To describe the epidemiology of Acinetobacter baumannii infection during 2000-2003 and to determine whether the multidrug-resistant strains were already present in our Toulouse hospital before the 2003 French national outbreak.

Descriptive molecular and clinical epidemiologic study of A. baumannii isolates using a combination of antibiotyping and pulsed-field gel electrophoresis (PFGE).

A 1,000-bed university hospital in Toulouse, France.

All clinical samples that had tested positive for A. baumannii between January 1, 2000, and December 31, 2003, were collected. Multidrug-resistant isolates of A. baumannii were then submitted to PFGE, and clinical characteristics of the source patients were noted.

A total of 1,277 A. baumannii samples were identified, 791 of which had not been previously identified; 148 were positive for multidrug-resistant strains. These strains were more likely to have been isolated in the intensive care unit (ICU) than were susceptible strains (P<.001; relative hazard, 3.77). The positive clinical samples were of various types (eg, nonprotected respiratory samples [43%] and blood [5%]), but no difference in type of source was seen between resistant and susceptible strains. A simultaneous analysis of pulsotypes and antibiotypes proved that the outbreak in the ICU in 2003 could be linked to an initially endemic clone that had been isolated in 2001. Furthermore, a second clone responsible for an extended-spectrum β-lactamase phenotype was sporadically present in our institution. Although the strains isolated in the burn unit were also genetically related one to another, the specific responsible clone only appeared in 2003.

Several multidrug-resistant clones can coexist endemically for several years and can be detected during an outbreak by close survey of epidemic sources.

To describe the epidemiology of Acinetobacter baumannii infection during 2000-2003 and to determine whether the multidrug-resistant strains were already present in our Toulouse hospital before the 2003 French national outbreak.

Descriptive molecular and clinical epidemiologic study of A. baumannii isolates using a combination of antibiotyping and pulsed-field gel electrophoresis (PFGE).

A 1,000-bed university hospital in Toulouse, France.

All clinical samples that had tested positive for A. baumannii between January 1, 2000, and December 31, 2003, were collected. Multidrug-resistant isolates of A. baumannii were then submitted to PFGE, and clinical characteristics of the source patients were noted.

A total of 1,277 A. baumannii samples were identified, 791 of which had not been previously identified; 148 were positive for multidrug-resistant strains. These strains were more likely to have been isolated in the intensive care unit (ICU) than were susceptible strains (P<.001; relative hazard, 3.77). The positive clinical samples were of various types (eg, nonprotected respiratory samples [43%] and blood [5%]), but no difference in type of source was seen between resistant and susceptible strains. A simultaneous analysis of pulsotypes and antibiotypes proved that the outbreak in the ICU in 2003 could be linked to an initially endemic clone that had been isolated in 2001. Furthermore, a second clone responsible for an extended-spectrum β-lactamase phenotype was sporadically present in our institution. Although the strains isolated in the burn unit were also genetically related one to another, the specific responsible clone only appeared in 2003.

Several multidrug-resistant clones can coexist endemically for several years and can be detected during an outbreak by close survey of epidemic sources.

To describe the control of multidrug-resistant Acinetobacter baumannii-calcoaceticus (MDRABC) colonization and infection in an intensive care unit (ICU).

An 18-bed ICU in a large tertiary care teaching hospital in London.

After recognition of the outbreak, a range of infection control measures were introduced over several months that were primarily aimed at reducing environmental contamination with the outbreak strain. Strategies included use of a closed tracheal suction system for all patients receiving mechanical ventilation, use of nebulized colistin for patients with evidence of mild to moderate ventilator-associated pneumonia, improved availability of alcohol for hand decontamination, and clearer designation of responsibilities and strategies for cleaning equipment and the environment in the proximity of patients colonized or infected with MDRABC.

The outbreak lasted from June 2001 through November 2002 and involved 136 new cases of MDRABC infection or colonization. The number of newly diagnosed cases per month reached a maximum of 15 in February 2002, and the number of new cases slowly decreased over the next 9 months.

This outbreak was controlled by emphasizing the control of environmental reservoirs and did not require recourse to ward closure or placement of affected patients in isolation.

