Issue: January 2022
Source: Healio Interviews.
Disclosures: Clancy reports being on advisory boards for Merck, Pfizer, Qpex and Shionogi, and receiving research grants from Merck, Pfizer and Qpex. Goff reports receiving a grant from Merck. LaPlante reports having research funded by AbbVie, Merck and Pfizer. Marcelin reports being a part of a grant review panel for Pfizer.
January 21, 2022
6 min read

In stewardship, trust is essential

Issue: January 2022
Source: Healio Interviews.
Disclosures: Clancy reports being on advisory boards for Merck, Pfizer, Qpex and Shionogi, and receiving research grants from Merck, Pfizer and Qpex. Goff reports receiving a grant from Merck. LaPlante reports having research funded by AbbVie, Merck and Pfizer. Marcelin reports being a part of a grant review panel for Pfizer.
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In 2014, the CDC established The Core Elements of Hospital Antibiotic Stewardship to help hospitals improve their prescribing practices. Over the next 2 years, it also published guidance for nursing homes and the outpatient setting.

As of 2019, 84% of hospitals reported having a program that meets the CDC’s seven “core elements.” We asked experts to tell us about the essential components of the programs at their institutions.

Cornelius (Neil) J. Clancy, MD
Stewardship programs have expanded beyond hospitals into the outpatient setting, noted Cornelius (Neil) J. Clancy, MD.

Source: Bill George/VA Pittsburgh Healthcare System

“Humans have been around for the blink of an eye. These bacteria have been on Earth for billions of years, and they are always going to get ahead of us,” Kerry LaPlante, PharmD, FCCP, FIDSA, FIDP, department chair and professor of pharmacy at the University of Rhode Island College of Pharmacy, told Healio | Infectious Disease News. “It feels some days like it is impossible to stay on top of antimicrobial resistance because there are millions of cells in the tip of a pencil, and they mutate quickly.”

‘Building relationships’

Debra A. Goff, PharmD, FCCP, a clinical professor of pharmacy practice and science at The Ohio State University College of Pharmacy, is a founding member of the university’s antimicrobial stewardship program.

“The key to doing any type of stewardship — inpatient, outpatient, anything — is really building relationships with health care providers, who you are trying to teach to change how they prescribe antibiotics,” Goff said. “Those health care providers need to know you and develop a relationship with you, so they trust you.”

Debra A. Goff, PharmD, FCCP
Debra A. Goff

Establishing those relationships is essential to making antibiotic stewardship programs work, Goff said.

“You can have all the knowledge in the world, but if people don’t trust you, they are not going to listen to your recommendations,” she said.

According to Cornelius (Neil) J. Clancy, MD, chief of infectious diseases for the VA Pittsburgh Healthcare System, the system’s original programs tended to focus on in-hospital antimicrobial stewardship. More recently, the programs have expanded to offer stewardship in other clinical settings.

“I think this sort of move out of a solely hospital-based focus into other spaces — outpatient spaces, or places like nursing homes — is part of a general trend within stewardship programs nationally,” Clancy said.

This trend poses several challenges. According to Clancy, there are many diverse clinics within the health system and many providers who work in other locations daily. There are doctors, residents, trainees, nurse practitioners and others who work in various disciplines.

“There is a lot of antibiotic use by internal medicine doctors, family practitioners, surgeons, ophthalmologists, dentists,” Clancy said. “The issues in the outpatient setting are really sort of far flung, and the patient populations that need practitioners are very, very different in the various settings.”

Clancy said the first thing his system did to address antibiotic resistance was locate where antibiotics were being used throughout all the outpatient clinics. Then, it decided where to prioritize addressing antibiotic use.

“Where we started was in our primary care outpatient clinics, which is where the bulk of the antibiotics were being used, and where we had a presence, geographically, over a very wide area,” he said. “In many of the places outside the city of Pittsburgh, in the more rural areas of our network, there was no infectious disease expertise on the ground.”

Jasmine Marcelin, MD, FACP
Jasmine R. Marcelin

Jasmine R. Marcelin, MD, FACP, FIDSA, associate medical director of the University of Nebraska Medical Center’s antimicrobial stewardship program, said infectious disease specialists are necessary to having a successful stewardship program.

“There are data to suggest that an ID specialist — really, both a physician and a pharmacist — should be a part of any antimicrobial stewardship program,” Marcelin said. “I think that the collaborating clinicians within the clinics in the hospital rounds should absolutely be involved, so we can all work together to have the best outcome.”

