Active Surveillance and Contact Precautions for Preventing Methicillin-Resistant Staphylococcus aureus Healthcare-Associated Infections During the COVID-19 Pandemic.

BACKGROUND: Statistically significant decreases in methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections (HAIs) occurred in Veterans Affairs (VA) hospitals from 2007 to 2019 using a national policy of active surveillance (AS) for facility admissions and contact precautions for MRSA colonized (CPC) or infected (CPI) patients, but the impact of suspending these measures to free up laboratory resources for testing and conserve personal protective equipment for coronavirus disease 2019 (COVID-19) on MRSA HAI rates is not known. METHODS: From July 2020 to June 2022 all 123 acute care VA hospitals nationwide were given the rolling option to suspend (or re-initiate) any combination of AS, CPC, or CPI each month, and MRSA HAIs in intensive care units (ICUs) and non-ICUs were tracked. RESULTS: There were 917 591 admissions, 5 225 174 patient-days, and 568 MRSA HAIs. The MRSA HAI rate/1000 patient-days in ICUs was 0.20 (95% confidence interval [CI], .15-.26) for facilities practicing "AS + CPC + CPI" compared to 0.65 (95% CI, .41-.98; P < .001) for those not practicing any of these strategies, and in non-ICUs was 0.07 (95% CI, .05-.08) and 0.12 (95% CI, .08-.19; P = .01) for the respective policies. Accounting for monthly COVID-19 facility admissions using a negative binomial regression model did not change the relationships between facility policy and MRSA HAI rates. There was no significant difference in monthly facility urinary catheter-associated infection rates, a non-equivalent dependent variable, in the policy categories in either ICUs or non-ICUs. CONCLUSIONS: Facility removal of MRSA prevention practices was associated with higher rates of MRSA HAIs in ICUs and non-ICUs.

Factors That Affect Legionella Positivity in Healthcare Building Water Systems from a Large, National Environmental Surveillance Initiative.

Legionella growth in healthcare building water systems can result in legionellosis, making water management programs (WMPs) important for patient safety. However, knowledge is limited on Legionella prevalence in healthcare buildings. A dataset of quarterly water testing in Veterans Health Administration (VHA) healthcare buildings was used to examine national environmental Legionella prevalence from 2015 to 2018. Bayesian hierarchical logistic regression modeling assessed factors influencing Legionella positivity. The master dataset included 201,146 water samples from 814 buildings at 168 VHA campuses. Overall Legionella positivity over the 4 years decreased from 7.2 to 5.1%, with the odds of a Legionella-positive sample being 0.94 (0.90-0.97) times the odds of a positive sample in the previous quarter for the 16 quarters of the 4 year period. Positivity varied considerably more at the medical center campus level compared to regional levels or to the building level where controls are typically applied. We found higher odds of Legionella detection in older buildings (OR 0.92 [0.86-0.98] for each more recent decade of construction), in taller buildings (OR 1.20 [1.13-1.27] for each additional floor), in hot water samples (O.R. 1.21 [1.16-1.27]), and in samples with lower residual biocide concentrations. This comprehensive healthcare building review showed reduced Legionella detection in the VHA healthcare system over time. Insights into factors associated with Legionella positivity provide information for healthcare systems implementing WMPs and for organizations setting standards and regulations.

Methicillin-resistant Staphylococcus aureus Colonization and Pre- and Post-hospital Discharge Infection Risk.

Background: The Department of Veterans Affairs implemented an active surveillance program for methicillin-resistant Staphylococcus aureus (MRSA) in 2007 in which acute care inpatients are tested for MRSA carriage on admission, unit-to-unit transfer, and discharge. Using these data, we followed patients longitudinally to estimate the difference in infection rates for those who were not colonized, those who were colonized on admission (importers), and those who acquired MRSA during their stay. We examined MRSA infections that occurred prior to discharge and at 30, 90, 180, and 365 days after discharge. Methods: We constructed a dataset of 985626 first admissions from January 2008 through December 2015 who had surveillance tests performed for MRSA carriage. We performed multivariable Cox proportional hazards and logistic regression models to examine the relationship between MRSA colonization status and infection. Results: The MRSA infection rate across the predischarge and 180-day postdischarge time period was 5.5% in importers and 7.0% in acquirers without a direct admission to the intensive care unit (ICU) and 11.4% in importers and 11.7% in acquirers who were admitted directly to the ICU. The predischarge hazard ratio for MRSA infection was 29.6 (95% confidence interval [CI], 26.5-32.9) for importers and 28.8 (95% CI, 23.5-35.3) for acquirers compared to those not colonized. Fully 63.9% of all MRSA pre- and postdischarge infections among importers and 61.2% among acquirers occurred within 180 days after discharge. Conclusions: MRSA colonization significantly increases the risk of subsequent MRSA infection. In addition, a substantial proportion of MRSA infections occur after discharge from the hospital.

Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.

BACKGROUND: Health care-associated infections with methicillin-resistant Staphylococcus aureus (MRSA) have been an increasing concern in Veterans Affairs (VA) hospitals. METHODS: A "MRSA bundle" was implemented in 2007 in acute care VA hospitals nationwide in an effort to decrease health care-associated infections with MRSA. The bundle consisted of universal nasal surveillance for MRSA, contact precautions for patients colonized or infected with MRSA, hand hygiene, and a change in the institutional culture whereby infection control would become the responsibility of everyone who had contact with patients. Each month, personnel at each facility entered into a central database aggregate data on adherence to surveillance practice, the prevalence of MRSA colonization or infection, and health care-associated transmissions of and infections with MRSA. We assessed the effect of the MRSA bundle on health care-associated MRSA infections. RESULTS: From October 2007, when the bundle was fully implemented, through June 2010, there were 1,934,598 admissions to or transfers or discharges from intensive care units (ICUs) and non-ICUs (ICUs, 365,139; non-ICUs, 1,569,459) and 8,318,675 patient-days (ICUs, 1,312,840; and non-ICUs, 7,005,835). During this period, the percentage of patients who were screened at admission increased from 82% to 96%, and the percentage who were screened at transfer or discharge increased from 72% to 93%. The mean (±SD) prevalence of MRSA colonization or infection at the time of hospital admission was 13.6±3.7%. The rates of health care-associated MRSA infections in ICUs had not changed in the 2 years before October 2007 (P=0.50 for trend) but declined with implementation of the bundle, from 1.64 infections per 1000 patient-days in October 2007 to 0.62 per 1000 patient-days in June 2010, a decrease of 62% (P<0.001 for trend). During this same period, the rates of health care-associated MRSA infections in non-ICUs fell from 0.47 per 1000 patient-days to 0.26 per 1000 patient-days, a decrease of 45% (P<0.001 for trend). CONCLUSIONS: A program of universal surveillance, contact precautions, hand hygiene, and institutional culture change was associated with a decrease in health care-associated transmissions of and infections with MRSA in a large health care system.

The Association between Low CO2 Production and Central Sleep Apnea in Men with Heart Failure.

Rationale: Hunter-Cheyne-Stokes breathing with central sleep apnea (CSA) is prevalent in some patients with heart failure with reduced ejection fraction (HFrEF). Theoretical models of Hunter-Cheyne-Stokes breathing predict that a low metabolic rate (MR) predisposes one to CSA. Objectives: In this study, we examined the role of MR in the pathogenesis of CSA. Methods: A physiological study was conducted in a sleep laboratory at a U.S. Department of Veterans Affairs medical center. Patients were 28 consecutive male Veterans with stable HFrEF. After an adaptation night, polysomnography, left ventricular ejection fraction, pulmonary function tests, carbon dioxide production ([Formula: see text]), and arterial blood samples were obtained under strict standardized conditions. Physiological variables were then entered into regression models to examine the association with CSA. Results: Body mass index varied from 20 to 40 kg/m2, and [Formula: see text] ranged from 167 to 434 ml/min. In the final regression model, low [Formula: see text] and low body mass index were associated with CSA index. [Formula: see text] had the strongest association (95% confidence interval, -0.36 to -0.06; P = 0.007). Conclusions: In patients with HFrEF, a low MR and related low [Formula: see text], but not low oxygen consumption, were associated with CSA. Mechanistically, in the face of low MR and [Formula: see text], a given change in ventilation results in large swings in partial pressure of CO2, thus promoting CSA. To our knowledge, this is the first study in humans that shows this association.

Lack of correlation between standardized antimicrobial administration ratios (SAARs) and healthcare-facility-onset Clostridioides difficile infection rates in Veterans Affairs medical facilities.

We detected no correlation between standardized antimicrobial administration ratios (SAARs) and healthcare facility-onset Clostridioides difficile infection (HO-CDI) rates in 102 acute-care Veterans Affairs medical centers over 16 months. SAARs may be useful for investigating trends in local antimicrobial use, but no ratio threshold demarcated HO-CDI risk.

