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Antimicrobial Stewardship and Telehealth for Critical Access and Regional Hospitals

The reality of increasing antimicrobial resistance in the United States has been looming within healthcare facilities over the past two decades. Twenty percent to 50% of all antimicrobial prescribing in acute care hospitals is deemed “inappropriate,” and new antimicrobial development has slowed and even stopped at times, thus making the need to protect this valuable resource crucial to modern medicine.1,2 
Formalized antimicrobial stewardship programs  (ASPs) are gaining momentum through the publication of national guidelines, a summary of program elements  available from the Centers for Disease Control and  Prevention (CDC), and guidance from national advisory  councils and the President on actions to combat  antimicrobial resistance.1-5 The National Action Plan for Combating Antibiotic-Resistant Bacteria proposed the goal of implementation of ASPs in all acute care  hospitals by 2020, with the goal of a 20% reduction in  inappropriate inpatient use of antimicrobials. This goal will be addressed through the incorporation of antimicrobial stewardship practices into Centers for Medicare & Medicaid Services conditions of participation and a Joint Commission accreditation standard.5,6 The most recent data (2014) regarding ASP implementation indicate that 39% of hospitals have ASPs compliant with all seven of the CDC’s core elements, with compliance declining sharply in facilities with <200 inpatient beds.7 
Given the above estimates of current ASP implementation and the scope of practice and regulatory change projected by 2020, it is crucial that smaller community and critical access hospitals are not left behind with regard to antimicrobial stewardship. These smaller facilities may encounter a number of perceived barriers to implementation of formal ASPs. Specifically, many lack the presence of an on-site infectious diseases (ID) physician and are unlikely to have direct access to an ID-trained pharmacist. 
A survey of US hospitals revealed that facilities with <50  beds were less likely to report having the support of their hospital leadership to develop an ASP or having received education regarding antimicrobial stewardship.7 One Australian study identified that the most commonly encountered barriers to ASP implementation included lack of access to ID physicians and/or training, lack of leadership, lack of willingness to change, and lack of senior clinician support.8 Increasing access to ID specialists and other resources through telehealth may overcome many of these barriers and present an opportunity for improvement in antimicrobial stewardship at these smaller care settings. 
Documented experience with antimicrobial stewardship via telehealth or teleconferencing is somewhat limited, but available literature lends promise to the concept. Providence St. Mary Medical Center in Walla Walla, Washington, implemented a comprehensive ASP that consisted of a robust, on-site antimicrobial stewardship team and a contracted physician at a remote site who provided weekly input on prospective chart audits performed by the ASP pharmacist via teleconferencing.9 This program found that after 13 months of operation, the number of ASP interventions increased from 2.1 to 6.8 per week. They also reported a large increase in the rate of de-escalation, a 28% decrease in antibiotic expenditure, and a decrease in the rate of hospital-onset C. difficile infection.9 

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