Skip to main content Accessibility help

Antibiotic-Stewardship Practices at Top Academic Centers Throughout the United States and at Hospitals Throughout Massachusetts

  • Tamar F. Barlam (a1) and Margarita DiVall (a2)



Improvements in antibiotic prescribing to reduce bacterial resistance and control hospital costs is a growing priority, but the way to accomplish this is poorly defined. Our goal was to determine whether certain antibiotic stewardship interventions were universally instituted and accepted at top US academic centers and to document what interventions, if any, are used at both teaching and community hospitals within a geographic area.


Two surveys were conducted. In survey 1, detailed phone interviews were performed with the directors of antibiotic stewardship programs at 22 academic medical centers that are considered among the best for overall medical care in the United States or as leaders in antibiotic stewardship programs. In survey 2, teaching and community hospitals throughout Massachusetts were surveyed to ascertain what antibiotic oversight program components were present.


In survey 1, each of the 22 participating hospitals had instituted interventions to improve antibiotic prescribing, but none of the interventions were universally accepted as essential or effective. In survey 2, of 97 surveys that were mailed to prospective participants, a total of 54 surveys from 19 teaching hospitals and 35 community hospitals were returned. Ninety-five percent of the teaching hospitals had a restricted formulary, compared with 49% of the community hospitals, and 89% of teaching hospitals had an antibiotic approval process, compared with 29% of community hospitals.


There was great variability among the approaches to the oversight of antibiotic prescribing at major academic hospitals. Antibiotic management interventions were lacking in more than half of the Massachusetts community hospitals surveyed. More research is needed to define the best antibiotic stewardship interventions for different hospital settings.


Corresponding author

Boston University Medical Center, 771 Albany Street, Dowling 3110, Boston, MA 02118 (


