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Appaneal et al.

Conclusions
In conclusion, this study identified several facilitators and
barriers to antibiotic stewardship as perceived by antibiotic
stewardship pharmacists in the VA New England Healthcare
System. Interviews revealed the importance of a supportive
organizational culture, protected time for antibiotic stewardship, and a cohesive organizational structure. Our findings
support the CDC core elements, in particular the importance
of leadership commitment in the creation of a culture that
not just supports antibiotic stewardship but also ensures
staff are given sufficient time for antibiotic stewardship
efforts. Strategies focused on continuing to build a supportive culture, and 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 health care
outcomes.
Authors' Note
The study protocol and informed consent document were approved
by the Institutional Review Board and the Research and
Development Committee of the Providence Veterans Affairs
Medical Center (approval number 2015-030). All participants provided informed consent before they participated in interviews.
Interview transcripts are not publically available or on request from
the corresponding author to protect the identity of the interview
respondents and their facilities. The views expressed are those of
the authors and do not necessarily reflect the position or policy of
the United States Department of Veterans Affairs. This material is
based upon work supported, in part, by the Office of Research and
Development, Department of Veterans Affairs.

Author Contributions
HA, KL, and DD developed the study design. HA recruited the participants. ML and TT conducted interviews. HA transcribed the
interviews. HA, ML, and TT performed the analyses. All authors
contributed to paper writing and have read and approved the final
manuscript.

Acknowledgments
We would like to acknowledge Jennifer M. DeAngelis, BA, the
Program Coordinator of the Rhode Island Infectious Diseases
Research Program (RIID), College of Pharmacy, University of
Rhode Island, Kingston, Rhode Island, for her assistance contacting
potential participants, collecting informed consent, and scheduling
interviews. We also would like to thank all of the pharmacists who
participated in the telephone interviews.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: Haley
Appaneal is supported in part by a Career Development Award,

Department of Veterans Affairs, and has received research funding
from Merck. Megan Luther is supported by a fellowship with the
Department of Veterans Affairs, Office of Academic Affiliations,
and has received research funding from Merck and Pfizer. Tristan
Timbrook has received honorarium for speaking and/or consulting
for BioFire Diagnostics and GenMark Diagnostics. David Dosa is a
Veterans Affairs government employee. He has received research
funding through the VA, The West Foundation, and National
Institutes of Aging. Kerry LaPlante has received research funding
or acted as a scientific advisor for Allergan, Bard, Merck, Ocean
Spray, Pfizer, and The Medicines Company. The funding source
did not have any involvement in the collection, analysis, or interpretation of data; in the writing of the report; or in the decision to submit the article for publication.

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