Hospitals can meet antibiotic stewardship rules without a full-time ID hire

When a hospital partners with Access TeleCare on antimicrobial stewardship, Ashley Selby starts by asking where it needs the help. Does it already have a pharmacist in place and mainly need physician oversight, or is the program still being built from the pharmacy work up? The answer decides how much of an infectious diseases team the hospital actually buys, and whether it needs a full-time hire at all.

Selby, who says she is currently the only pharmacist on the team, described the model in a MarketScale Studio segment. Antimicrobial stewardship, the organized effort to make sure each patient gets the right antibiotic at the right dose for the right length of time, has been around for years. What changed is who is allowed to lead it, and from where.

Since January 1, 2023, every Joint Commission-accredited hospital and critical access hospital, the federal designation for the smallest rural hospitals, has answered to a revised antibiotic stewardship standard, MM.09.01.01, set out in the commission's R3 Report of June 2022. The Centers for Disease Control and Prevention (CDC) refreshed its Core Elements page for hospital stewardship in September 2025, and in October 2025 a Vanderbilt University Medical Center team published a review of tele-stewardship strategies in Antimicrobial Stewardship & Healthcare Epidemiology. The standard is now in its third year, and the research on delivering it remotely is catching up.

An FTE is a full-time equivalent, one person's full working schedule. Selby's point is that the standard does not price stewardship in those units, and a telehealth contract does not have to either.

The rule names a qualified leader, not a full-time employee

Joint Commission Standard MM.09.01.01 requires a qualified physician and/or pharmacist to lead stewardship, and lets committee members take part remotely. The June 2022 R3 Report lays out 12 elements of performance (EPs), the specific requirements a surveyor checks under the standard. Element 11 says the governing body appoints a physician and/or pharmacist who is qualified through education, training or experience in infectious diseases or antibiotic stewardship, on the recommendation of medical staff and pharmacy leadership.

The federal rule reads almost the same way. The Medicare Condition of Participation at 42 CFR 482.42(b), one of the conditions a hospital must meet to bill Medicare, as posted by Cornell Law School's Legal Information Institute, requires the governing body to appoint one or more individuals qualified through education, training or experience in infectious diseases and/or antibiotic stewardship as program leader. The same section says the program must reflect the scope and complexity of the services the hospital provides.

Neither text says the leader must be an employee, and neither says full time. For a hospital administrator, that is the opening: the rule measures qualification and accountability, not head count.

The money still has to be real. Element 10, new in the 2023 revision, requires the hospital to allocate financial resources for staffing and information technology to support the program, according to the R3 Report. Whether that budget line pays a salary or a contract is left to the hospital.

Selby's wording tracks the standard with one difference. The Joint Commission and the federal rule say physician and/or pharmacist; she says physician and, ideally, pharmacist. The federal text, as Cornell posts it, also requires that the appointment rest on recommendations from both medical staff leadership and pharmacy leadership, so both professions have a voice in who leads even when only one holds the title.

Remote participation is written into the committee rule

Element 13 of the standard requires a multidisciplinary committee to oversee the program, and the commission's note says the committee may include part-time or consultant staff and that participation may occur on site or remotely, per the June 2022 R3 Report. The note lists who can sit on that committee: medical staff, pharmacy, infection prevention, nursing, microbiology, information technology and quality improvement.

That language is narrower than it first appears. The remote wording sits under the committee element, not under Element 11, which governs the leader appointment, and the R3 Report does not say in so many words that the appointed leader may work off site. Professional guidance fills part of that gap: according to a May 2021 explainer on ID Stewardship, written by three infectious diseases pharmacists, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) stewardship guidelines stress ID pharmacist and physician co-leaders and treat telehealth participation as an acceptable alternative to in-person expertise.

Selby's reading is practical. The pairing is what the hospital must show, and the pairing can be assembled from what the hospital already has plus what the contract adds. A hospital with a stewardship pharmacist on staff may need only the physician oversight, she says, while a hospital starting from scratch needs both.

More than 2,380 pharmacists hold the ID board certification

The Board of Pharmacy Specialties counts more than 2,380 board-certified infectious diseases pharmacists nationally. The credential, BCIDP, is the board's specialty certification for pharmacists who lead and optimize antimicrobial stewardship and manage patients with or at risk for infectious diseases, as the board describes it on its certification page.

The standards do not require BCIDP. Both the Joint Commission element and the federal rule accept education, training or experience, which leaves room for a pharmacist who learned stewardship on the job. The ID Stewardship authors describe what that often looks like in practice: clinical pharmacists without infectious diseases training are handed the regulatory responsibility for stewardship without the tools or resources to carry it.

The pipeline behind the shortage is narrow. According to the same May 2021 ID Stewardship explainer, the available PGY-2 infectious diseases pharmacy residencies, the second-year postgraduate training programs that produce ID specialists, do not meet demand, and smaller hospitals find it increasingly difficult to obtain funding for full-time infectious diseases specialist positions. The authors add that antimicrobial overuse and multidrug-resistant organisms are rising in community hospitals at rates equal to or higher than at academic centers.

The physician side is harder to count. The Board of Pharmacy Specialties keeps a public tally of its certificants, and no equivalent figure for infectious diseases physicians serving small hospitals appears in the standards or guidance that govern these programs. Selby's description of physician medical directors each covering different hospitals is itself a response to that scarcity.

