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How to Conduct an Antimicrobial Stewardship Gap Analysis

Whether you already have an antimicrobial stewardship program (AMS) in place or are looking to start one, conducting a gap analysis will provide critical information to help you determine your next steps. The Centers for Disease Control and Prevention (CDC) provide checklists that simplify the antimicrobial stewardship gap analysis process no matter where you are in the development of your program.1

If you’re early in the process, it’s easy to be overwhelmed. The CDC recommends that hospitals introduce new antimicrobial stewardship policies sequentially, with time to educate staff and see measurable results before implementing subsequent changes. Of the items listed below, the CDC or the Infectious Disease Society of America (IDSA) consider the bolded, first-level items essential to the success of an AMS program. The second level items should be considered “menu options” from which each facility will choose those likely to have the greatest impact or to produce early successes that will give the AMS program momentum. 2,3

Look first to ensure leadership support.

Executive backing of the antimicrobial stewardship program can be exhibited in two ways, and both are important. Generally, a written statement by leadership states that the hospital supports efforts to improve antibiotic use and encourages staff to participate in antimicrobial stewardship efforts. The rubber meets the road in the second critical step: the executive team provides funding for antimicrobial stewardship efforts that go toward salaries for the physician and pharmacist program leaders, education and IT support. If you have stated support and no budget, your antimicrobial stewardship gap analysis has revealed your first priority.

Determine if you have both a physician leader and a pharmacist leader.

The CDC recommends a physician leader to accept accountability for program outcomes and to communicate with medical staff, particularly other senior physicians. The pharmacist brings critical drug expertise to the antimicrobial stewardship program.

Find evidence or secure broad support for the AMS program.

Does your AMS team include or have the support of infection prevention, epidemiology, quality improvement, microbiology, IT, nursing and other clinicians? A broad-based team will be better able to identify the aspects of antibiotic use that most need improvement in your facility. If you have two or three, identify which areas you want to involve next.

Identify actions that support optimal antibiotic use.

Many policies may support your goal. How many have you implemented? A few of the possible policies include:

  • Documenting dose, duration and indication for all antimicrobial prescriptions
  • Providing treatment recommendations for antibiotic selection based on local conditions or your facility’s antibiogram
  • Implementing an antibiotic timeout after 48 hours
  • Requiring pre-authorization of specific antibiotics
  • Initiating prospective audit of antibiotic prescriptions by a pharmacist and providing prompt feedback to providers
  • Automatically changing antibiotic therapy from IV to oral under specific circumstances
  • Automating alerts to clinicians for duplicative prescriptions

Measure and monitor antibiotic prescribing, use and resistance.

Often programs start out by capturing defined daily dose (DDD) per 1,000 patient days, days of therapy (DOT), antimicrobial pharmacy costs and DRG based length of stay. Over time, you may measure adherence to the policies implemented, acceptance rates for interventions, resistance rates and antibiotic use.

Report back to stakeholders.

Reports provide feedback to all parties on which policies have been embraced by the organization and where improvements are needed. At a minimum, reporting enables the hospital to track performance over time, promote adoption of best practices, and direct interventions for greatest impact. High performing ASPs typically share data with prescribers including the hospital’s antibiogram, prescribing patterns for all providers and most common interventions.  


Do you have enough hours budgeted to provide ongoing training to clinicians and staff that covers the basics of antimicrobial stewardship as well as specific policies and their rationale, such as IV to PO conversion, renal dose adjustments, use of narrowest effective antimicrobial and streamlined principles? An effective program will maintain awareness of the importance of your ASP and its progress to date through training programs and ongoing communication.

Your antimicrobial stewardship gap analysis will always uncover areas for improvement.

Clinical OneSource Services Antimicrobial Stewardship Gap Analysis

The Clinical OneSource Services team partners with healthcare organizations to implement change management programs that substantially improve the impact of clinical programs. Our offering includes an antimicrobial stewardship (AMS) gap analysis/clinical assessment. Following recognized clinical best practices and guidelines, our expert clinicians will assess your current AMS program to identify gaps and opportunities for improvement. An AMS Performance Score™ provides a benchmark against nationally recognized best practices and peer organizations. Take our brief survey to understand the gaps in your stewardship initiatives.

For more information on the AMS gap analysis/clinical assessment offered by Clinical OneSource Services, call (800) 654-8395 ext. 1 (Sales & Marketing).

1 CDC. Checklist for Core Elements of Hospital Antibiotic Stewardship Programs. 2014.

2 CDC. CDC/IHI Antibiotic Stewardship Drivers and Change Package. Get Smart for Healthcare.

3 Dellit et al: Clinical Infectious Diseases 2007; 44:159–77.

Antimicrobial stewardship for the c-suite. Click to Download eBook.

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