Antibiotics can produce miracles in transplant surgery, cancer therapy and in the fight against infectious bacterial diseases. However, antibiotic usage comes with a serious and growing threat to our nation’s health and security – antibiotic resistance. Some bacteria seem to be able to resist any antibiotic we throw at them and new antibiotics are not being developed fast enough. The only solution to this potential disaster is to more effectively use the antibiotics we have.

Like no other drug, antibiotic usage in one patient can compromise its efficacy in another. Antibiotic-resistant infections lead to more than 2.25 million illnesses, killing 23,000 to 38,000 Americans per year. According to the Centers for Disease Control and Prevention (CDC), antibiotic-resistance costs $20 billion in excess, direct health care costs. Patients receiving antibiotics have a seven- to 10-fold increased risk of developing Clostridium difficile infection (CDI). CDI alone accounts for 453,000 infection cases and 15,000 deaths annually; plus $1 billion in direct health care costs.

Antibiotics also cause adverse drug events leading to 142,000 emergency department (ED) visits per year; they are the most common cause of drug-related ED visits in children. Additionally, there is growing evidence linking antibiotic use to chronic diseases, caused by disruption of the microbiota and microbiome.

Clinicians are key to reducing resistance

As a clinician, you are the key to limiting antibiotic resistance. Several studies confirm that about half of antibiotic prescriptions are not appropriate in terms of selection, dosing, duration or unnecessary prescribing. Inappropriate antibiotic prescribing is the most modifiable risk factor for antibiotic resistance.  

The outpatient setting accounts for more than 60 percent of antibiotic expenditures for humans in the United States. The CDC ranks Arkansas sixth highest in the nation in the rate of antibiotic outpatient prescriptions dispensed – 1,155 antibiotic prescriptions per 1,000 people, compared to the national average of 835.

The Arkansas Foundation for Medical Care (AFMC), as part of its 11th Scope of Work for the Centers for Medicare and Medicaid Services (CMS), was recently awarded funding for help improve the appropriate use of antibiotics in the outpatient setting. AFMC quality staff will be working with 72 clinics that have committed to work on antibiotic stewardship by implementing the CDC’s outpatient core elements that were released in November 2016. Although clinic recruitment ended July 31, clinics may still join the TMF-QIN network online here.

The CDC’s resources

The CDC’s Outpatient Core Elements are:

  1. Commitment: Demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety.
  2. Action for policy and practice: Implement at least one policy or practice to improve antibiotic prescribing, assess its effectiveness and modify as needed.
  3. Tracking and reporting: Monitor antibiotic prescribing practices and offer regular feedback to clinicians, or have clinicians assess their own antibiotic prescribing practices.
  4. Education and expertise: Provide educational resources to clinicians and patients on antibiotic prescribing and ensure access to needed expertise on optimizing antibiotic prescribing.

Implementing a stewardship program

  • Do one thing now. An antibiotic stewardship program can start small and grow to fit your practice’s needs. For example, displaying commitment posters in your clinic lobby and exam rooms can serve as a reminder of your accountability as well as a great conversation starter for patient education. The CDC’s website includes commitment posters and numerous educational tools for patient education.
  • Use evidence-based diagnostic criteria and treatment recommendations. In 2011, U.S. prescribing data indicated that sinus infections, middle ear infections and pharyngitis accounted for 44 million antibiotic prescriptions each year. However, only 52 percent of patients with these infections and who were treated with antibiotics received recommended first-line drugs based on established practice guidelines.
  • Don’t prescribe antibiotics for viral, or noninfectious or nonbacterial symptoms, even when patients ask for them. When possible, include microbiology cultures when ordering antibiotics. Pay attention to dose and duration when writing prescriptions.
  • Reassess within 48 hours of starting the antibiotic, when you have the patient’s culture results. Adjust the prescription, if necessary. Stop the prescription, if indicated. This is especially important for hospital and nursing home patients.
  • Talk to your patients about appropriate antibiotic use. Provide them with symptomatic relief and a clear plan for follow up if infection symptoms do not improve.
  • Err on the side of caution and do not prescribe until lab results prove the efficacy of an antibiotic. Acting cautiously used to mean writing an antibiotic prescription. Thinking that “it can’t hurt and it might help” has now become potentially dangerous. Implement a policy for “watchful waiting,” when appropriate.
  • Delay antibiotic prescriptions. This is an evidence-based approach that can safely reduce antibiotic use when used in accordance with clinical practice guidelines.
  • Track and report antibiotic usage. This step is crucial in helping to guide your practice and measure progress. Potential sources of data include existing quality measures data, automatic electronic medical record extraction or manual periodic chart review. Providing individual antibiotic prescribing reports can be an effective way to ensure adherence to evidence-based treatment guidelines.

Since 2014, Arkansas hospitals have been working on antibiotic stewardship after the CDC released the Inpatient Hospital Core Elements for Antibiotic Stewardship Programs (ASP). The Joint Commission also adopted antibiotic stewardship standards for hospitals that were effective in January 2017. Their standards align with the CDC’s hospital core elements.

More recently, the Federal Office of Rural Health Policy will be adding antibiotic stewardship as a measure for critical access hospitals as part of the Medicare Beneficiary Quality Improvement Program, starting September 2018.

Stewardship over the prescribing and use of antibiotics requires a commitment to change and thoughtful efforts to improve outcomes. Antibiotic stewardship is one the most important strategies in fighting antibiotic resistance, keeping your patients safe, our communities healthy, saving health care dollars, and reducing the overall burden of antibiotic resistance.

For more information:

Visit The Society for Healthcare Epidemiology of America’s website.

Join the QIN-QIO Antibiotic Stewardship network at here.