Hospital Pharmacy - July/August 2019 - 250

781916
research-article2018

HPXXXX10.1177/0018578718781916Hospital PharmacyAppaneal et al.

Original Article

Facilitators and Barriers to Antibiotic
Stewardship: A Qualitative Study of
Pharmacists' Perspectives

Hospital Pharmacy
2019, Vol. 54(4) 250-258
© The Author(s) 2018
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https://doi.org/10.1177/0018578718781916
DOI: 10.1177/0018578718781916
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Haley J. Appaneal1,2, Megan K. Luther1,2, Tristan T. Timbrook1,2,
Kerry L. LaPlante1,2,3, and David M. Dosa1,4

Abstract
Background: The Veterans Affairs (VA) is a leader in the implementation and advancement of antibiotic stewardship
programs throughout the nation. The Centers for Disease Control and Prevention (CDC) has also led national antibiotic
stewardship efforts and has outlined core elements to improve antibiotic use in hospitals, long-term care, and outpatient
settings. Many facilities still face challenges to the implementation and maintenance of successful programs, particularly
in nonacute care settings. The objective of this study was to identify barriers and facilitators to antibiotic stewardship
within the VA medical centers through qualitative interviews with pharmacists. Methods: Eight semi-structured
telephone interviews were conducted with pharmacists from 6 VA medical centers within VA New England Healthcare
System. Pharmacist respondents were either pharmacy champions (for medical centers with established programs) or
pharmacists with responsibilities in making antibiotic recommendations (locations without established programs). All
interviews were audio recorded and transcribed verbatim. NVivo 8 was used for data coding and analysis. Results:
Pharmacists from all 8 medical centers were contacted for interviews and pharmacists from 6 medical centers agreed
to interviews (75% VA New England medical center participation). Three main themes regarding antibiotic stewardship
were identified from the interviews with pharmacists. Respondents described the importance of (1) a supportive
organizational culture, (2) protected time for antibiotic stewardship, and (3) a cohesive organizational structure in the
success of antibiotic stewardship programs. Conclusions: Our findings support the CDC core elements for antibiotic
stewardship, in particular the importance of leadership commitment in the creation of a culture that supports antibiotic
stewardship and in ensuring staff are given sufficient time for antibiotic stewardship efforts. Although a strong supportive
culture has been built, strategies focused on fostering increased protected time for antibiotic stewardship and a cohesive
organizational structure may be helpful in advancing and sustaining successful antibiotic stewardship programs that
improve patient outcomes.
Keywords
antibiotic stewardship, antibiotic use, qualitative interviews, pharmacists

Introduction
Antibiotic resistance is a major public health threat.1-3
Infections due to antibiotic-resistant bacteria and Clostridium
difficile (C difficile) are associated with increased morbidity,
mortality, longer hospital stays, and excess health care
costs.4-6 In 2013, the Centers for Disease Control and
Prevention (CDC) estimated that at minimum, antibioticresistant organisms caused 2 million infections and 23 000
deaths in the United States and that C difficile caused at least
250 000 illnesses and 14 000 deaths.2 In the United States,
resistant infections are responsible for $28 to $33 billion in
excess health care costs each year.7
Antibiotic use is the driving force that selects for antibiotic-resistant bacteria and promotes C difficile infection. It

is estimated that approximately 50% of antibiotic use in hospitals is inappropriate.8 Antibiotic stewardship interventions, defined as coordinated strategies that are designed to
improve the appropriate use of antibiotics by promoting the
optimal drug, dose, duration, and route of administration,
1

Veterans Affairs Medical Center, Providence, RI, USA
University of Rhode Island, Kingston, RI, USA
3
Warren Alpert Medical School of Brown University, Providence, RI, USA
4
Brown University School of Public Health, Providence, RI, USA
2

Corresponding Author:
Haley J. Appaneal, Research Health Science Specialist, Providence
Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI
02908, USA.
Email: haley.appaneal@va.gov

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Hospital Pharmacy - July/August 2019

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