Implementation of an antimicrobial stewardship program in a rural hospital.

The implementation of a pharmacy-directed antimicrobial stewardship (AMS) program involving the use of telemedicine technology is described. Pursuant to a gap analysis of AMS services at a rural hospital where physician specialists in infectious diseases (ID) or pharmacists with advanced ID training were not available, a multidisciplinary team was formed to implement a stewardship program targeting six antimicrobials with a high potential for misuse. A key part of the program was the participation of a remotely located ID physician specialist in weekly case review teleconferences. An evaluation of the first 13 months of the initiative (May 2010-June 2011) indicated that pharmacist-initiated AMS interventions increased dramatically after program implementation, from a baseline average of 2.1 interventions per week to an average of 6.8 per week; the rate of antimicrobial streamlining increased from 44% to an average of 96%. Due to inconsistent documentation, an increase in the rate of physician-pharmacist agreement could not be demonstrated; however, anecdotal evidence suggested an increase in physician requests for case reviews by the AMS team and enhanced interdisciplinary collaboration. An analysis of 2010 purchasing data demonstrated a decrease in annual antibiotic costs of about 28% from 2009 levels (and a further decrease of about 51% in the first two quarters of 2011). The rate of nosocomial Clostridium difficile infection decreased from an average of 5.5 cases per 10,000 patient-days to an average of 1.6 cases per 10,000 patient-days. Implementation of an AMS program at a rural hospital led to increases in pharmacist-recommended interventions and streamlining of antimicrobial therapy, as well as decreases in health care-associated C. difficile infections and antimicrobial purchasing costs.