For decades, medical science has waged war against the bacteria that have long bedeviled mankind. That fight goes on, but it’s taken on an ironic new dimension. The antibiotics that gave medical providers the upper hand in battling infectious diseases have in many cases made the job more difficult.
The problem is widespread overprescribing of antibiotics. These medications save lives and limbs, but they can wreak havoc if they are administered indiscriminately or for too long a time. In such cases, antibiotics can wipe out bacteria in the gut that people need – opening the door to dangerous infections, like Clostridium difficile (C. diff) – and encourage the evolution of ever-more resistant strains that menace public health and require more powerful antibiotics that can cause separate health problems.
The threat is real, as increasing rates of C. diff in Colorado and elsewhere and outbreaks of highly resistant infections attest. It’s drawn intense attention from the Centers for Disease Control and Prevention and the White House. That’s not surprising, considering that the total economic burden of treating patients with antibiotic-resistant infections has been estimated at between $20 billion and $35 billion. A recent study from the CDC and the Pew Charitable Trust concluded that one in three antibiotic prescriptions written is unnecessary.
The concern is shared by state public health officials and medical providers across the country, including a collaborative of 27 hospitals in Colorado whose representatives gathered at University of Colorado Hospital May 6. They convened for a Colorado Hospital Association (CHA) conference on antimicrobial stewardship – the safe and responsible administration of antibiotics.
The group forms CHA’s “Antimicrobial Stewardship Collaborative,” which came together a year ago. The effort focuses on raising the awareness in hospitals of the importance of managing antibiotic prescribing and finding ways to make antibiotic stewardship a part of everyday clinical practice.
In its first year, the collaborative concentrated on antibiotic prescribing for urinary tract infections (UTIs), skin and soft tissue infections, and on more accurate diagnosis of UTIs – an important part of preventing overprescribing of antibiotics.
The stewardship collaborative focused in its first year on reviewing infection cases, gathering data, and sharing information between hospitals, said Gerry Barber, RPh, MPH, coordinator of Pharmacy and Therapeutics and Clinical Pharmacy Services at UCH. Barber and Heidi Wald, MD, MPH, vice chair for quality for the CU School of Medicine’s Department of Medicine, serve on the steering committee for the collaborative.
In the first year, the member hospitals shortened median use of antibiotics for skin infections by one day. “We’re now beginning to show the fruits of our labor,” Barber said.
A single-day, across-the-board decrease in the duration of antibiotic administration can have a significant effect on public health, Barber said.
“If you think about all the patients admitted to this hospital, let alone all of them in Colorado, one less day of antibiotic therapy means hundreds, if not thousands, fewer days patients are on these medications,” he said. Taking those antibiotics out of the hospital environment, he added, reduces the opportunities for bacteria to adapt and become antibiotic-resistant, he added.
“It’s axiomatic that if you treat one patient with antibiotics, you’re treating all patients, because you are changing the environment in which bacteria live,” Barber said.
The collaborative will sharpen its focus on managing antibiotic treatment of UTIs, Barber added. “We clearly have room for improvement in that area,” he said.
Looking for leadership
A key for hospitals looking to develop a strong antibiotic stewardship program is leadership that provides expertise and education, drives collection and reporting of data, and makes providers accountable for their clinical decisions, said Arjun Srinivasan, MD, of the CDC. Srinivasan gave conference attendees a national update on antimicrobial stewardship.
Large hospitals, especially teaching institutions, are more likely to have these “core elements” of stewardship in place, Srinivasan said. At UCH, for example, Norihiro Yogo, MD, director of antimicrobial stewardship, and Matt Miller, PharmD, an infectious disease pharmacy specialist, have developed guidelines for treating common infections, including those of the skin and UTIs. But Srinivasan noted that some 100 critical-access hospitals that serve mainly rural areas across the United States incorporate all the necessary core elements of a strong stewardship program.
“Smaller hospitals are finding ways to get this done,” Srinivasan said.
One of those paying close attention to managing antibiotics is Rio Grande Hospital, a 17-bed facility in Del Norte, Colo. Candice Allen, RN, MS, the hospital’s chief nursing officer, joined a four-provider “stewardship panel” moderated by Srinivasan at the May 6 meeting. Allen said Rio Grande’s 13 providers, including its nurses, “jumped on board” to join the work of the collaborative.
“I was surprised at how well everyone embraced it,” Allen said. She noted that Rio Grande’s stewardship strategy centers on collecting data that helps providers understand “what we are doing and why” and developing clinical pathways and order sets to guide antibiotic prescribing.
The work also includes explaining to patients why it’s okay not to order tests, such as urine cultures for asymptomatic bacteriuria – the presence of bacteria in the urine without symptoms or signs of a UTI. Treating bacteriuria with antibiotics is an important contributor to antibiotic resistance.
“We are comfortable telling patients, ‘It’s okay that we don’t do a culture. You’re asymptomatic,” Allen said.
The collaborative has extended its work to other providers. For example, 25-bed Southwest Memorial Hospital in Cortez, Colo., part of the Southwest Health System (SHS), has joined with the CHA to help eight long-term care facilities in the area develop antibiotic stewardship programs, said Marc Meyer, RPh, a pharmacist and infection preventionist with SHS.
The project included a day-long conference in late March with presentations by Wald and a CDC medical epidemiology expert. “We’ve challenged ourselves to think outside of the walls of the hospital and get into the community,” said Meyer.
Time to get on board
It’s vital that hospitals, whatever their size, focus attention on how they administer antibiotics, the conference participants agreed. For one, Colorado has seen an increase in the incidence of C. diff, a gut-dwelling, toxin-producing bacterium that causes severe diarrhea and colitis and is especially dangerous to already weakened patients, such as the elderly and the immunocompromised. Overprescribing antibiotics opens the door to C. diff by wiping out “good bacteria” and allowing the rogue intruders to take over.
Wendy Bamberg, MD, of the Colorado Department of Public Health and Environment, noted that there were 3,600 cases of C. diff. in the Denver metro area alone each year from 2010 to 2014.
“The number is trending up,” she said. “The Antibiotic Stewardship Collaborative is an important part of C. diff infection prevention in this state.”
Hospitals that solidify their stewardship programs now will not only protect their patients and public health; they also will be ahead of the health care curve, Srinivasan added. He noted that the Centers for Medicare and Medicaid Services has proposed that antibiotic stewardship programs be a “condition of participation” for long-term care facilities. The same requirement could be coming for hospitals, Srinivasan said. If it does, the Joint Commission, which “echoes” CMS regulations, would likely include stewardship programs in its accreditation criteria, he said.
“CMS is signaling to the world that it is considering antibiotic use as a condition for payment,” Srinivasan said. “It is putting a marker down.”
Despite the progress and the urgency of continuing it, much work remains to be done to change a health care system that continues to rely heavily on antibiotics in patient care – often justifiably so, Barber said.
“The biggest challenge is changing practice,” he said. “We have a wide group of providers and they all want to do what is best for the patient. But we have reached a critical point in the number of antibiotics we give patients. We now often need broader-spectrum, more expensive and more toxic agents. We need stewardship programs that minimize the collateral damage that can be caused by antibiotics.”