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Size Matters in Antibiotic Overuse

 |  By cclark@healthleadersmedia.com  
   March 06, 2014

Smaller hospitals appear to be more often guilty of giving patients antibiotics they don't need. Help may be on the way from the CDC.

This week's news that far too many hospitals give patients antibiotics they don't need—with prescription error rates as high as 40%—illustrates the urgent need for the CDC's "seven critical components" stewardship program.

Between 20% and 50% of the antibiotics given to patients in hospitals are either unnecessary or inappropriate. The Centers for Disease Control and Prevention director, Tom Frieden, MD, is worried the nation needs to "step back from the brink" of having no drugs to treat resistant bacteria.

But lest we lose all the drugs in our quiver, and resistant bacteria and Clostridium difficile toxins spiral out of control to kill us all, there may be strategic ways to tackle the problem where it lives very soon.

The new CDC report indicates that variation in prescribing practices is enormous, with some hospitals prone to give antibiotics as much as three times more often than other hospitals, despite a similar patient mix.

So it's not all hospitals and all doctors flagrantly ignoring good antibiotic stewardship practices. All we need now is to determine which hospitals and which doctors need an aggressive intervention, zoom in to reeducate their teams, and change prescribing protocols. Simple—well, probably not.

Size Matters

But here's a clue. Is it possible, I wondered, that doctors who aren't observing good prescribing practices are more likely located in smaller, perhaps rural, or critical access hospitals? Might these facilities lack access to rapid, sophisticated lab equipment to identify the type of bugs their patients bring in?

That's exactly the question the CDC is asking too, says Arjun Srinivasan, MD, CDC medical epidemiologist and associate director for the agency's Healthcare Associated Infection Prevention Programs. There's strong indications that's where a chunk of the problem might lie.

"That's what we've seen from some studies," Srinivasan confirms. "Just yesterday someone sent me an abstract presented at a meeting which actually showed that the rates of antibiotic use were somewhat higher in small hospitals compared to larger hospitals. There's a lot we have to learn about what underlies this variation."

Srinivasan sent me the abstract, authored by clinicians at Ascension Health, a St. Louis, MO-based system with more than 80 hospitals in 21 states.

It's titled "Does Size Matter? Systemwide Variation of Antimicrobial Utilization" and features a review of antibiotic prescribing practices at 69 Ascension hospitals. This team, too, found significant variation in use of antibiotics across the Ascension system.

But counterintuitively, they found that the lower the "case mix index," or severity of illness at a particular hospital, and the smaller the hospital in terms of number of beds, the more antibiotics were used on patients and the more money was spent on the cost of those drugs.

Less sick patients = more antibiotics? Smaller hospital = more antibiotics? Yes, you got that right.

"Likely smaller hospitals do not have as robust of an antimicrobial stewardship program as larger hospitals," the authors write. "Largest hospital: very strict control on antibiotics with very active pharmacy and Infectious Diseases physicians involvement."

For example, at one of the smallest hospitals in the study, with 68 beds, the average use of antimicrobials per patient day was 1.07, compared with an 804-bed hospital where the average use per patient day was 0.34.

In an e-mail yesterday, one of the poster authors, Ascension pharmacist Roy Guharoy, elaborates:

"Our hypothesis was hospitals with higher acuity (aka case mix index) should use more antibiotics," he writes. "But our findings were different and found that smaller hospitals with lower acuity use more antibiotic than hospitals with higher acuity.

"We also found huge practice variances among the hospitals. The variation may be due to limited resources or lack of expertise or teamwork between the stakeholders."

Guharoy added that the Ascension research documented several factors associated with higher antibiotic use at smaller hospitals:

  • Lack of awareness on judicious antibiotic use
  • Lack of teamwork among pharmacists and physicians
  • Lack of a formal process on appropriate indications for broad spectrum agent use
  • Lack of prospective monitoring on continuation of broad spectrum agent use, such as de-escalation of use after negative result from culture and sensitivity testing
  • Lack of resistance trend monitoring and making appropriate process changes to reduce resistance.

Obama to the Rescue

This is where President Obama's proposed FY2015 budget comes in.

A line item would double the CDC's funding to combat antibiotic resistance, with $30 million per year over five years for the Detect and Protect Against Antibiotic Resistance. The initiative would "identify the sources of emerging infectious diseases faster, determine whether microbes are resistant to antibiotics, and study how microbes are moving through a population."

The initiative has a special effort to help hospitals and other healthcare facilities, including small rural hospitals, by establishing a five-region resistance laboratory network, says Abbigail Tumpey, associate director for the CDC's Communications Science.

The idea is that these labs would have "reference" capable technology similar to the gold standard equipment the CDC has, so the hospital could much more quickly find out what drug the patient's bacteria might be susceptible to. Tumpey says that most hospitals' labs "do not have every antibiotic drug included in their susceptibility panels."

In some cases, "the hospital may not be sure what type of resistance the patient has" unless it sends the sample back to the CDC, she says.

The budget proposal include funding for prevention collaboratives to stimulate cooperative efforts in communities to track resistant strains of bacteria, for example within nursing homes, long-term care facilities, and hospitals.

Problematic Prescribing Practices

Srinivasan emphasizes that the issue of hospital practices is complicated. "There's a lot we still have to learn about what underlies this variation," he says.

But the CDC is narrowing in on where the problem lies within hospital workflows. There are two major weaknesses, he says.

First, many clinicians fail to order cultures to properly identify a bacterial infection, which would enable them to prescribe an effectively targeted antibiotic. "There's obvious room for improvement there," he says.

What too often happens is that doctors start vancomycin because "they're worried a patient has a methicillin-resistant staph aureus infection or MRSA. However, recommendations are that if you don't recover MRSA from the culture results, that's a good indication the patient does not have MRSA, and many experts would say that's a good time to stop therapy with vancomycin.

"But what we saw in our analysis is that there is a very large number of patients who had vancomycin started initially, had cultures obtained, but then three days later the patients were still on vancomycin, even though the culture results did not reveal MRSA.

"But we also know that there are times when patients are started on antibiotics, but there was no evidence of a patient having symptoms of infection. For urinary tract infections, guidelines tell us that before you treat a patient for a urinary tract infection, they should have both bacteria in their urine and some symptoms that go along with a diagnosis."

In the CDC study, he says, "we saw a large number of instances where there was bacteria in the urine—so half of the equation was there—but there was no evidence the symptoms were present."

A Condition for Hospital Accreditation

I asked Srinivasan why antibiotic stewardship practices don't already exist in all hospitals. Doesn't the Joint Commission require such programs as a condition for accreditation?

He replied, "No, they do not."

But shouldn't they? Srinivasan says, "That's an important area for more discussion, and something we're interested in talking about. Certainly the Centers for Medicare and Medicaid Services recognizes the importance of the need to improve antibiotic use, and we are engaged in discussions with them for different options to make that a reality."

Hmmm. Perhaps a pay for reporting measure is down the road. Something like, "Hospital always pauses antibiotic prescription after 48 hours to determine drug appropriateness. Yes? No?" Readers, what do you think?

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