Antimicrobial Stewardship in Colorado

Firstline houses clinical pathways from Children’s and Denver health along with antimicrobial dosing information, pathogen information, infection prevention information, and more. It is intended for use in all clinical settings. The app is free to download, and is available on iOS and Android devices, as well as a web-based format. CDPHE supports the Firstline app in an effort to provide antimicrobial stewardship treatment guidelines and resources across healthcare settings.

Use the QR code above to find the app. Once downloaded, you can set your location to Denver Health and/or Children’s Hospital Colorado to access all of our materials. Once in the app, clicking on the FirstLine logo in the top left corner will allow you to toggle between locations to access adult vs pediatric guidance. Contact cdphe_hai_ar@state.co.us for more information or feedback.

CDPHE joins CDC in a national effort to combat the growing threat of antibiotic resistance by asking Colorado health care providers to Be Antibiotics Aware. This year U.S. Antibiotic Awareness Week is November 18-24. CDPHE is participating by providing updated data and resources on the appropriate use of antimicrobials. For more information, visit Antibiotic Awareness | Colorado Department of Public Health and Environment.

The Antimicrobial Use (AU) Option and Antimicrobial Resistance (AR) Option are components of the Antimicrobial Use and Resistance (AUR) Module within the Patient Safety Component of the NHSN. CMS will require hospitals to submit AUR module data beginning calendar year 2024 as a requirement under the Public Health and Clinical Data Exchange objective of the CMS Promoting Interoperability Program.

CDPHE Individual Hospital Reports of Antibiotic Use from NHSN module:

We have created antibiotic use reports which compare individual hospitals to others of similar bed size and region. The reports highlight broad spectrum antibiotic use for targeting antimicrobial stewardship efforts. The de-identified data is exported from the NHSN AU option and shared privately with each hospital ASP.
In an effort to support hospitals in submitting data to the AUR module, CDPHE created a Frequently Asked Questions guidance document. 

Quarterly NHSN Office Hours for Antimicrobial Stewardship Programs: Contact cdphe_hai_ar@state.co.us to register for the next AUR Office Hours.

For additional information and steps to fulfill this requirement, visit CDC’s website.

The Core Elements of Antimicrobial Stewardship are a framework for antimicrobial stewardship across healthcare settings. Below are a series of resources for support and development of antimicrobial stewardship programs to perform action, tracking, and reporting within the Core Elements.

CDC’s Core Elements of Antibiotic Stewardship Programs

• Core Elements of Hospital Antibiotic Stewardship Programs
• Core Elements of Outpatient Antibiotic Stewardship
• Core Elements of Antibiotic Stewardship for Nursing Homes
• Implementation of Antibiotic Stewardship Core Elements in Resource-Limited Settings

Additional implementation resources

• National Quality Forum. National Quality Partners Playbooks
• Children's Hospital Colorado Professional Resources
• Stenehjem et al. Antibiotic Stewardship in Small Hospitals: Barriers and Potential Solutions. Clin Infect Dis 2017.
• Infectious Diseases Society of America. Implementing an Antibiotic Stewardship Program 

Antimicrobial stewardship (AS) is critical to effectively treat infections and combat antibiotic resistance. The Healthcare-Associated Infections/Antimicrobial Resistance (HAI/AR) program at CDPHE used state-level data to set public health priorities for AS across diverse hospital settings. The CDPHE antimicrobial stewardship hospital goals are described in the infographic below.

Facility-specific clinical practice guidelines serve as a gold standard for antibiotic selection and duration of therapy and are a foundation for antibiotic stewardship program actions. Recommendations should be based on national guidelines but should reflect hospital treatment preferences based on local susceptibilities, treatment options, and patient mix. Facility-specific guidelines should address common indications for antibiotic use, including community-acquired pneumonia, urinary tract infection, skin and soft tissue infection, intra-abdominal infection, and surgical prophylaxis.

• Infectious Diseases Society of America Practice Guidelines 
• American Academy of Pediatrics Practice Guidelines
• Sanford Guide (subscription required) 
• American Academy of Pediatrics Red Book (subscription required) 

• Children's Hospital Colorado 
• Denver Health 
• University of Nebraska
• Children's Hospital of Philadelphia
• Seattle Children's

Antimicrobial stewardship programs should prioritize actions that are most likely to improve antibiotic use. Some actions that are recommended by evidence-based guidelines include:

• Prospective audit with feedback: An external review of antibiotic therapy by a member of the antibiotic stewardship team, accompanied by suggestions to optimize use, at some point after the agent has been prescribed.
• Handshake stewardship: Rounding-based review of antibiotic therapies by the antibiotic stewardship team with in-person suggestions to optimize use.
• Preauthorization: Prescribers gain approval prior to the use of certain antibiotics designated by the antibiotic stewardship team.