To describe the control of multidrug-resistant Acinetobacter baumannii-calcoaceticus (MDRABC) colonization and infection in an intensive care unit (ICU).

An 18-bed ICU in a large tertiary care teaching hospital in London.

After recognition of the outbreak, a range of infection control measures were introduced over several months that were primarily aimed at reducing environmental contamination with the outbreak strain. Strategies included use of a closed tracheal suction system for all patients receiving mechanical ventilation, use of nebulized colistin for patients with evidence of mild to moderate ventilator-associated pneumonia, improved availability of alcohol for hand decontamination, and clearer designation of responsibilities and strategies for cleaning equipment and the environment in the proximity of patients colonized or infected with MDRABC.

The outbreak lasted from June 2001 through November 2002 and involved 136 new cases of MDRABC infection or colonization. The number of newly diagnosed cases per month reached a maximum of 15 in February 2002, and the number of new cases slowly decreased over the next 9 months.

This outbreak was controlled by emphasizing the control of environmental reservoirs and did not require recourse to ward closure or placement of affected patients in isolation.

To evaluate whether skin colonization with Acinetobacter calcoaceticus-baumannii complex exists in a population of healthy, nondeployed US Army soldiers and, if present, how it might relate to the infections seen in current war casualties.

We sampled various skin sites of soldiers to test for the presence of A. calcoaceticus-baumannii complex and to establish the prevalence of colonization. We then used ribotyping and antimicrobial susceptibility profiles to compare the isolates we recovered with A. calcoaceticus-baumannii complex isolates from injured soldiers.

Fort Sam Houston, Texas.

A population of healthy, nondeployed US Army soldiers in training.

A total of 17% of healthy soldiers were found to harbor A. calcoaceticus-baumannii complex. However, the strains differed from those recovered from injured soldiers.

Skin carriage of A. calcoaceticus-baumannii complex exists among soldiers before deployment. However, the difference in the strains isolated from healthy soldiers, compared with the strains from injured soldiers, makes it difficult to identify skin colonization as the source of infection.

To evaluate whether skin colonization with Acinetobacter calcoaceticus-baumannii complex exists in a population of healthy, nondeployed US Army soldiers and, if present, how it might relate to the infections seen in current war casualties.

We sampled various skin sites of soldiers to test for the presence of A. calcoaceticus-baumannii complex and to establish the prevalence of colonization. We then used ribotyping and antimicrobial susceptibility profiles to compare the isolates we recovered with A. calcoaceticus-baumannii complex isolates from injured soldiers.

Fort Sam Houston, Texas.

A population of healthy, nondeployed US Army soldiers in training.

A total of 17% of healthy soldiers were found to harbor A. calcoaceticus-baumannii complex. However, the strains differed from those recovered from injured soldiers.

Skin carriage of A. calcoaceticus-baumannii complex exists among soldiers before deployment. However, the difference in the strains isolated from healthy soldiers, compared with the strains from injured soldiers, makes it difficult to identify skin colonization as the source of infection.

Education-based interventions can reduce the incidence of catheter-associated bloodstream infection. The generalizability of findings from single-center studies is limited.

To assess the effect of a multicenter intervention to prevent catheter-associated bloodstream infections.

An observational study with a planned intervention.

Twelve intensive care units and 1 bone marrow transplantation unit at 6 academic medical centers.

Patients admitted during the study period.

Updates of written policies, distribution of a 9-page self-study module with accompanying pretest and posttest, didactic lectures, and incorporation into practice of evidence-based guidelines regarding central venous catheter (CVC) insertion and care.

Standard data collection tools and definitions were used to measure the process of care (ie, the proportion of non-tunneled catheters inserted into the femoral vein and the condition of the CVC insertion site dressing for both tunneled and nontunneled catheters) and the incidence of catheter-associated bloodstream infection.

Between the preintervention period and the postintervention period, the percentage of CVCs inserted into the femoral vein decreased from 12.9% to 9.4% (relative ratio, 0.73; 95% confidence interval [CI], 0.61-0.88); the total proportion of catheter insertion site dressings properly dated increased from 26.6% to 34.4% (relative ratio, 1.29; 95% CI, 1.17-1.42), and the overall rate of catheter-associated bloodstream infections decreased from 11.2 to 8.9 infections per 1,000 catheter-days (relative rate, 0.79; 95% CI, 0.67-0.93). The effect of the intervention varied among individual units.

