With one CDC official saying "we have truly entered a post-antibiotic era," the agency is urging hospitals to develop effective antibiotic stewardship programs to save lives and money.
Arjun Srinivasan, MD |
With half of hospitals thought to lack an antibiotic stewardship program to prevent emergence of drug-resistant bacteria, the American Hospital Association has teamed up with the Centers for Disease Control and Prevention to help hospitals start these programs.
"We know that antibiotic overuse is a major contributor to huge threats to patient safety in our hospitals," the CDC's Arjun Srinivasan, MD, said during an AHA "Town Hall" webcast last week.
"We're running out of antibiotics to treat common infections, and we're not going to get new ones anytime soon," he said. A lot of hospital antibiotic use is "either unnecessary or in some cases, suboptimal….and we know there's tremendous room for improvement," he added.
The CDC estimates that two million times a year in the U.S., a patient gets infected with a bacterial strain that is resistant to at least one of the first line of antibiotics, leading to 23,000 deaths.
On top of that, Srinivasan said, 250,000 people each year come down with Clostridium difficile, which occurs when antibiotics kill normal healthy bacteria that would otherwise keep it in check. Of these, 14,000 die.
CRE, or carbapenem-resistant enterobacteriaceae, is now resistant to all first-line drugs and some strains are resistant to all drugs. "For this subset of patients, we have truly entered a post-antibiotic era; we have entered a time when we have to stand helplessly by and hope these patients get better on their own."
But many will not. When CRE gets into the bloodstream, mortality is 50%."You begin to get a sense of the magnitude of the problem antibiotic overuse is creating," Srinivasan said.
Deadly CRE Infection Spreading Fast in Hospitals
"Half of all hospitalized patients will get an antibiotic at some point in their hospital stay," he added.
Antibiotic stewardship programs are simply systems to make sure each patient "only gets the right agent at the right dose for the right duration," he explained.
Size Matters in Antibiotic Overuse
Some ways hospitals can improve, Srinivasan suggested, include more diligence in treating urinary tract infections. In a CDC hospital study several years ago, "in about 40% of the cases there was an opportunity to improve…either through obtaining a culture before therapy was started or not giving an antibiotic to a patient who did not appear to have an infection," he said.
Plus, hospitals that develop an effective antibiotic stewardship program can save money.
The University of Maryland Medical Center, provides a great and "dramatic" example, Srinivasan said. The hospital system saved more than $1 million the year after implementing its stewardship program. It suspended the program, "and saw an almost immediate increase of about one million dollars a year in antibiotic expenditures."
Scott Malaney, president and CEO, Blanchard Valley Health System, a 150-bed hospital and a 25-bed critical access facility in Findlay, OH, gave some tips on how his hospital developed such a program, which it began a decade ago and formally launched in 2009.
Antibiotic Steward Strategies
Blanchard's program includes:
- Daily reviews of all antibiotic orders by pharmacists, and review with infectious disease specialists at formal "lunch bunch" meetings, where every patient on an antibiotic is reviewed for appropriateness.
- Diligence in checks for emergence of resistance in strains of bacteria within the hospital.
- Medication reconciliation by pharmacy staff in the emergency department on all patients who are about to be admitted. This also helps the hospital learn about community physician practices' prescribing habits, where "there's clearly an opportunity to improve" on inappropriate prescribing.
- Giving appropriate antibiotics to patients undergoing surgical procedures.
These initiatives have resulted in "drastically reduced" use of expensive antibiotics. "This year there's been zero use" because a team works with physicians to find other agents," Malaney said. "We do not mandate physician behavior; we recommend, coach, and cajole."
Another trick at Blanchard Valley that was at first an experiment, was putting the broad-spectrum antibiotic ceftazadine, "on the bench" after its effectiveness started to wane.
"We restricted its use for one year, and a year later, brought it back on and it began to work. As a physician or scientist, you would know that's possible. But for someone like me, I thought that's was really interesting, that given some restriction with time, a well-known drug…can be used again and used very effectively."
Hard Stop
The CDC's Srinivasan says hospitals should consider having hard stop policies on antibiotics. "The phrase we like to use at the CDC is the idea of an antibiotic 'time-out.' There should be a deliberate pause.
"We know oftentimes when patients are admitted and are very sick, and it's not clear what's going, but there's a suspicion of infection and a need to treat that very quickly.
"So we want a careful assessment before antibiotics are started, of course. But that 'hard stop' opportunity really comes after about 48 hours or so… hopefully there are culture results back, results from radiology, and most important, the clinical evaluation that has been refined over those two-day period."
That, he said, is a great time for a reevaluation to ask if the patient really had an infection, and if so are they on the right antibiotic. Let's look at the culture results and make sure."