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Saint Joseph Mercy Health System

A bundled approach to antimicrobial stewardship: Advancing pharmacy practice through comprehensive infectious disease state management

Curtis D. Collins, Pharm.D., M.S., BCPS AQ-ID, FASHP; Nina West, Pharm.D.; Anurag N. Malani, M.D., FIDSA, FSHEA


An antimicrobial stewardship program (ASP) was established in 2009 at our 537-bed community teaching hospital which is a member of a 5-hospital network and larger 93-member corporate system (Trinity Health).  Development of the program was associated with significant decreases in antimicrobial utilization, expenditures, and an approximate 50% reduction in the odds of developing Clostridium difficile infection (CDI).1

As our program continued to evolve, we developed novel ways in which ASPs can improve the overall care of patients while enhancing more traditional ASP surveillance efforts.  Amongst a suite of initiatives was an expansion of ASP responsibilities along with focused efforts on strategies likely to improve patient care, including through the use of syndrome-specific care bundles (e.g., sets of evidence-based interventions designed to systematically improve the management of various disease states).  We report the systematic development and implementation of a series of syndrome-specific care bundles targeting high-impact infectious disease states (CDI and urinary tract infections (UTIs)) combined within an established ASP. 

Description of the Program

Syndrome-specific bundles, developed in cooperation with a multi-disciplinary team, were introduced for patients with confirmed or suspected  infectious diseases.  The bundles were based on institutional guidelines developed from published literature reports including international treatment guidelines.  Bundle alerts were developed for use by clinical pharmacists in our real-time clinical surveillance system, Sentri7 (Philadelphia, PA). In the case of the CDI bundle, we developed an additional prescriber-based orderset in our computerized prescriber order entry system, Cerner PowerChart (Kansas City, MO).  The bundles consisted of a series of questions assessing compliance with individual bundle elements.  Pharmacist follow-up and documentation of efforts and compliance with bundle elements was expected throughout the patients' clinical course. 

Experience with the Program

Single-center, quasi-experimental, pretest-posttest designs analyzed patients before and after implementation.  The UTI bundle led to a higher rate of discontinuation of therapy for asymptomatic bacteriuria (ASB) (52.4% vs. 12.5%, p=0.004), lower treatment duration in patients with ASB (2.3 vs. 4.9 days, p=<0.001), more appropriate durations of therapy overall (88.7% vs. 63.6%, p=0.001), and significantly higher overall bundle compliance (75% vs. 38.2%, p<0.001).2  In the CDI bundle comparison, overall bundle compliance (81% vs. 45%, p<0.001), discontinuation of non-essential acid suppressants (90% vs. 18%, p<0.001), and administration of appropriate CDI therapy (81% vs. 64%, p<0.009) significantly improved compared with historical controls.3

The regimented nature of bundle review and subsequent redistribution of workload allowed us to implement a number of additional quality initiatives which, collectively, led to subsequent improvements in antimicrobial utilization with decreased rates of hospital-onset CDI (21%) and multi-drug resistant organism infections (34%) over a five-year period (2012-2016).


Implementation of a bundled-approach to antimicrobial stewardship led to significant improvements in the management of high-impact infectious disease syndromes.  Improvement efforts were multidisciplinary, but largely attributable to pharmacists expanding their roles to ensure compliance with a range of evidence-based management and treatment recommendations.  Pharmacy departments may take note of the consistent, accountable approach that bundle implementation affords and explore opportunities in other disease states and processes. 


  1. Malani AN, Richards PG, Kapila S, et al. Clinical and economic outcomes from a community hospital's antimicrobial stewardship program.Am J Infect Control. 2013 Feb;41(2):145-8.
  2. Collins CD, Kabara JJ, Michienzi SM, Malani AN.Impact of an Antimicrobial Stewardship Care Bundle to Improve the Management of Patients with Suspected or Confirmed Urinary Tract Infection. Infect Control Hosp Epidemiol. 2016 Dec;37(12):1499-1501.
  3. Brumley PE, Malani AN, Kabara et al. Effect of an antimicrobial stewardship bundle for patients with Clostridium difficile infection.J Antimicrob Chemother. 2016;71:936-940.


From left to right: Anurag Malani, Nina West, Curtis Collins

St. Joseph Mercy Health System

From left to right: Anurag Malani, Nina West, Curtis Collins