An education-based intervention that uses evidence-based practices can be successfully implemented in a diverse group of medical and surgical units and reduce catheter-associated bloodstream infection rates.

Education-based interventions can reduce the incidence of catheter-associated bloodstream infection. The generalizability of findings from single-center studies is limited.

To assess the effect of a multicenter intervention to prevent catheter-associated bloodstream infections.

An observational study with a planned intervention.

Twelve intensive care units and 1 bone marrow transplantation unit at 6 academic medical centers.

Patients admitted during the study period.

Updates of written policies, distribution of a 9-page self-study module with accompanying pretest and posttest, didactic lectures, and incorporation into practice of evidence-based guidelines regarding central venous catheter (CVC) insertion and care.

Standard data collection tools and definitions were used to measure the process of care (ie, the proportion of non-tunneled catheters inserted into the femoral vein and the condition of the CVC insertion site dressing for both tunneled and nontunneled catheters) and the incidence of catheter-associated bloodstream infection.

Between the preintervention period and the postintervention period, the percentage of CVCs inserted into the femoral vein decreased from 12.9% to 9.4% (relative ratio, 0.73; 95% confidence interval [CI], 0.61-0.88); the total proportion of catheter insertion site dressings properly dated increased from 26.6% to 34.4% (relative ratio, 1.29; 95% CI, 1.17-1.42), and the overall rate of catheter-associated bloodstream infections decreased from 11.2 to 8.9 infections per 1,000 catheter-days (relative rate, 0.79; 95% CI, 0.67-0.93). The effect of the intervention varied among individual units.

An education-based intervention that uses evidence-based practices can be successfully implemented in a diverse group of medical and surgical units and reduce catheter-associated bloodstream infection rates.

Case-control studies analyzing antibiotic exposure as a risk factor for antimicrobial resistance usually assume single-drug resistance in the bacteria under study, even though resistance to multiple antimicrobials may be present. Since antibiotic selection pressures differ depending on the susceptibility profile of the antimicrobial-resistant bacteria, an accurate assessment of whether exposure to an individual antimicrobial is a risk factor for the emergence of resistance should distinguish between single-drug–resistant and multidrug-resistant bacteria.

To determine whether the exposures to individual antibiotics that were identified as independent risk factors in case-control studies differed depending on whether single-drug–resistant or multidrug-resistant bacteria were evaluated.

Two retrospective case-control studies were performed with data on patients harboring Pseudomonas aeruginosa strains resistant only to ciprofloxacin (CRPA) and patients harboring P. aeruginosa strains resistant to ciprofloxacin and other antibiotics (multidrug-resistant P. aeruginosa [MDR-PA]). These 2 groups were compared with patients not harboring P. aeruginosa.

Two tertiary care hospitals.

A total of 41 patients harboring CRPA and 151 patients harboring MDR-PA were identified and matched to 192 control subjects. By conditional logistic regression, independent risk factors associated with presence of CRPA were nonambulatory status (OR, 5.6 [95% confidence interval {CI}, 1.4-23]; P = .02) and prior ciprofloxacin exposure (OR, 5.0 [95% CI, 1.2-21]; P = .03). Independent risk factors for presence of MDR-PA were a Charlson score greater than 2 (OR, 3.3 [95% CI 1.8-6.0]; P<.001) and exposure to quinolones (OR, 2.8 [95% CI, 1.2-5.0]; P = .001), third- and fourth-generation cephalosporins (OR, 3.5 [95% CI, 1.7-7.1]; P<.001), imipenem (OR, 3.8 [95% CI, 1.2-12.1]; P = .02), and/or aminoglycosides (OR, 2.3 [95% CI, 1.04-5.1]; P = .04).

There were substantial differences in exposure to individual antimicrobials between patients harboring CRPA and patients harboring MDR-PA. Future case-control studies addressing risk factors for single-drug–resistant bacteria should consider the complete susceptibility profile of the bacteria under investigation.