Hide All
1. Cohen, ML. Epidemiology of drug resistance: implications for a post-antimicrobial era. Science 1992; 257:10501055.
2. Craig, WA, Uman, SJ, Shaw, WR, Ramgopal, V, Eagan, LL, Leopold, ET. Hospital use of antimicrobial drugs: survey at 19 hospitals and results of antimicrobial control program. Ann Intern Med 1978; 89:793795.
3. Hecker, MT, Aron, DC, Patel, NP, Lehmann, MK, Donskey, CJ. Unnecessary use of antimicrobials in hospitalized patients. Arch Intern Med 2003; 163: 972978.
4. Office of Technology Assessment. Impacts of antibiotic-resistant bacteria (OTA-H-629). Washington, DC: US Government Printing Office; 1995.
5. McGowan, JE. Economic impact of antimicrobial resistance. Emerg Infect Dis 2001; 7:286292.
6. Goldmann, DA, Weinstein, RA, Wenzel, RP, et al. Strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in hospitals. JAMA 1996; 275:234240.
7. Shlaes, DM, Gerding, DN, John, JF, et al. Society for Healthcare Epidemiology of American and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Clin Infect Dis 1997; 25:584599.
8. Lawton, RM, Fridkin, SK, Gaynes, RP, et al. Practices to improve antimicrobial use at 47 US hospitals: the status of the 1997 SHEA/IDSA position paper recommendations. Infect Control Hosp Epidemiol 2000; 21:256259.
9. Lesar, TS, Briceland, LL. Survey of antibiotic control policies in university-affiliated teaching institutions. Ann Pharmacother 1996; 30:3134.
10. America's best hospitals. U.S. News and World Report 2001; 131:4458.
11. America's best hospitals. U.S. News and World Report 2002; 133:4445.
12. Comarow, A. America's best hospitals. U.S. News and World Report 2003; 135:47.
13. Fridkin, SK, Steward, CD, Edwards, JR, et al, and Project ICARE. Surveillance of antimicrobial use and antimicrobial resistance in United States hospitals: Project ICARE Phase 2. Clin Infect Dis 1999; 29:245252.
14. Schiff, GD, Wisniewski, M, Bult, J, Parada, JP, Aggarwal, H, Schwartz, DN. Improving inpatient antibiotic prescribingdnsights from participation in a national collaborative. Jt Comm J Qual Improv 2001; 27:387402.
15. Gross, R, Morgan, AS, Kinky, DE, Weiner, M, Gibson, GA, Fishman, NO. Impact of a hospital-based antimicrobial management program on clinical and economic outcomes. Clin Infect Dis 2001; 33:289295.
16. Frank, MO, Batteiger, BE, Sorensen, SJ, et al. Decrease in expenditure and selected nosocomial infections following implementation of an antimicrobial—prescribing improvement program. Clin Perform Qual Health Care 1997; 5: 180188.
17. Fraser, GL, Stogsdill, P, Dickens, JD, Wennberg, DE, Smith, RP, Prato, S. Antibiotic optimization: an evaluation of patients safety and economic outcomes. Arch Intern Med 1997; 157:16891694.
18. White, AC, Atmar, RL, Wilson, J, Cate, TR, Stager, CE, Greenberg, SB. Effects of requiring prior authorization for selected antimicrobials: expenditures, susceptibilities, and clinical outcomes. Clin Infect Dis 1997; 25:230239.
19. Gould, IM. A review of the role of antibiotic policies in the control of antibiotic resistance. J Antimicrob Chemother 1999; 43:459465.
20. Harris, AD, Karchmer, TB, Carmeli, Y, Samore, MH. Methodological principles of case-control studies that analyzed risk factors for antibiotic resistance: a systematic review. Clin Infect Dis 2001; 32:10551061.
21. McGowan, JE. Do intensive hospital antibiotic control programs prevent the spread of antibiotic resistance? Infect Control Hosp Epidemiol 1994; 15:478483.
22. Gaynes, R. The impact of antimicrobial use on the emergence of antimicrobial-resistant bacteria in hospitals. Infect Dis Clin North Am 1997; 11:757765.
23. Lipsitch, M, Samore, MH. Antimicrobial use and antimicrobial resistance: a population perspective. Emerg Infect Dis 2002; 8:347354.
24. Gerding, DN, Larson, TA, Hughes, RA, Weiler, M, Shanholtzer, C, Peterson, LR. Aminoglycoside resistance and aminoglycoside usage: ten years of experience in one hospital. Antimicrob Agents Chemother 1991; 35:12841290.
25. Friedrich, LV, White, RL, Bosso, JA. Impact of use of multiple antimicrobials on changes in susceptibility of gram-negative aerobes. Clin Infect Dis 1999; 28:10171024.
26. Rahal, JJ, Urban, C, Horn, D, et al. Class restriction of cephalosporin use to control total cephalosporin resistance in nosocomial Klebsiella . JAMA 1998; 280:12331237.
27. Paladino, JA. Economic justification of antimicrobial management programs: implications of antimicrobial resistance. Am J Health Syst Pharm 2000; 57:S10S12.
28. Rifenburg, RP, Paladino, JA, Hanson, SC, Tuttle, JA, Schentag, JJ. Benchmark analysis of strategies hospitals use to control antimicrobial expenditures. Am J Health Syst Pharm 1996; 53:20542062.
29. Burke, JP. Antibiotic Resistance—squeezing the balloon? JAMA 1998; 280:12701271.
30. Linden, P, Paladino, JA, Saul, M, et al. The economic impact of bacteremia due to vancomycin-resistant Enterococcus faecium: a case-control study. Paper presented at the 38th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 24-27, 1998; San Diego, CA. Abstract 0-7.
31. Welch, KE, Goff, DA, Fish, DN, et al. A multicenter economic analysis of bacteremia caused by methicillin resistant Staph aureus. Paper presented at the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 26-29, 1999; San Francisco, CA. Abstract 1865.
32. Schentag, JJ, Ballow, CH, Fritz, AL, et al. Changes in antimicrobial agent usage resulting from interactions among clinical pharmacy, the infectious disease division, and the microbiology laboratory. Diagn Microbiol Infect Dis 1993; 16:255264.
33. Cabana, MD, Rand, CS, Powe, NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282:14581465.
34. Singer, MV, Haft, R, Barlam, T, Aronson, M, Shafer, A, Sands, KE. Vancomycin control measures at a tertiary care hospital: impact of interventions on volume and patterns of use. Infect Control Hosp Epidemiol 1998; 19:248253.
35. Davis, D, Thomson O'Brien, MA, Freemantle, N, Wolf, FM, Mazmanian, P, Taylor-Vaisey, A. Impact of formal continuing medical education. JAMA 1999; 282:867874.
36. Solomon, DH, Van Houten, L, Glynn, RJ, et al. Academic detailing to improve use of broad spectrum antibiotics at an academic medical center. Arch Intern Med 2001; 161:18971902.
37. John, JF, Fishman, NO. Programmatic role of the infectious diseases physician in controlling antimicrobial costs in the hospital. Clin Infect Dis 1997; 24:471485.
38. Evans, RS, Pestotnik, SL, Classen, DC, et al. A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med 1998; 338:232238.
39. Teich, JM, Merchia, PR, Schmiz, JL, Kuperman, GJ, Spurr, CD, Bates, DW. Effects of computerized physician order entry on prescribing practices. Arch Intern Med 2000; 160:27412747.
40. Gerding, DN The search for good antimicrobial stewardship. Jt Comm J Qual Improv 2001; 27:403404.
41. Soumerai, SB, Avorn, J, Taylor, WC, Wessels, M, Maher, D, Hawley, SL. Improving choice of prescribed antibiotics through concurrent reminders in an educational order form. Medical Care 1993; 31:552558.
42. Quale, JM, Landman, D, Bradford, PA, et al Molecular epidemiology of a citywide outbreak of extended-spectrum β-lactamase-producing Klebsiella pneumoniae infection. Clin Infect Dis 2002; 35:834841.


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed