Developing Stewardship Measures

Developing Patient Safety Outcome Measures and Measurement Tools for Antibiotic Stewardship Programs

This joint initiative was made possible by a partnership between the CDC Foundation and Merck & Co., Inc., Kenilworth, NJ, USA


DASON recently led a project aimed at addressing the foundational need for strong antimicrobial stewardship metrics that reflect the impact of stewardship on patient safety and optimized care.

Each year in the United States, over 2 million people are infected with antibiotic resistant bacteria, and nearly 25,000 die from these infections.1 In response to the growing threat of antibiotic resistance, the Centers for Disease Control and Prevention (CDC) and other major health organizations have created guidelines, standards, and recommendations to help hospitals address the need to improve use of antimicrobials.23   Each of these highlights the role of analysis and response to local data for ultimate ASP success.  Despite the importance of data to drive action for stewardship, the current status for most facilities is limited access to local data, limited voluntary participation in our national surveillance systems, and thus a limited ability to assess the impact of ASPs.In addition, a large amount of development work is needed to better define metrics that reflect the impact of ASP. Assessment of ASPs to this point have often focused on cost-based outcomes, which don’t give an accurate picture of the effect ASPs have on resistance, patient health, and safety.

This project aimed to address the foundational need for strong ASP metrics that reflect ASP impact on patient safety and optimized care. We called together some of the top minds in healthcare and drug resistance to create an expert panel. The Structured Taskforce of Experts Working At Reliable Standards for Stewardship (STEWARDS) panel reviewed metrics previously utilized or proposed in the medical literature, and took suggestions from the panel on additional metrics not yet described in the literature. The panel then rated and discussed the list of proposed metrics to best identify the ones that 1) improve antimicrobial prescribing practices 2) improve patient care 3) aid in targeting antimicrobial stewardship efforts and 4) can be feasibly monitored in any hospital with an electronic health record.4 The result of this consensus process provided a list of candidate metrics from which to test the feasibility of data collection, analysis, and feedback in 5 pilot sites.

Working closely with these pilot partner sites, the feasibility of data capture and analysis as well as the utility of each candidate metric to guide local stewardship activities was assessed during on-site visits, frequent communication with the stewardship teams, and formal survey techniques.  This Guide reflects the outcome from this development and feasibility project. 

In this Guide, you will find a Technical Manual, which describes in detail the steps taken to define, collect data, and analyze each piloted metric. In addition, we discuss feasibility considerations along with suggestions for routine use. For the purposes of this project, metrics were considered feasible if electronic definition development, data collection, and analysis were completed within the 2-year project timeline.  Metrics were considered useful if pilot sites and investigators felt that analyses using the metric could inform decisions about their ASP goals and development. Thus, the manual is categorized by:

  1. Metrics that were both useful and feasible
  2. Metrics that were feasible, but not for routine antimicrobial stewardship program assessments
  3. Metrics that did not pass feasibility testing
  4. Metrics that were feasible, but not useful

In addition, we have created a simplified Reporting Tool for days of therapy based antibiotic use  and C. difficile rates to make them accessible to front-line antibiotic stewards who have limited access to patient-level data and analysts. Simply using a Microsoft Excel spreadsheet, we have created a practical tool that will allow hospital staff to input their facility’s aggregate data and receive calculated metrics and graphs as output. We hope this Reporting Tool will facilitate and enhance communication on antimicrobial stewardship in a wide variety of hospital settings.

The appendix for this Final Tool includes three items: data table structures and a data dictionary, the STEWARDS panel outcome, and samples of the feedback reports we presented to each site during the evaluation phase. These reports were valuable discussion pieces during our assessment of the feasibility and usefulness of each metric.

The close of this project is certainly not a close to the work needed to demonstrate the impact of antimicrobial stewardship on patient safety. Although this Guide provides important, practical insights about the feasibility of data collection, proposed metric definitions based on electronic data fields, and a standardized electronic dataset for patient-level analyses, it in no way provides all the answers. Major findings of this project included a lack of clinical outcomes that were felt to be feasible and useful in assessments of ASP impact. In addition, this project further demonstrates that investment into data collection and analysis tailored to an individual hospital’s electronic health records is necessary for many metrics that go beyond simple quantities of use. Thus, stewards on the ground need more support for data infrastructure and analytics. Finally, support for dedicated research into metrics identified here and in the future is necessary to fully demonstrate the impact of antimicrobial stewardship.

Read the Guide


  1. CDC. Centers for Disease Control and Prevention: Antimicrobial Resistance Threat Report 2013. Accessed October 15, 2013.
  2. Pollack LA, Srinivasan A. Core elements of hospital antibiotic stewardship programs from the Centers for Disease Control and Prevention. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2014;59 Suppl 3:S97-100.
  3. The Joint Commission. Antimicrobial Stewardship Standard. MM.09.01.01. 2017; Accessed April 11, 2017.
  4. Moehring RW, Anderson DJ, Cochran RL, Hicks LA, Srinivasan A, Dodds Ashley ES. Expert Consensus on Metrics to Assess the Impact of Patient-Level Antimicrobial Stewardship Interventions in Acute-Care Settings. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2017;64(3):377-383.