Hospital coronavirus disease 2019 (COVID-19) public health reporting: Lessons from validation of an automated surveillance tool to facilitate data collection.

A comparison of computer-extracted and facility-reported counts of hospitalized coronavirus disease 2019 (COVID-19) patients for public health reporting at 36 hospitals revealed 42% of days with matching counts between the data sources. Miscategorization of suspect cases was a primary driver of discordance. Clear reporting definitions and data validation facilitate emerging disease surveillance.

Healthcare-associated infections in Veterans Affairs acute-care and long-term healthcare facilities during the coronavirus disease 2019 (COVID-19) pandemic.

OBJECTIVE: To assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on healthcare-associated infections (HAIs) reported from 128 acute-care and 132 long-term care Veterans Affairs (VA) facilities. METHODS: We compared central-line-associated bloodstream infections (CLABSIs), ventilator-associated events (VAEs), catheter-associated urinary tract infections (CAUTIs), methicillin-resistant Staphylococcus aureus (MRSA), and Clostridioides difficile infections and rates reported from each facility monthly to a centralized database before the pandemic (February 2019 through January 2020) and during the pandemic (July 2020 through June 2021). RESULTS: Nationwide VA COVID-19 admissions peaked in January 2021. Significant increases in the rates of CLABSIs, VAEs, and MRSA all-site HAIs (but not MRSA CLABSIs) were observed during the pandemic in acute-care facilities. There was no significant change in CAUTI rates, and C. difficile rates significantly decreased. There were no significant increases in HAIs in long-term care facilities. CONCLUSIONS: The COVID-19 pandemic had a differential impact on HAIs of various types in VA acute care, with many rates increasing. The decrease in CDI HAIs may be due, in part, to evolving diagnostic testing. The minimal impact of COVID-19 in VA long-term facilities may reflect differences in patient numbers and acuity and early recognition of the impact of the pandemic on nursing home residents leading to increased vigilance and optimization of infection prevention and control practices in that setting. These data support the need for building and sustaining conventional infection prevention and control strategies before and during a pandemic.

Association between Clostridioides difficile infection testing results and decision to treat.

We sought to determine how often patients with a negative toxin enzyme immunoassay following a positive nucleic acid amplification test for Clostridioides difficile infection (CDI) were treated for CDI in Veterans Affairs facilities. From October 2018 through March 2021, 702 (29.5%) of 2,374 unique patients with these test results were treated.

Spinal cord injury/disorder teleconsultation outcome study.

The purpose of this study was to compare the costs of providing specialty wound care to spinal cord injury/disorder (SCI/D) veterans by teleconsultation and traditional care. A retrospective design was used to conduct this descriptive, correlational study. A convenience sample of 76 SCI/D veterans (2 women, 74 men) met inclusion criteria from a possible 123 subjects. Variables were compared between groups using nonparametric methods (Wilcoxon rank sums and chi-square). There was no significant difference in inpatient admissions or inpatient bed days of care between the two groups. The teleconsultation group had more outpatient encounters (medians 12 vs. 4, p = .007; Wilcoxon statistic = 412.5) and longer inpatient stays (medians 81 vs. 19 days/admission, p = .05; Wilcoxon statistic = 227.0) compared to the traditional care group. There was no significant difference in inpatient cost between the two groups; however, the teleconsultation group had a significantly higher median cost per outpatient encounter ($440 vs. $141, p <.0001; Wilcoxon statistic = 469.0). Although this study only looked at costs directly associated with wound management, continued research exploring the use of teleconsultation in other areas of SCI/D specialty is needed to enhance its application.

Health after Legionnaires' disease: A description of hospitalizations up to 5 years after Legionella pneumonia.