• Infectious Diseases Society of America. Implementing an Antibiotic Stewardship Program 
• Tinker et al. Interventions to Optimize Antimicrobial Stewardship. Antimicrobial Stewardship & Healthcare Epidemiology. 

• Doernberg et al. Essential Resources and Strategies for Antibiotic Stewardship Programs in the Acute Care Setting. Clin Infect Dis 2018. 
• Hurst et al. Handshake Stewardship A Highly Effective Rounding-based Antimicrobial Optimization Service. Pediatric Infectious Disease Journal 2016. 
• Tamma et al. What Is the More Effective Antibiotic Stewardship Intervention: Preprescription Authorization or Postprescription Review With Feedback? Clin Infect Dis 2017. 
• Anderson et al. Feasibility of Core Antimicrobial Stewardship Interventions in Community Hospitals. JAMA Network Open 2019. 
• Stenehjem et al. Impact of Implementing Antibiotic Stewardship Programs in 15 Small Hospitals: A Cluster-Randomized Intervention. Clin Infect Dis 2018.

Measurement is critical to identify opportunities for improvement and to assess the impact of interventions. Measurement of antibiotic stewardship interventions may involve evaluation of both processes and outcomes. A priority metric for antibiotic use is antibiotic days of therapy (DOT). DOT is the total number of days for which a specific antibiotic is given. It is usually expressed as a rate per 1,000 patient-days or days present and can be stratified by location of prescription or antibiotic class. Antibiotic use data can also be used to provide feedback to prescribers.

The National Healthcare Safety Network (NHSN) offers an Antibiotic Use and Resistance Module that allows hospitals to track antibiotic DOT in their facility against national benchmarks and submit data to inform public health priorities. CDPHE created a Frequently Asked Questions guidance document with links to resources from CDC to support hospitals in reporting AUR data to NHSN. CDPHE also offers NHSN AUR Office Hours quarterly. Contact cdphe_hai_ar@state.co.us to register for the next AUR Office Hours. Learn more about tracking antibiotic use from the resources below.

• National Action Plan. National Action Plan for Combating Antibiotic-Resistant Bacteria, 2020-2025 
• CDC. Antibiotic Use & Stewardship | A.R. & Patient Safety Portal

• Benic et al. Metrics for quantifying antibiotic use in the hospital setting: results from a systematic review and international multidisciplinary consensus procedure. J. Antimicrob Chemother 2018.
• Moehring et al. Expert Consensus on Metrics to Assess the Impact of Patient-Level Antimicrobial Stewardship Interventions in Acute-Care Settings. Clin Infect Dis 2016. 
• Polk et al. Measurement of Adult Antibacterial Drug Use in 130 US Hospitals: Comparison of Defined Daily Dose and Days of Therapy. Clin Infect Dis 2007.

• CDC, National Healthcare Safety Network. Antimicrobial Use and Resistance (AUR) Options.
• CDC, National Healthcare Safety Network. FAQ: Antimicrobial Use (AU) Option
• CDC, National Healthcare Safety Network. AU Case Examples
• CDC, National Healthcare Safety Network. Vendors that have Passed the AU SDS Validation
• CDPHE, NHSN AUR module Frequently Asked Questions and Guidance Document

Antibiotic resistance is a public health threat and a key motivator of antibiotic stewardship. Reporting antibiotic resistance can inform public health priorities, provide targets for antibiotic stewardship in hospitals, and give clinicians information necessary to prescribe appropriate antibiotics for patients. In Colorado, clinical laboratories and health care providers are required to report certain organisms found to be resistant to certain antibiotics to public health. More information about diseases that must be reported and how to report to public health can be found at https://cdphe.colorado.gov/report-a-disease.

• Clinical and Laboratory Standards Institute. M100 Performance Standards for Antimicrobial Susceptibility Testing
• Clinical and Laboratory Standards Institute. M39 Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data, 5th Edition. (purchase required).
• Hindler et al. Analysis and Presentation of Cumulative Antibiograms: A New Consensus Guideline from the Clinical and Laboratory Standards Institute. Clin Infect Dis 2007.   
• Moehring et al. Challenges in Preparation of Cumulative Antibiogram Reports for Community Hospitals. J Clin Micro 2015.

• CDC, National Healthcare Safety Network. Antimicrobial Use and Resistance (AUR) Options
• CDC, National Healthcare Safety Network. FAQs: Antimicrobial Resistance (AR) Option