Core elements

According to the CDC, the seven core elements of hospital antibiotic stewardship programs are hospital leadership commitment, accountability, pharmacy expertise, action, tracking, reporting and education.

Kerry LaPlante, PharmD, FCCP, FIDSA, FIDP
Kerry LaPlante

LaPlante said it was important to put leadership support first.

“Without the highest level of leadership support saying that antimicrobial stewardship is a priority, everything else we are talking about is going to fail,” LaPlante said. “I say it all the time, everything else falls after, but leadership support is number one. The CDC got it right.”

Goff believes the core elements should be tweaked to make expectations more realistic in executing each element in U.S. hospitals. Although she prefers not to rank the elements in order of importance, she said action and educating health care workers on the importance antibiotic stewardship are “key components.”

Having core elements helps hospitals’ stewardship initiatives function, she said.

When the CDC initially developed the guidance, there were actually eight core elements, including educating patients and family members about antibiotic stewardship, Goff explained. This element was eventually eliminated as unrealistic, she said.

“It was a good intention, but that was a really difficult metric to try to be compliant with,” Goff said.

Recruiting physicians

Like LaPlante, Marcelin believes that leadership commitment is the most important of the seven core elements, citing institutional financial support as the reason why.

“The money that is needed, as well as the workforce and labor that is needed to be able to develop those initiatives within a program, are the most important reasons to develop a [successful stewardship program],” Marcelin said.

Goff said it is difficult to recruit physicians for stewardship programs because of a lack of financial support.

“Who wants to work for free? It is a very unrealistic expectation,” Goff said. “When you ask people to take on important tasks without any compensation, you’re going to get what you pay for.”

According to Clancy, it was a challenge recruiting medical students for infectious diseases, but because of the visibility of ID experts during the COVID-19 pandemic, the number of applicants has risen.

“Even with that, about 30% of ID training program positions for physicians every year go unfilled,” Clancy said. “That’s been the case even over the past couple of years, even though the numbers have gone up.”

Most people entering the medical field assume there are not many ID practitioners, and it dissuades some from entering the specialty, Clancy said.

“It is a constant battle to get as many people into infectious diseases as possible and as many people as we would ideally need in this country,” he said.

LaPlante also noted this trend, which she believes may be a driving factor in the low recruitment of experts for stewardship programs.

On the pharmacy side, however, inter­est in infectious diseases has been ris­ing since 2019, she said.

“It’s the exact opposite,” LaPlante said. “There is a significant increase. There are about 111 pharmacy ID training programs in the country, and there are a lot of candidates interested in infectious diseases as pharmacists. I have had 22 pharmacy students at our college reach out to me personally since March.”

Nontraditional programs

Stewardship has expanded into other areas of medicine, including dentistry. According to Goff, dentists prescribe the highest amount of clindamycin in the U.S., which is the leading cause in the development of Clostridioides difficile infections. Dentists write about 24 million antibiotic prescriptions each year, and about 80% are unnecessary, according to a 2019 study.

Goff was one of just 25 experts selected by WHO to be a part of its antimicrobial stewardship program. She spent much of her time working in South Africa, but when the COVID-19 pandemic began and her international work was halted, she decided to work with dental antibiotic stewardship programs.

antibiotics fast facts

Source: CDC

Goff, whose husband is a dentist, said she felt it was time to further an initiative that looked at dental and orthopedic surgeons’ use of antibiotic prophylaxis.

“I said, let’s try to engage more dentists in dental antibiotic stewardship,” Goff said. “It has been a phenomenally positive and a personally rewarding initiative to become involved in.”

Goff and colleagues conducted a dental antibiotic stewardship study, in which they taught stewardship to groups of dentists.

“They had never even heard of the term ‘dental antibiotic stewardship’ before,” she said. “So, imagine: Are you even going to listen to a lecture with that title if you don’t even know what the term means? That has been a common finding.”

Goff and colleagues have taken their skillset in engaging health care providers in the hospital setting and translated it to different outpatient settings.

“We have literally changed dentists’ prescribing. Clindamycin, fluroquinolone — we have eliminated that from their prescribing,” she said. “Most important was teaching them the understanding of why we need more responsible antibiotic use and the key message that antibiotics can harm patients.” – by Ken Downey Jr.

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