BACKGROUND AND OBJECTIVES: Research on Legionnaires' Disease (LD) suggests there may be long-term health complications, but data are limited. This study investigated whether Intensive Care Unit (ICU) admission during LD hospitalization may be associated with adverse health outcomes and characterized subsequent discharge diagnoses in patients with LD up to 5 years post-LD. METHODS: We conducted a retrospective case series study with follow up for 5 years among patients hospitalized at a Department of Veterans Affairs (VA) Medical Center between 2005 and 2010 with LD. Data were collected from medical records on health history, LD severity (including ICU admission), and discharge diagnoses for 5 years post-LD or until death. We used ordinal logistic regression to explore associations between ICU admission and hospitalizations post-LD. Frequency counts were used to determine the most prevalent discharge diagnoses in the 5 years post-LD. RESULTS: For the 292 patients with laboratory-confirmed LD, those admitted to the ICU during LD hospitalization were more likely to have a greater number of hospitalizations within 5 years compared to non-ICU patients (ORHosp 1.92 CI95% 1.25, 2.95). Fifty-five percent (161/292) had ≥ 1 hospitalization within 5 years post-LD. After accounting for pre-existing diagnosis codes in patients with at least one hospitalization in the 2 years prior to LD (n = 77/161 patients, 47.8%), three of the four most frequent new diagnoses in the 5 years post-LD were non-chronic conditions: acute renal failure (n = 22, 28.6%), acute respiratory failure (n = 17, 22.1%) and unspecified pneumonia (n = 15, 19.5%). CONCLUSIONS: Our findings indicate that LD requiring ICU admission is associated with more subsequent hospitalizations, a factor that could contribute to poorer future health for people with severe LD. In addition to chronic conditions prevalent in this study population, we found new diagnoses in the 5-year post-LD period including acute renal failure. With LD incidence increasing, more research is needed to understand conditions and factors that influence long term health after LD.

Effect of testing methods on incidence of Clostridioides difficile infection rates in Veterans' Affairs medical centers.

Clostridioidesdifficile infection rates from 7 facilities that used nucleic acid amplification testing (NAAT) alone for 12 months then switched to NAAT plus toxin enzyme immunoassay (EIA) and reported the latter result for 12 months were compared to 70 facilities that used NAAT alone for all 24 months. There was no significant difference in rates between facility groups over the first 12 months (P = .21, linear regression), but we detected a decrease in rates for the facilities that changed to NAAT+EIA (P < .0001).

Adherence to antihypertensive agents and blood pressure control in chronic kidney disease.

BACKGROUND: hypertension is a modifiable risk factor in chronic kidney disease (CKD), and medication adherence (MA) is critical in reaching the treatment goals. Patterns of MA for antihypertensive agents and its impact on blood pressure (BP) in CKD practice settings are not well studied. METHODS: we examined 7,227 CKD patients receiving at least one antihypertensive prescription between 2006 and 2007. Outpatient BP measurements were averaged as high (>130/ 80 mm Hg) versus normal (others). MA was calculated using medication possession ratio (MPR = actual treatment days/total possible treatment days). Good versus Poor MA (MPR ≥ 0.8 vs. <0.8) groups were compared for differences in demographic, co-morbid, and laboratory variables. The relationship between MA and BP was examined by logistic regression. RESULTS: 4,867/7,227 patients (67%) had Good MA; the frequency of patients with Good MA varied by each drug class (p < 0.0001). MPR declined with worsening CKD (stage III: MPR = 0.83 standard deviation (SD 0.18); stage IV: MPR = 0.78 (SD 0.22); stage V: MPR = 0.75 (SD 0.21); p < 0.0001). Hospitalization episodes also negatively impacted adherence. Only 35% of CKD patients had normal BP. By multivariate analysis, Poor MA was associated with high BP (odds ratio 1.23, 95% confidence interval 1.11-1.37). CONCLUSIONS: 33% of CKD patients have Poor MA for antihypertensive agents, and MA worsens with declining renal function. Poor MA is associated with a 23% greater risk of uncontrolled hypertension. Monitoring and improving adherence in CKD practice may improve outcomes.

A targeted assessment for prevention strategy to decrease Clostridioides difficile infections in Veterans Affairs acute-care medical centers.

OBJECTIVE: A guideline for the prevention of Clostridioides difficile infection (CDI) in 127 Veterans Health Administration acute-care facilities was implemented in July 2012. Beginning in 2015, a targeted assessment for prevention strategy was used to evaluate facilities for hospital-onset healthcare-facility-associated CDIs to focus prevention efforts where they might have the most impact in reaching a reduction goal of 30% nationwide. METHODS: We calculated standardized infection ratios (SIRs) and cumulative attributable differences (CADs) using a national data baseline. Facilities were ranked by CAD, and those with the 10 highest CAD values were targeted for periodic conference calls or a site visit from January 2016-September 2019. RESULTS: The hospital-onset healthcare-facility-associated CDI rate in the 10 facilities with the highest CADs declined 56% during the process improvement period, compared to a 44% decline in the 117 nonintervention facilities (P = .03). CONCLUSION: Process improvement interventions targeting facilities ranked by CAD values may be an efficient strategy for decreasing CDI rates in a large healthcare system.

