Health care practitioners at many small community hospitals often feel as though they do not have the necessary resources to initiate a traditional antimicrobial stewardship program, and they rarely have dedicated, specially-trained infectious disease (ID) pharmacists and ID physicians on staff. Nevertheless, these hospitals are confronted by the same challenges as large institutions concerning antibiotic misuse. Prudent and appropriate antimicrobial use benefits the hospital, the community, and overall patient outcomes. By developing guidelines that ensure appropriate antibiotic use, limit or reduce overuse, and encourage conversion to oral medications, the hospital can reduce the potential development of multiple drug resistant organisms, reduce harmful side effects, maintain antibiotic efficacy, and reduce costs. 

Work Within Your Means
As a small hospital, our goal was to develop a program that would help ensure the appropriate use of antimicrobials without requiring additional resources or consuming large amounts of time. Our initial interventions were designed using readily available tools and we began by requesting that our lab’s culture and sensitivity (C&S) report print directly to the pharmacy for evaluation. We asked our lab personnel to provide an in-service on how to accurately interpret the culture results. Culture results were reviewed daily to check for appropriate and effective antibiotic treatment and to determine whether the patient received the correct dose of the correct medication by the most efficient route. By focusing on minimizing waste (ensuring the minimum number of antibiotics required to effectively treat the infection) and maximizing effects (using the antibiogram and C&S results), we were able to positively influence prescription adjustments for our patients in just minutes per day. Inspired by these results, we looked for other interventions we could implement, still mindful of our minimal resources. 



Other Intervention Areas
Additional steps were taken to improve antimicrobial use in our facility:

• We worked with the lab to release more frequent antibiogram updates to our providers and to post the information in the physician dictation areas. 
• We prepared an antibiotic formulary grouping antimicrobials by class and listing available injectable and oral dosage forms. Pharmacists and physicians compared the list to standards, and presented it to the P&T committee with recommendations for possible deletions. After approval, the list was posted in dictation areas to aid providers in ordering available medications and identifying IV to PO options.
• A review of specific antibiotic usage coupled with antibiogram sensitivity data from the last several years helped track ordering trends and identify increased bacterial resistance. 
• Laminated, pocket-sized cards with guidelines for empiric inpatient antibiotic usage were distributed to hospitalists and attending physicians. (For a copy of the card, visit www.pppmag.com/antibioticcard )

An IV to PO program helped reduce the incidence of inherent issues with IV administration of medications, eased conversion from hospital to home administration, and decreased the cost of administration. 

Changes Advised and Accepted 
From January 1 through August 31, 2011, the pharmacy reviewed 264 days of C&S data; the average time required per day was 7 minutes. A total of 503 finalized inpatient cultures were evaluated, along with numerous gram stain results and partially completed cultures. Interventions or changes were suggested in 14% of the cultures reviewed; of those, 59% were accepted by the providers. Soft cost savings are difficult to capture, but both pharmacists and providers are convinced that the resulting interventions have had a positive effect on patient outcomes and will have long-term benefits for the community.

The Willingness to Try
Non-traditional antimicrobial stewardship programs can be customized to any size facility and still provide positive outcomes. The key is to begin by developing guidelines and staging small interventions using readily available tools and basic antimicrobial knowledge. Success from these initial steps will provide additional motivation and guidance to continue. The goals of any such program should be: appropriate use of effective antibiotics, reduction of antibiotic resistance, improved patient outcomes, and decreased use of unnecessary and/or ineffective antibiotics. We found the time requirements were less than anticipated and our physicians and staff have been very supportive of this initiative. We presented information on our program at a state of New Mexico MRSA collaborative. Subsequently, we developed an outreach program and in late April 2011, the pilot program began involving two large hospitals interacting with three or four smaller facilities to hone their antimicrobial stewardship programs. As our project has demonstrated, the size of your facility is not the sole determinant of whether patient care can be improved.

Mary Jo Garst, RPh, is a staff pharmacist at Gerald Champion Regional Medical Center (GCRMC) in Alamogordo, New Mexico. She received a BS in pharmacy and an MS in medicinal chemistry from the University of Iowa, and completed a hospital pharmacy residency at Harris Hospital in Fort Worth, Texas. 

Marti Heinze, RN, BS, is the infection control practitioner at GCRMC. She received a BS from Friends University in Wichita, Kansas, and will receive another BS in nursing from Eastern New Mexico University in Portales later this year. Marti is the current president of APIC New Mexico.