not-for-profit organization that works with health care providers and leaders to achieve safe and effective health care. An epidemiologist with experience in quality improvement, risk management, and infection control in hospitals, she directs an antibiotic stewardship pilot testing project developed by IHI and the Centers for Disease Control and Prevention (CDC), and leads other IHI initiatives related to infectious diseases.

Disclosure Statement: Ms. Jacobsen has been involved professionally in a variety of private and public initiatives relevant to the work described in this profile. The CDC/IHI antibiotic stewardship pilot testing project is being supported by a grant from the CDC.

Original publication: June 06, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 02, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 04, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.