Correlation of prevention practices with rates of health care-associated Clostridioides difficile infection.

OBJECTIVE: We examined Clostridioides difficile infection (CDI) prevention practices and their relationship with hospital-onset healthcare facility-associated CDI rates (CDI rates) in Veterans Affairs (VA) acute-care facilities. DESIGN: Cross-sectional study. METHODS: From January 2017 to February 2017, we conducted an electronic survey of CDI prevention practices and hospital characteristics in the VA. We linked survey data with CDI rate data for the period January 2015 to December 2016. We stratified facilities according to whether their overall CDI rate per 10,000 bed days of care was above or below the national VA mean CDI rate. We examined whether specific CDI prevention practices were associated with an increased risk of a CDI rate above the national VA mean CDI rate. RESULTS: All 126 facilities responded (100% response rate). Since implementing CDI prevention practices in July 2012, 60 of 123 facilities (49%) reported a decrease in CDI rates; 22 of 123 facilities (18%) reported an increase, and 41 of 123 (33%) reported no change. Facilities reporting an increase in the CDI rate (vs those reporting a decrease) after implementing prevention practices were 2.54 times more likely to have CDI rates that were above the national mean CDI rate. Whether a facility's CDI rates were above or below the national mean CDI rate was not associated with self-reported cleaning practices, duration of contact precautions, availability of private rooms, or certification of infection preventionists in infection prevention. CONCLUSIONS: We found considerable variation in CDI rates. We were unable to identify which particular CDI prevention practices (i.e., bundle components) were associated with lower CDI rates.

Evaluating the Effect of a Clostridium difficile Infection Prevention Initiative in Veterans Health Administration Long-Term Care Facilities.

We evaluated rates of clinically confirmed long-term-care facility-onset Clostridium difficile infections from April 2014 through December 2016 in 132 Veterans Affairs facilities after the implementation of a prevention initiative. The quarterly pooled rate decreased 36.1% from the baseline (P<.0009 for trend) by the end of the analysis period. Infect Control Hosp Epidemiol 2018;39:343-345.

Achieving balance between implementing effective infection prevention and control practices and maintaining a home-like setting in U.S. Department of Veterans Affairs nursing homes.

Nursing homes present a unique challenge for implementing infection prevention and control practices while striving to maintain a home-like environment. Medical devices such as urinary catheters and central venous catheters have become a part of nursing home care but can predispose residents to associated infections. Because evidence-based prevention bundles were implemented, catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs) were monitored in all U.S. Department of Veterans Affairs (VA) nursing homes, and outcomes were evaluated. Bundle components for CLABSIs focused on insertion technique, site selection, and routine assessment of central line necessity, while the CAUTI bundle focused on insertion technique, appropriate indication, and routine assessment of urinary catheter necessity. From October 2010 through September 2016, VA nursing homes reported nationwide reductions of CAUTIs (51.2%; P < .0001) and CLABSIs (25.0%; P = .0009).

Legionnaires Disease Surveillance in US Department of Veterans Affairs Medical Facilities and Assessment of Health Care Facility Association.