Case-control studies analyzing antibiotic exposure as a risk factor for antimicrobial resistance usually assume single-drug resistance in the bacteria under study, even though resistance to multiple antimicrobials may be present. Since antibiotic selection pressures differ depending on the susceptibility profile of the antimicrobial-resistant bacteria, an accurate assessment of whether exposure to an individual antimicrobial is a risk factor for the emergence of resistance should distinguish between single-drug–resistant and multidrug-resistant bacteria.

To determine whether the exposures to individual antibiotics that were identified as independent risk factors in case-control studies differed depending on whether single-drug–resistant or multidrug-resistant bacteria were evaluated.

Two retrospective case-control studies were performed with data on patients harboring Pseudomonas aeruginosa strains resistant only to ciprofloxacin (CRPA) and patients harboring P. aeruginosa strains resistant to ciprofloxacin and other antibiotics (multidrug-resistant P. aeruginosa [MDR-PA]). These 2 groups were compared with patients not harboring P. aeruginosa.

Two tertiary care hospitals.

A total of 41 patients harboring CRPA and 151 patients harboring MDR-PA were identified and matched to 192 control subjects. By conditional logistic regression, independent risk factors associated with presence of CRPA were nonambulatory status (OR, 5.6 [95% confidence interval {CI}, 1.4-23]; P = .02) and prior ciprofloxacin exposure (OR, 5.0 [95% CI, 1.2-21]; P = .03). Independent risk factors for presence of MDR-PA were a Charlson score greater than 2 (OR, 3.3 [95% CI 1.8-6.0]; P<.001) and exposure to quinolones (OR, 2.8 [95% CI, 1.2-5.0]; P = .001), third- and fourth-generation cephalosporins (OR, 3.5 [95% CI, 1.7-7.1]; P<.001), imipenem (OR, 3.8 [95% CI, 1.2-12.1]; P = .02), and/or aminoglycosides (OR, 2.3 [95% CI, 1.04-5.1]; P = .04).

There were substantial differences in exposure to individual antimicrobials between patients harboring CRPA and patients harboring MDR-PA. Future case-control studies addressing risk factors for single-drug–resistant bacteria should consider the complete susceptibility profile of the bacteria under investigation.

To assess whether patients hospitalized in beds physically adjacent to critically ill patients are at increased risk to acquire multidrug-resistant pathogens.

Cohort study.

Shaare Zedek Medical Center, a 550-bed medical referral center.

From April to September 2004, we enrolled consecutive newly admitted patients who were hospitalized in beds adjacent to either mechanically ventilated patients or patients designated as “do not resuscitate” (DNR). For each of these patients, we also enrolled a control patient who was not hospitalized in a bed adjacent to a critically ill patient. We collected specimens from the anterior nares, the oral cavity, and the perianal zone at the time of admission and subsequently at 3-day intervals until discharge or death. Specimens were cultured on selective media to detect growth of antibiotic-resistant pathogens, including Acinetobacter baumannii, methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum β lactamase (ESBL)–producing Enterobacteriaceae, and vancomycin-resistant enterococci (VRE).

We enrolled 46 neighbor-control pairs. Among neighbors and controls, respectively, the incidence rates for isolation of A. baumannii was 8.3 and 4 isolations per 100 patient-days (relative risk [RR], 2.1 [95% confidence interval {CI}, 0.8-5.2]; P = .12), the incidence rates for MRSA were 1.4 and 2.6 isolations per 100 patient-days (RR, 0.6 [95% CI, 0.1-2.3]; P = .45), the incidence rates for ESBL-producing Enterobacteriaceae were 10.5 and 9 isolations per 100 patient-days (RR, 1.2 [95% CI, 0.6-2.4]; P = .84), the incidence rates for VRE were 4.3 and 4.8 isolations per 100 patient-days (RR, 0.9 [95% CI, 0.3-2.4]; P = 1), and the composite incidence rate was 21.7 and 16.2 isolations per 100 patient-days (RR, 1.3 [95% CI, 0.8-2.3]; P = 0.3).

