Implementation of antibiotic stewardship in the United States

Sarah Kabbani and Michael Craig from the U.S. Centers for Disease Control and Prevention discuss the organization’s efforts to implement and support antibiotic stewardship

Antimicrobial resistance is an urgent public health threat. In the United States, more than 2.8 million antimicrobial-resistant infections occur each year, and more than 35,000 people die as a result, according to the 2019 Antibiotic Resistance (AR) Threats Report. Improving the way antibiotics are prescribed and used is one of the Centers for Disease Control and Prevention’s (CDC) core strategies to combat the threat of antimicrobial resistance. Antibiotic stewardship is a set of key principles to guide efforts to improve antibiotic use and, therefore, advance patient safety and improve healthcare outcomes.

How the CDC supports healthcare organizations in implementing and monitoring antimicrobial stewardship programs

CDC developed a guidance framework to outline principles for implementing antibiotic stewardship in healthcare settings. The Core Elements of Antibiotic Stewardship provide components that outline the structure and activities that are associated with successful antibiotic stewardship programs. Healthcare facilities and organizations across the country use the Core Elements to guide antibiotic stewardship efforts in hospitals and other types of healthcare settings. The Core Elements also form a foundation of stewardship accreditation standards referenced by US hospital accreditation agencies, such as The Joint Commission. Federal regulations developed by the Centers for Medicare and Medicaid Services for hospitals and long-term care facilities also reference the Core Elements.

CDC tracks and reports the uptake of the seven Core Elements in hospitals and long-term care facilities yearly to identify opportunities for improving prescribing and identify settings that need the most support. CDC also conducts antibiotic use surveillance in multiple healthcare settings and funds antibiotic stewardship research to inform effective implementation. CDC works with public and private partners, including professional societies, to disseminate best practices for antibiotic stewardship. State and local health departments are critical public health partners in the United States with an important role in antibiotic stewardship. Through a cooperative agreement, CDC supports all state health departments, as well as health departments in some large cities and territories, to provide access to stewardship expertise and implement stewardship activities.

CDC leads the US Antibiotic Awareness Week (USAAW) observance, which takes place annually from November 18-24. Before and during this observance, CDC communicates with key audiences about the importance of appropriate antibiotic and antifungal use and the threat antimicrobial resistance poses to people, animals, plants, and their shared environment. CDC also develops and disseminates educational content on antibiotic stewardship to healthcare professionals and the public.

Challenges in implementing AMS programs and best practices in antimicrobial prescribing

The US has made great strides in implementing antibiotic stewardship programs in hospitals and long-term care settings. However, almost 80% of antibiotics are prescribed in outpatient settings. Although improvements in antibiotic prescribing in outpatient settings have been reported, clinicians who practice in outpatient settings face many challenges that could lead to inappropriate antibiotic prescribing. Those can include competing priorities, communication barriers, and time pressures. Prescribers working in outpatient settings need access to resources, antibiotic stewardship expertise, and a data infrastructure that allows tracking of antibiotic use and providing feedback to clinicians on their prescribing practices. Adapting antibiotic stewardship best practices to changes in healthcare delivery, such as the expansion of telemedicine services, is also needed. Even in hospital and long-term care settings, where regulatory requirements support implementation, ensuring the resiliency of stewardship staffing remains important.

Addressing antibiotic prescribing health inequities

In 2022, the CDC conducted a review of published studies to identify antibiotic prescribing health inequities. The review found that antibiotic prescribing rates and appropriateness varied by factors such as patient race, insurance status, and clinician type. The findings in these studies emphasize the importance of integrating health equity into antibiotic stewardship policies, practices, and research. Many risks for antimicrobial-resistant infections are tied to social determinants of health, including where someone lives, their environmental exposures, how often they engage with healthcare, the quality of care they receive, and other socioeconomic factors. As part of an agency-wide strategy to increase equity across public health, CDC is expanding the collection of disparities and equity- focused data across multiple surveillance systems, supporting infection control and patient safety efforts, including support to states to address health disparities related to AMR pathogens and antibiotic use, addressing educational needs that impact diverse frontline healthcare workers, and focusing on strategies to address disparities in quality of care in long-term care.

The importance of international collaboration in combatting AMR

An antimicrobial-resistant threat somewhere can quickly become a threat anywhere. When the capacities to prevent infections and rapidly detect and control the spread of antimicrobial resistance are strengthened in one country, the world benefits. Effectively combating antimicrobial resistance requires strong global partnerships. In 2016, effective coordinated approaches were emphasized in the political declaration from the first United Nations High-Level Meeting on Antimicrobial Resistance and the World Health Organization Global Action Plan on Antimicrobial Resistance.

The importance of international collaboration to combat antimicrobial resistance was underscored in late September 2024 when global leaders met and adopted the second United Nations General Assembly High-level Meeting on Antimicrobial Resistance political declaration. The declaration established global goals, commitments, and targets for combating antimicrobial resistance, including a goal to reduce global deaths associated with bacterial antimicrobial resistance by 10% by 2030. The political declaration identifies specific prevention interventions in health care and communities, including:

• Immunization (reduces infections and antibiotic use) • Early and accurate detection of pathogens
• Infection prevention and control
• Water, sanitation, and hygiene (WASH)

Departments and agencies across the US Government collaborate to implement the US National Action Plan for Combating Antibiotic-Resistant Bacteria (National Action Plan or CARB) in human health, animal health, and the environment. The National Action Plan includes a goal specifically focused on global partnerships and collaboration to combat antimicrobial resistance.