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Is your facility prepared with an antimicrobial stewardship program?

In June of 2016, new Antimicrobial Stewardship Standards were proposed and accepted, effective January 1, 2017.

Is your facility prepared with an antimicrobial stewardship program?

This means Antimicrobial Stewardship Standards are a Joint Commission requirement, supported by evidence-based national guidelines.

Examples of protocols are as follows:

  • Antibiotic Formulary Restrictions
  • Assessment of Appropriateness of Antibiotics for Community-Acquired Pneumonia
  • Assessment of Appropriateness of Antibiotics for Skin and Soft T issue Infections


  • Assessment of Appropriateness of Antibiotics for Urinary Tract Infections
  • Care of the Patient with Clostridium difficile (C. diff)
  • Guidelines for Antimicrobial Use in Adults
  • Guidelines for Antimicrobial Use in Pediatrics
  • Plan for Parenteral to Oral Antibiotic Conversion
  • Preauthorization Requirements for Specific Antimicrobials
  • Use of Prophylactic Antibiotics

Review all 8 elements at: [pdf 254KB]

What’s next?

In June 2016, the Centers for Medicare & Medicaid Services (CMS) also announced that it is proposing to update the requirements that hospitals and critical access hospitals (CAHs) must meet to participate in Medicare and Medicaid. The proposed changes to the requirements, formally called the Conditions of Participation, would reflect current standards of practice and support improvements in quality of care by:

  • Reducing the incidence of hospital-acquired conditions (including healthcare-associated infections)
  • Improving the use of antibiotics (including the potential for reduced antibiotic resistance)

Under the proposed rule, hospitals and CAHs would be required to:

  • Have hospital-wide infection prevention and control and antibiotic stewardship programs for the surveillance, prevention, and control of health-care-associated infections and other infectious diseases, and for the appropriate use of antibiotics.
  • Designate leaders of the infection prevention and control program and the antibiotic stewardship program respectively, who are qualified through education, training, experience, or certification. This requirement allows for flexibility in staffing in order to suit the needs of each hospital or CAH.

CMS hasn’t stated an expected timeline, but the comment period has passed and proposed rule is in development. After the final rule is published, CMS has 3 years to publish the final rule.

Don’t wait to prioritize antimicrobial stewardship in your facility!

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