In this pilot study, we did not detect an increased incidence rate of isolation of multidrug-resistant pathogens among patients hospitalized in beds adjacent to critically ill patients. Further studies with larger samples should be conducted in order to generate valid data and provide patients, physicians, and policy makers with a sufficient knowledge base from which decisions can be made.

To assess whether patients hospitalized in beds physically adjacent to critically ill patients are at increased risk to acquire multidrug-resistant pathogens.

Cohort study.

Shaare Zedek Medical Center, a 550-bed medical referral center.

From April to September 2004, we enrolled consecutive newly admitted patients who were hospitalized in beds adjacent to either mechanically ventilated patients or patients designated as “do not resuscitate” (DNR). For each of these patients, we also enrolled a control patient who was not hospitalized in a bed adjacent to a critically ill patient. We collected specimens from the anterior nares, the oral cavity, and the perianal zone at the time of admission and subsequently at 3-day intervals until discharge or death. Specimens were cultured on selective media to detect growth of antibiotic-resistant pathogens, including Acinetobacter baumannii, methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum β lactamase (ESBL)–producing Enterobacteriaceae, and vancomycin-resistant enterococci (VRE).

We enrolled 46 neighbor-control pairs. Among neighbors and controls, respectively, the incidence rates for isolation of A. baumannii was 8.3 and 4 isolations per 100 patient-days (relative risk [RR], 2.1 [95% confidence interval {CI}, 0.8-5.2]; P = .12), the incidence rates for MRSA were 1.4 and 2.6 isolations per 100 patient-days (RR, 0.6 [95% CI, 0.1-2.3]; P = .45), the incidence rates for ESBL-producing Enterobacteriaceae were 10.5 and 9 isolations per 100 patient-days (RR, 1.2 [95% CI, 0.6-2.4]; P = .84), the incidence rates for VRE were 4.3 and 4.8 isolations per 100 patient-days (RR, 0.9 [95% CI, 0.3-2.4]; P = 1), and the composite incidence rate was 21.7 and 16.2 isolations per 100 patient-days (RR, 1.3 [95% CI, 0.8-2.3]; P = 0.3).

In this pilot study, we did not detect an increased incidence rate of isolation of multidrug-resistant pathogens among patients hospitalized in beds adjacent to critically ill patients. Further studies with larger samples should be conducted in order to generate valid data and provide patients, physicians, and policy makers with a sufficient knowledge base from which decisions can be made.

To identify differences between unit-specific and hospital-wide antibiograms and to determine the potential impact of these differences on selection of empirical antimicrobial therapy.

A 625-bed tertiary care medical center.

Antimicrobial susceptibility results were collected for all inpatient clinical bacterial isolates recovered over a 3-year period; isolates were categorized by the hospital location of the patient at the time of sampling and by the anatomic site from which the isolate was recovered. Antibiograms from each unit were compiled for the most commonly isolated organisms and were compared to the hospital-wide antibiogram.

A total of 9,970 bacterial isolates were evaluated in this study, including 2,646 enterococcal isolates, 2,806 S. aureus isolates, 2,795 E. coli isolates, and 1,723 Pseudomonas aeruginosa isolates. The percentages of bacterial isolates resistant to antimicrobials were significantly higher in the medical ICU and surgical ICU than the hospital-wide antibiogram would have predicted, whereas the percentages of isolates susceptible to antimicrobials were significantly higher in the non-ICU units, compared with the hospital overall. However, on general medicine units, the prevalence of susceptibility to levofloxacin was significantly lower than that for the hospital overall.

Unit-specific antibiograms are important for making informed decisions about empirical antimicrobial therapy, because the hospital-wide antibiogram may mask important differences in susceptibility rates across different units. These differences may have important implications for selecting the optimal empirical antimicrobial therapy.

To identify differences between unit-specific and hospital-wide antibiograms and to determine the potential impact of these differences on selection of empirical antimicrobial therapy.

A 625-bed tertiary care medical center.

Antimicrobial susceptibility results were collected for all inpatient clinical bacterial isolates recovered over a 3-year period; isolates were categorized by the hospital location of the patient at the time of sampling and by the anatomic site from which the isolate was recovered. Antibiograms from each unit were compiled for the most commonly isolated organisms and were compared to the hospital-wide antibiogram.