CDC's framing points the same direction. Its Core Elements of Hospital Antibiotic Stewardship Programs, first issued in 2014, updated in 2019 and supplemented with implementation priorities in 2022, apply to every hospital regardless of size, and the agency publishes separate guidance on putting them in place at small and critical access hospitals, according to the page it updated in September 2025. Under the accountability element, the agency calls for a leader or co-leaders to be appointed.

One pharmacist, several hospitals, programs at different stages

Each of those programs looks a little different, Selby says. Some are early in their life, so the team is building them from the pharmacy work up, and she works closely with the on-site pharmacists to educate them as the program grows. What the team learns at one hospital it carries to the next, hospital by hospital rather than all at once.

The ID Stewardship authors sort tele-stewardship programs into three working models. In a fully remote model, an off-site specialist performs preauthorization, approving certain antibiotics before they are dispensed, or prospective audit with feedback, reviewing active orders and recommending changes, through a secure web application, a phone hotline, a shared electronic health record or a shared decision support tool. In an integrated model, the remote specialists and on-site clinicians meet by video at least weekly to review cases, and recommendations reach the prescriber either through the local pharmacist or directly.

The third, collaborative, model focuses on education, gap analysis, usage data and consults as needed, without day-to-day case review. Selby's description of building programs from the pharmacy work and educating on-site pharmacists reads closest to the integrated and collaborative models, with the mix adjusted to what each hospital has in place.

The standard asks for the same tools. Element 17 of MM.09.01.01 requires the program to implement one or both of two prescribing strategies, the first being preauthorization for specific antibiotics, according to the R3 Report. Element 16 requires the program to monitor antibiotic use as days of therapy per 1,000 days present or per 1,000 patient days, or to report use to the National Healthcare Safety Network's Antimicrobial Use Option, and a day of therapy counts each antibiotic a patient receives on each day, so a patient on two drugs for five days contributes ten.

Outcome data is strong on process and silent on mortality

Intermountain Healthcare's telehealth team logged 2,487 physician interactions across 16 small community hospitals between November 2016 and April 2018. That figure comes from a SHEA review by James Cutrell of UT Southwestern Medical Center of a study by Vento and colleagues published in Open Forum Infectious Diseases in June 2021. The program combined a 24-hour advice phone line, eConsults, written consultations routed through the record, telemedicine video consults and stewardship surveillance from a centralized infectious diseases pharmacy team.

Set that against Selby's claim that a hospital may not need a full FTE. One centralized team covered 16 hospitals for roughly 18 months by the dates reported, with 35% of interactions by phone, 30% by eConsult and 35% by telemedicine, according to the review. Bacteremia, bacteria in the bloodstream, and Staphylococcus aureus bacteremia in particular, was the most common reason for consultation, and about a third of consults led to a referral for in-person follow-up in an infectious diseases clinic.

The antibiotic numbers moved. Across eight stewardship projects the program supported, the review reports significant reductions in high-use drugs including vancomycin, meropenem and fluoroquinolones. For a hospital pharmacy director, those are the drug classes a surveyor will ask about under Element 16.

The broader literature is consistent, with one limit. A systematic review and meta-analysis of 14 studies in the Journal of Telemedicine and Telecare found telehealth-based stewardship was associated with a pooled odds ratio of 2.78 for adherence to guidelines, meaning the odds of guideline-concordant prescribing were close to three times higher, and a pooled odds ratio of 0.60 for antimicrobial prescription rate, with the strongest reduction in lower respiratory infections. Days of therapy fell by a pooled mean of 47.12, with the largest effect in acute care settings.

Mortality did not change significantly, with a pooled odds ratio of 1.20 that did not reach statistical significance, according to the same meta-analysis. The authors concluded that telehealth stewardship improves guideline adherence and reduces prescribing without significantly affecting patient clinical outcomes, and recommended wider use after further studies. A hospital building its business case can promise cleaner prescribing and lower days of therapy; it cannot yet promise fewer deaths.

Where the model is harder to copy

The SHEA review attaches a caution to Intermountain's results. Replicating the program will be harder, it says, for health systems with fewer dedicated telehealth and infectious diseases resources, and for small community hospitals without an existing link to a large health system. Intermountain's 16 hospitals sat inside its own region, with the system's telehealth infrastructure already in place.

That unaffiliated hospital is the one Selby is describing when she talks about client hospitals around the nation, met where they are. A contracted team supplies the infrastructure and the specialists the system-affiliated model assumes. The October 2025 review by Matthew James Peworchik, Ritu Banerjee and Sophie Katz of Vanderbilt set out to catalogue tele-stewardship strategies and their application to the rural outpatient setting, a sign the field is now asking how far beyond the hospital walls the same approach can reach.

For a hospital leader checking the program against the standard, the questions follow from the elements. Who is named in the governing body's appointment under Element 11, and what education, training or experience qualifies that person. Whether the committee charter permits remote participation under Element 13, and whether the Element 10 budget line for staffing and technology actually exists.

The benchmark Selby sets is an infectious diseases physician and pharmacist pair leading stewardship at every hospital in the country. The measure the Joint Commission will read is days of therapy per 1,000 days present, and the drug classes Intermountain moved are the ones to watch first.