Improving Antimicrobial Stewardship: AAAHC Publishes New Toolkit

By Matt Phillion

To help combat drug-resistant bacteria, the Accreditation Association for Ambulatory Health Care (AAAHC) has published a new toolkit for improving antimicrobial stewardship. The toolkit, which also addresses COVID-19 considerations, offers an overview of the challenges organizations face in this arena, as well as strategies for optimizing the use of antibiotics.

Organizations will find specific information on unnecessary or inappropriate use of antibiotics across the spectrum, including ambulatory, dental, primary care, and surgical settings.

The toolkit offers a core elements checklist for assessing policies and procedures, treatment recommendations in primary care taken from the CDC, and a flow chart that maps out considerations for surgical procedures. It also provides recent information on potential threats to antimicrobial stewardship due to COVID-19.

According to the CDC, drug-resistant bacteria cause at least 2.8 million illnesses and 35,000 deaths every year in the U.S. At the same time, a strong antimicrobial stewardship program offers the ability to reduce:

  • Antibiotic resistance
  • Adverse drug effects
  • Mortality
  • Healthcare costs

The toolkit comes on the heels of feedback from the field, says Belle Lerner, MA, assistant director of the AAAHC Institute for Quality Improvement.

“We produce several patient safety toolkits and choose our topics based on client needs, as well as interest voiced in surveys,” she says. “They align with our standards, but they’re really more—they can also go beyond and offer best practice information.”

New and updated information

When addressing antimicrobial stewardship, the AAAHC has standards requiring patients to be given information on safe, effective use of medications, as well as standards for quality of care. The toolkit goes into more specific details on these areas.

It also follows up on a toolkit in 2017 that addressed antibiotics use. “We do update our toolkits on a regular basis with the latest and greatest research,” says Lerner. “And this toolkit was timely, with a section that addresses the pandemic.”

The team building the toolkit was aware there could be an increase in prescriptions for mild or moderate symptoms that didn’t have a demonstrated fungal or bacterial infection. They were also aware of the potential increase in healthcare-associated infections during a pandemic that could lead to more use of antibiotics. “These were both potential threats due to COVID,” says Lerner.

To this end, the team received expert input from the CDC’s Office of Antibiotic Stewardship on their potential toolkit materials (much of the material is also based on CDC guidelines). “In terms of additional guidance, we also looked at information on increases in prescribing put out by the World Health Organization (WHO),” says Lerner.

Key antimicrobial issues addressed

There are two key issues when it comes to addressing antimicrobial stewardship, says Cheryl Pistone, AAAHC’s clinical director.

“One is patient education,” she says. “There is an expectation out there that patients want to be prescribed antibiotics when they’re not feeling well. That puts pressure on the prescriber, which may not always be in accordance with what’s recommended with national guidelines. There’s a reluctance to do the wait-and-see approach.” Many illnesses are not bacterial in nature, Pistone explains, and patients will benefit from being educated about this.

Secondly, providers need to be allowed to refer to standardized protocols for prescribing based on national guidelines. “So the second step is educating the clinician as well as the patient,” says Lerner.

“We need to use a multidisciplinary approach to determining and monitoring prescription practices against national guidelines,” says Pistone. “How do we do it, and how do we align it on a national level?”

Patients aren’t necessarily aware that upper respiratory issues with viral symptoms are very different from bacterial infections, Lerner explains. A patient might walk into a clinic and ask for antibiotics right away, when waiting to see if the symptoms clear up could show that antibiotics are unnecessary for the patient’s condition.

“To Belle’s point, if you educate the patient on the symptoms and you wait the symptoms out, explaining that you look for symptoms at a certain point,” it can be a game changer, says Pistone. “Saying we’ll treat your symptoms, but if it’s viral, not bacterial, you don’t need antibiotics.”

This is a two-pronged approach: verifying the issue is bacterial before prescribing antibiotics, but also making sure the right dose of the right antibiotic is prescribed at the right time, if one is needed.

Lerner notes that progress has been made in terms of patient education. “There was a study by the University of Michigan Institute for Healthcare Policy & Innovation about the perception of use of antibiotics among adults 50–80 years old that surveyed over 2,200 adults,” she says. “Nine out of 10 are cautious about using antibiotics, and 80% knew that antibiotic overuse increased the chances they wouldn’t work next time.”

However, the study found that despite patients knowing this, they still wanted treatment with antibiotics when they themselves were sick. “More education needs to take place in terms of not requesting antibiotics,” says Lerner.

Implementing the toolkit

The toolkit, Pistone explains, provides the elements an organization would need to run an antimicrobial stewardship program. But where do you start with such a program?

“Typically, it works best if you have a physician champion,” she says. “They can be the one to spearhead it and help other physicians get on board.”

If you have a strong advocate to act as a “true believer” in the program, the toolkit outlines how to verify whether you’re complying with these best practices and what you can put in place to monitor prescribing and usage.

“It’s really designed to encourage organizations to develop their own unique antibiotic stewardship programs at their facilities and curtail the types of antibiotics they’re prescribing,” says Lerner. “It gives providers the evidence-based information to help them explain this to their patients.”

Where antibiotics prescribing is now

Strangely, though perhaps not unexpectedly, there is anecdotal evidence that antibiotic prescriptions have decreased during the pandemic—not because people are necessarily healthier, but because they’ve had fewer opportunities to catch a respiratory illness due to staying at home.

“Isolation did something for us,” says Pistone.

Even before COVID-19, there were the rumblings of change, though. Lerner refers to an anecdote of her own.

“Pre-COVID, I got sick while on vacation and contacted my PCP. Their policy was now to not prescribe antibiotics without seeing the patient,” said Lerner. “I believe that as part of antimicrobial stewardship there may be organizations adopting policies that unless they can see you and better diagnose your condition, they’re not prescribing over the phone.”

There are a few barriers to be aware of before implementing some of the components of the toolkit to ensure your organization gets the most from it. In some cases, your facility may have inadequate data tracking systems, limiting its ability to collect good data about how your providers are prescribing. Without that data, it will be hard to measure your success. “We call that internal benchmarking,” says Lerner.

Secondly, once you have a good way of tracking that information, you’ll also want a way to measure your progress as the program evolves.  “Part of it is to target your high-priority conditions—the common ones you prescribe antibiotics for,” says Lerner. “You’ll want targeted tracking systems. Once you track it, you can then benchmark against national guidelines. This is the perfect opportunity [for] a quality improvement study to move the needle.” Prescribers are more likely to change their behavior if they can see the data tracked.

What would the AAAHC team like to see from the toolkit’s implementation? “My takeaway would be that this improves and measures prescribing, so medicines are only used when needed,” says Lerner.

Pistone, meanwhile, says she’d like to “dream bigger.” “We have something called the annual ‘Bernie’ Awards—the Bernard A. Kershner Innovations in Quality Improvement Award,” she says. “I would like to see an organization make improvements using this toolkit that they’re able to implement in their system and be able to save money, better treat their patients, and use it as a quality improvement study and truly impact patient care—and I’d love to see them win a Bernie Award.”

Visit to order the AAAHC’s Antimicrobial Stewardship Toolkit.

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at