A survey of nearly 400 hospitals found that roughly half of the facilities do not have antibiotic stewardship programs, particularly those that would limit the use of drugs that can increase the clear and present danger of Clostridium difficile infections (CDIs).

While nearly all of the 398 hospitals in the study use a variety of measures to protect their patients from CDIs, 48% of respondents have not adopted antibiotic stewardship programs.1

“There are many ways to try to limit the spread, and from our data it looks like hospitals are aware of the evidence behind them and acting on many where they believe the evidence is strong,” says Sanjay Saint, MD, MPH, lead author of the paper and a specialist-hospitalist in the allied research program at the University of Michigan in Ann Arbor. “But the one area where there’s a major disconnect between evidence and practice is antimicrobial stewardship, or limiting antibiotics use to only when necessary. This is a real opportunity for improvement.”

Patients on broad-spectrum antibiotics are at risk for developing CDIs, as the drugs can wipe out commensal bacteria in the gut and leave the patient vulnerable if spores spread from an environmental surface or from another patient via the hands of care workers. More than half of all hospitalized patients will get an antibiotic at some point during their hospital stay, but the Centers for Disease Control and Prevention estimates that 30% to 50% percent of antibiotics prescribed in hospitals are unnecessary. Some 450,000 people are being infected with C. diff annually in the U.S., with 29,000 patients dying within 30 days of the initial diagnosis of a CDI. The CDC winnows the toll down to about 15,000 deaths “directly attributable” to CDIs in a recent study, but C. diff is still the leading cause of health care-associated infections (HAIs) in the country.2

In Saint and colleagues study at the University of Michigan Medical School and VA Ann Arbor Healthcare System a survey was sent to a national random sample of hospitals. In surveys primarily aimed at infection preventionists, they polled 571 US hospitals regarding practices used to prevent CDIs. The IPs were also asked about their perceptions of the strength of evidence for their CDI prevention practices, using a Likert scale from 1 (no evidence) to 5 (extremely strong evidence).

The overall survey response rate was 71%, with most hospitals reporting regularly using key CDI prevention practices, and perceiving their strength of evidence as high. Virtually all the hospitals had programs to monitor for CDIs, get patients into isolation, use protective gear, and clean the patient environment on an ongoing basis and vigorously at discharge. Antibiotic stewardship was the only practice surveyed for which there was a sizeable gap between practice use and perceived strength of evidence. Strength of evidence for antimicrobial stewardship was rated at 91% of respondents, but by only 52% reported that they had programs in place. One explanation is that the IPs responding to the survey know the clear need for antibiotic stewardship, but do not have the power to implement programs that take a commitment from top clinical and administrative leadership.

“I think part of this is that there are a lot of organizational issues in getting an antibiotic stewardship program implemented,” says co-author Sarah Krein, PhD, RN, research associate and professor in internal medicine at the University of Michigan in Ann Arbor. “So even if the infection control coordinator recognizes that there is a good evidence-based practice that we should be doing, the reality is that implementing these programs is challenging. We know these are things that we should be doing but there a lot of organizational, behavioral challenges when it comes to putting these things in place.”

A testy problem

In addition to the lack of antimicrobial stewardship programs, the researchers also found a widespread lack of written policies to test patients for CDI when they developed diarrhea, one of the prime symptoms of the infection. While 97% of hospitals reported having an established facility wide surveillance system for CDI rates, only 24% have a written policy to routinely test for C. diff. when patients have diarrhea while on antibiotics or within several months of taking them.

“Their definitions of diarrhea [may vary] and part of this may be coming up with a definition that can be applied in a consistent ways,” Krein says. “Some patients may have loose stools in general, and determining if it is diarrhea suggesting C. diff may be difficult.”

In terms of testing, clinicians seek a balance that allows detection of infections without over-testing and generating false positives.

“There are people who carry C. diff that are asymptomatic,” she says. “You don’t want to just be out there screening everybody because you are going to pick up a lot of false positives. There is a kind of tension between overuse and underuse of the test. We want to make sure we are doing it appropriately and accurately to truly capture those cases so we can treat [and isolate] them to make sure it doesn’t spread, but we don’t want to overdo it and be screening everybody.”

Saint notes that reducing antibiotic use in hospitals not only reduces the risk of CDI – it also reduces the chance of bacteria developing resistance to the remaining antibiotics in the diminishing hospital formulary.

Federal health agencies and top levels of government have set a goal of reducing CDI by 50% by 2020 as part of the National Strategy for Combating Antibiotic-Resistant Bacteria. The CDC also has targeted C. diff as a key threat to public health and is working with the Centers for Medicare & Medicaid Services to create a regulation requiring antibiotic stewardship programs in the next few years. Michigan has started a state-based collaboration program between hospitalists and infectious disease prevention specialists to reduce use of antibiotics, Saint says.

“The doctors who prescribe most of these antibiotics, and who would have to buy in to stewardship programs, are hospitalists,” he says. “Nationally, they’re the ones we must engage with to overcome this disconnect between what people think works and what they’re actually doing, and to implement stewardship programs. This is about changing physician behavior and that makes it more challenging.”

Why has antibiotic overuse persisted despite repeated admonitions and warnings about a post-antibiotic era? Noting that America has been described as the most individualistic country in the world, Saint wrote in a viewpoint piece that essentially the needs of the one have triumphed over the needs of the many. Thus the individual patient, the individual physician, are not sufficiently compelled by the common good to forego antibiotic treatment that might provide some benefit.3


  1. Saint S, MD, MPH; Fowler, KE, Krein SL, et al. Clostridium Difficile Infection in the United States: A National Study Assessing Preventive Practices Used and Perceptions of Practice Evidence Infect Control Hosp Epidemiol 2015: In press.
  2. Lessa, FC, Mu Y, Bamberg WM, et al. Burden of Clostridium difficile Infection in the United States N Engl J Med 2015; 372:825-834
  3. Flanders SA, Saint S. Why Does Antimicrobial Overuse in Hospitalized Patients Persist? JAMA Intern Med 2014;174(5):661-662.