Antibiotic use and misuse is driving drug resistance. Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die each year as a result of these infections, according to the Centers for Disease Control and Prevention.

Over 70% of U.S. hospitals are small community hospitals with 200 beds or fewer; however, our understanding of antibiotic use in these facilities is extremely limited. Most of the existing data on antibiotic use rates come from larger academic medical centers. Describing antibiotic usage patterns in small facilities is a high priority, given they constitute the majority of acute care hospitals and national antibiotic stewardship is forthcoming.

A study conducted by researchers from Intermountain Medical Center and the University of Utah School of Medicine examined antibiotic use at 19 hospitals (15 small community hospitals and four large community hospitals) within Intermountain’s network. The results of the study showed substantial variation in patterns of antibiotic use among small community hospitals but usage was similar to large community and academic-based hospitals.

Intermountain has a long history of antibiotic use measurements and digital data support. All facilities use an electronic medical record system that transmits data to a centralized enterprise data warehouse. Since 2011, antibiotic use reports have been collected from the data system and submitted to the CDC’s National Healthcare and Safety Network Antimicrobial Use (NHSN AU) module.

Using data from the NHSN AU module from January 2011 through December 2013, we calculated monthly and 3-year antibiotic use rates for each facility, care unit type, and antibiotic category. Data included in the NHSN AU modules include:

•Patient care location.

•Facility-wide antibiotic use.

•Use of individual antibiotics.

•Classes of antibiotics.

•Days of therapy.

•Patient-day data.

Antibiotic agents were categorized into five groups based on antibiotic spectrum and ability to treat multidrug-resistant organisms (MDROs). Category one antibiotics are narrower-spectrum agents, and category five antibiotics are the broadest-spectrum antibiotics or associated with treating MDROs. Categories four and five were classified as broad-spectrum antibiotics. Hospital care units were categorized as intensive care, medical/surgical, pediatric, or miscellaneous.

Antibiotic use rates, expressed as days of therapy per 1,000 patient-days (DOT/1000PD), were calculated for each small community hospital and compared with rates in large community hospitals. Negative-binomial regression was used to relate antibiotic use.

The key findings of the study include:

•Total antibiotic use rates varied widely across the 15 small community hospitals and were similar to rates in four large community hospitals.

•The proportion of patient-days spent in the respective care unit types varied substantially within small community hospitals and had a large impact on facility-level antibiotic use rates.

•Broad-spectrum antibiotics accounted for 26% of use in small community hospitals, similar to the proportion in large community hospitals.

•Significant predictors of antibiotic use include case mix index, proportion of patient-days in specific care unit types, and season.

•Small community hospitals need to become a focus of antibiotic stewardship efforts.

All hospitals in 2017 are required to have an antibiotic stewardship program in place according to Joint Commission guidelines. Small community hospitals in the United States face significant challenges meeting the national antibiotic stewardship requirements. These challenges include: limited access to infectious diseases physician and/or pharmacist leadership, limited information technology support, and lack of antibiotic guidance.

In order to holistically address the growing problem of antibiotic-resistant bacteria, the infectious disease community must respond to antibiotic use in ALL hospitals, not just the large academic medical facilities. Small hospitals are least likely to have stewardship programs even though antibiotic usage patterns are similar to larger facilities. We need to bring stewardship support to ALL hospitals, but the challenges come in knowing how to do that.

To address the challenges, researchers at Intermountain Healthcare are currently conducting a study to identify recommendations that will help build antibiotic stewardship programs for these facilities.

Eddie Stenehjem, MD, is an infectious disease physician and researcher at Intermountain Medical Center, Salt Lake City, the flagship facility for the Intermountain Healthcare system.

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