Importance: Legionnaires disease (LD) incidence is increasing in the United States. Health care facilities are a high-risk setting for transmission of Legionella bacteria from building water systems to occupants. However, the contribution of LD in health care facilities to national LD rates is not well characterized. Objectives: To determine the burden of LD in US Department of Veterans Affairs (VA) patients and to assess the amount of LD with VA exposure. Design, Setting, and Participants: Retrospective cohort study of reported LD data in VA medical facilities in a national VA LD surveillance system from January 1, 2014, to December 31, 2016. The study population included total veteran enrollees and enrollees who used the VA health care system. Main Outcomes and Measures: The primary outcome was assessment of annual LD rates, categorized by VA and non-VA exposure. Legionnaires disease rates for cases with VA exposure were determined on both population and exposure potential levels. Rates by VA exposure potential were calculated using inpatient bed days of care, long-term care resident days, or outpatient encounters. In addition, types and amounts of LD diagnostic testing were calculated. Case and testing data were analyzed nationally and regionally. Results: There were 491 LD cases in the case report surveillance system from January 1, 2014, to December 31, 2016. Most cases (447 [91%]) had no VA exposure or only outpatient VA exposure. The remaining 44 cases had VA exposure from overnight stays. Total LD rates from January 1, 2014, to December 31, 2016, increased for all VA enrollees (from 1.5 to 2.0 per 100 000 enrollees; P = .04) and for users of VA health care (2.3 to 3.0 per 100 000 enrollees; P = .04). The LD rate for the subset who had no VA exposure also increased (0.90 to 1.47 per 100 000 enrollees; P < .001). In contrast, the LD rate for patients with VA overnight stay decreased on a population level (5.0 to 2.3 per 100 000 enrollees; P < .001) and an exposure level (0.31 to 0.15 per 100 000 enrollees; P < .001). Regionally, the eastern United States had the highest LD rates. The urine antigen test was the most used LD diagnostic method; 49 805 tests were performed in 2015-2016 with 335 positive results (0.67%). Conclusions and Relevance: Data in the VA LD databases showed an increase in overall LD rates over the 3 years, driven by increases in rates of non-VA LD. Inpatient VA-associated LD rates decreased, suggesting that the VA's LD prevention efforts have contributed to improved patient safety.

Eight years of decreased methicillin-resistant Staphylococcus aureus health care-associated infections associated with a Veterans Affairs prevention initiative.

BACKGROUND: Declines in methicillin-resistant Staphylococcus aureus (MRSA) health care associated infections (HAIs) were previously reported in Veterans Affairs acute care (2012), spinal cord injury (SCIU) (2011), and long-term-care facilities (LTCFs) (2012). Here we report continuing declines in infection rates in these settings through September 2015. METHODS: Monthly data entered into a national database from 127 acute care facilities, 22 SCIUs, and 133 LTCFs were evaluated for trends using negative binomial regression. RESULTS: There were 23,153,240 intensive care unit (ICU) and non-ICU, and 1,794,234 SCIU patient-days from October 2007-September 2015, and 22,262,605 LTCF resident-days from July 2009-September 2015. Admission nasal swabbing remained >92% in all 3 venues. Admission prevalence changed from 13.2%-13.5% in acute care, from 35.1%-32.0% in SCIUs, and from 23.1%-25.0% in LTCFs during the analysis periods. Monthly HAI rates fell 87.0% in ICUs, 80.1% in non-ICUs, 80.9% in SCIUs, and 49.4% in LTCFs (all P values < .0001 for trend). During September 2015, there were 2 MRSA HAIs reported in ICUs, 20 (with 3 in SCIUs) in non-ICUs, and 31 in LTCFs nationwide. CONCLUSIONS: MRSA HAI rates declined significantly in acute care, SCIUs, and LTCFs over 8 years of the Veterans Affairs MRSA Prevention Initiative.

A Report of the Efforts of the Veterans Health Administration National Antimicrobial Stewardship Initiative.

OBJECTIVE To detail the activities of the Veterans Health Administration (VHA) Antimicrobial Stewardship Initiative and evaluate outcomes of the program. DESIGN Observational analysis. SETTING The VHA is a large integrated healthcare system serving approximately 6 million individuals annually at more than 140 medical facilities. METHODS Utilization of nationally developed resources, proportional distribution of antibiotics, changes in stewardship practices and patient safety measures were reported. In addition, inpatient antimicrobial use was evaluated before and after implementation of national stewardship activities. RESULTS Nationally developed stewardship resources were well utilized, and many stewardship practices significantly increased, including development of written stewardship policies at 92% of facilities by 2015 (P<.05). While the proportional distribution of antibiotics did not change, inpatient antibiotic use significantly decreased after VHA Antimicrobial Stewardship Initiative activities began (P<.0001). A 12% decrease in antibiotic use was noted overall. The VHA has also noted significantly declining use of antimicrobials prescribed for resistant Gram-negative organisms, including carbapenems, as well as declining hospital readmission and mortality rates. Concurrently, the VHA reported decreasing rates of Clostridium difficile infection. CONCLUSIONS The VHA National Antimicrobial Stewardship Initiative includes continuing education, disease-specific guidelines, and development of example policies in addition to other highly utilized resources. While no specific ideal level of antimicrobial utilization has been established, the VHA has shown that improving antimicrobial usage in a large healthcare system may be achieved through national guidance and resources with local implementation of antimicrobial stewardship programs. Infect Control Hosp Epidemiol 2017;38:513-520.