A total of 9,970 bacterial isolates were evaluated in this study, including 2,646 enterococcal isolates, 2,806 S. aureus isolates, 2,795 E. coli isolates, and 1,723 Pseudomonas aeruginosa isolates. The percentages of bacterial isolates resistant to antimicrobials were significantly higher in the medical ICU and surgical ICU than the hospital-wide antibiogram would have predicted, whereas the percentages of isolates susceptible to antimicrobials were significantly higher in the non-ICU units, compared with the hospital overall. However, on general medicine units, the prevalence of susceptibility to levofloxacin was significantly lower than that for the hospital overall.

Unit-specific antibiograms are important for making informed decisions about empirical antimicrobial therapy, because the hospital-wide antibiogram may mask important differences in susceptibility rates across different units. These differences may have important implications for selecting the optimal empirical antimicrobial therapy.

Antimicrobial stewardship programs (ASPs) decrease unnecessary antimicrobial use, decrease antimicrobial resistance, and improve patient outcomes. The effectiveness of a prior approval system—that is, the requirement that approval be obtained from ASP practitioners before certain antimicrobials can be used—depends on the accuracy of the patient data communicated from the primary service.

To determine the incidence of inaccurate communication of patient data during ASP interactions, describe examples of inaccurate communications, and identify risk factors for inaccurate communication.

We used a retrospective cohort design. We evaluated the communicated patient data for clinically important inaccuracies, using the patients' medical records as the gold standard.

A tertiary care medical center that has a prior approval system for restricted antimicrobials.

Inpatients discussed in telephone ASP interactions.

Observational study.

Of telephone calls requesting prior approval from ASP practitioners, 39% (95% confidence interval [CI], 31%-48%) contained an inaccuracy in at least 1 type of patient data (eg, current antimicrobial therapy); the incidence varied widely between data types. Examples of inaccuracies are given to demonstrate their clinical relevance. In multivariable analysis, inaccurate communications were more common for telephone calls from surgical services (versus calls from nonsurgical services: odds ratio, 2.1 [95% CI, 1.1-3.9]) and for calls received by Infectious Diseases fellows (versus pharmacists: odds ratio, 2.0 [95% CI, 1.1-3.8]).

A high proportion of ASP calls requesting prior approval included patient data inaccuracies, which have the potential to affect the prescribing of antimicrobials. Although risk factors were identified, these communication errors were common across the different types of ASP interactions. Inaccurate communications may compromise the utility of ASPs that use a prior approval system for optimizing antimicrobial use.

Antimicrobial stewardship programs (ASPs) decrease unnecessary antimicrobial use, decrease antimicrobial resistance, and improve patient outcomes. The effectiveness of a prior approval system—that is, the requirement that approval be obtained from ASP practitioners before certain antimicrobials can be used—depends on the accuracy of the patient data communicated from the primary service.

To determine the incidence of inaccurate communication of patient data during ASP interactions, describe examples of inaccurate communications, and identify risk factors for inaccurate communication.

We used a retrospective cohort design. We evaluated the communicated patient data for clinically important inaccuracies, using the patients' medical records as the gold standard.

A tertiary care medical center that has a prior approval system for restricted antimicrobials.

Inpatients discussed in telephone ASP interactions.

Observational study.

Of telephone calls requesting prior approval from ASP practitioners, 39% (95% confidence interval [CI], 31%-48%) contained an inaccuracy in at least 1 type of patient data (eg, current antimicrobial therapy); the incidence varied widely between data types. Examples of inaccuracies are given to demonstrate their clinical relevance. In multivariable analysis, inaccurate communications were more common for telephone calls from surgical services (versus calls from nonsurgical services: odds ratio, 2.1 [95% CI, 1.1-3.9]) and for calls received by Infectious Diseases fellows (versus pharmacists: odds ratio, 2.0 [95% CI, 1.1-3.8]).

A high proportion of ASP calls requesting prior approval included patient data inaccuracies, which have the potential to affect the prescribing of antimicrobials. Although risk factors were identified, these communication errors were common across the different types of ASP interactions. Inaccurate communications may compromise the utility of ASPs that use a prior approval system for optimizing antimicrobial use.

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.

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.