Antimicrobial Stewardship in the Veterans Health Administration: Collaboration and Cooperation Generates Results

Posted on by CDC's Safe Healthcare Blog
Kelly Echevarria, PharmD, BCPS, AQ-ID
Kelly Echevarria, PharmD, BCPS, AQ-ID
Kelly Echevarria, PharmD, BCPS, AQ-ID
National Clinical Pharmacy Program Manager, Infectious Diseases
VHA Pharmacy Benefits Management
PBM Designee co-lead; VHA National Antimicrobial Stewardship Task Force (ASTF)

Today marks the beginning of U.S. Antibiotic Awareness Week on the day we observe Veterans Day. Promoting appropriate use of antibiotics within the Veterans Health Administration (VA) is one way we support VA’s mission to provide exceptional healthcare that improves the health and well-being of our nation’s Veterans. This mission is very personal to me as a VA employee involved in national antimicrobial stewardship efforts, as a Veteran who served in the Middle East during Operation Desert Storm, and as the wife of a retired soldier.

A dwindling antibiotic pipeline, the emergence of drug-resistant bacteria, and other harms of antibiotic use have driven the development of antimicrobial stewardship programs, systematic processes to reduce inappropriate use of antibiotics. Although requirements for hospital antimicrobial stewardship programs, such as the Joint Commission Accreditation standards, are recent, the VA has coordinated national efforts focused on the development of these programs for nearly a decade.

In 2009, work began on a series of antimicrobial stewardship program conferences to identify key players and the needs of facilities when implementing stewardship programs. The VA’s Antimicrobial Stewardship Task Force (ASTF) was officially created by charter in 2011, and is co-led by the National Infectious Diseases Service and VA’s Pharmacy Benefits Management, with representation from a diverse group of physicians, pharmacists, and other professionals across VA. Through the ASTF and a network of extremely dedicated volunteers, the VA has several notable achievements related to antimicrobial stewardship programs and improvement of antibiotic use:


  • VHA Directive 1031 requires each VA facility to develop and implement an antimicrobial stewardship program with a written policy, annual evaluation, and adequate dedicated staffing and resources, especially for the physician and pharmacist who co-lead the program.
  • A validated staffing calculator that helps facilities estimate staffing needs for antimicrobial stewardship programs.1
  • More than 80% of VA facilities participate in CDC’s Antibiotic Use reporting, with dashboards and reports that trend overall inpatient antibiotic use, use of select classes, and allow comparisons with similar VA facilities.
  • Educational efforts for antimicrobial stewardship program members, hospital employees, patients, and families include monthly educational webinars, educational slide sets and flyers, and tracking of pharmacist certification in antimicrobial stewardship programs.
    • Every year, the ASTF prepares an email blast for each day during U.S. Antibiotic Awareness Week with a common theme throughout the week.
    • More than 150 pharmacists have self-certified that they have completed or are enrolled in a stewardship certification program or have other infectious diseases training.
    • More than 80% of VA stewardship pharmacy champions have training in antimicrobial stewardship programs or infectious diseases.
  • Annual multicenter, antibiotic-related Medication Use Evaluations generate findings about where antibiotic use can be improved. These include:
    • pneumonia treatment, which led to an intervention to reduce excessive duration of treatment.2
    • urinary tract infections, which led to an intervention to avoid treatment of asymptomatic bacteriuria.3
    • acute respiratory tract infection treatment in outpatients, which led to a collaboration between the ASTF and VA’s Academic Detailing to provide educational materials and dashboards to identify and target high-prescribing providers.
  • The ASTF has developed other example interventions and sample approaches, which can be adapted by facilities, such as intravenous to oral switch and de-escalation of antibiotic therapy.
  • A national ASTF SharePoint site serves as a reservoir where stewardship champions can find documents, links, and reports and can communicate via email to more than 200 physicians, pharmacists, nurses, and others interested in antimicrobial stewardship programs.

The collaboration between dedicated pharmacists, physicians, and others resulted in a 12% decrease in inpatient antibiotic use from 2008 to 2015 through these efforts, putting the VA on track to meet the 20% goal set as part of the National Action Plan for Combating Antibiotic-Resistant Bacteria.4 Most importantly, however, is the prevention of unwanted complications of antibiotic use, such as antibiotic resistance, serious adverse drug events, and C. difficile infection, in our nation’s Veterans, and caring for those who care for us.

Thank you to all of America’s Veterans!



  1. Echevarria K, Groppi J, Kelly A, et al.  Development and application of an objective staffing calculator for antimicrobial stewardship programs in the Veterans Health Administration. Am J Health-Syst Pharm 2017;74:1785-90
  2. Madaras-Kelly K, Burk M, Caplinger C, et al.  Total duration of antimicrobial therapy in veterans hospitalized with uncomplicated pneumonia: results of a national medication use evaluation. J Hosp Med 2016;11(12):832-9
  3. Spivak E, Burk M, Zhang R, et al.  Management of bacteriuria in Veterans Affairs Hospitals.  Clin Infect Dis 2017;65:910-7
  4. Kelly A, Jones M, Echevarria K, et al.  A report of the efforts of the Veterans Health Administration National Antimicrobial Stewardship Initiative.  Infection Control Hosp Epidemiol 2017;38:513-20

Kelly Echevarria, PharmD, BCPS, AQ-ID, is an infectious diseases trained pharmacist who has worked in the VA for 20 years. She is a National Clinical Pharmacy Program Manager with Pharmacy Benefits Management (PBM) and serves as the designated PBM co-lead for the VA Antimicrobial Stewardship Task Force (ASTF). She is also a Veteran, wife, and mother.

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Page last reviewed: September 23, 2020
Page last updated: September 23, 2020