Antibiotics reduce deaths from infectious bacterial diseases and are important adjuncts to modern medical advances like surgery, transplants and cancer therapy. However, antibiotic usage comes with a serious and growing threat to our nation’s health and economy – antibiotic resistance.
Like no other drug, antibiotic usage in one patient can compromise its efficacy in other patients. Antibiotic resistance causes:
- More than 2 million illnesses and 23,000 deaths per year in the United States, according to the Centers for Disease Control and Prevention (CDC)
- Approximately $20 billion in excess direct health care costs
- A seven- to 10-fold increased risk of patients developing Clostridium difficile; accounting for 453,000 infection cases and 15,000 deaths annually; plus $1 billion in excess direct health care costs and readmissions
- 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
- An increasing body of evidence linking antibiotic use to chronic disease, due to disruption of the microbiota and microbiome
Inappropriate antibiotic prescribing is the most important modifiable risk factor for antibiotic resistance. The outpatient setting accounts for more than 60 percent of antibiotic expenditures for humans in the United States. Several studies have confirmed that about half of antibiotic prescriptions are inappropriate in terms of selection, dosing, duration and/or unnecessary prescribing.
The CDC ranks Arkansas sixth highest in the nation in the rate of antibiotic outpatient prescriptions dispensed with 1,155 antibiotic prescriptions per 1,000 people, compared to the national average of 835.
The White House released the National Action Plan for Combating Antibiotic Resistant Bacteria in March 2015. Goals include reducing inappropriate outpatient antibiotic usage by 50 percent and a 20 percent reduction in prescribing antibiotics to hospital inpatients by 2020.
The CDC is actively working to combat antibiotic resistance. Hospitals, nursing homes and other health care settings are engaging in antibiotic stewardship activities, including measuring and improving the efficacy of antibiotic prescribing, minimizing misdiagnoses or delayed diagnoses leading to underuse of antibiotics, and ensuring selection of the right drug, dose and duration.
The CDC has developed sets of core elements for antibiotic stewardship for hospitals and nursing homes that include checklists for clinicians and facilities. These elements are intended for physicians, physician assistants, nurse practitioners and dentists in primary care clinics, emergency rooms, health care systems, outpatient specialty and subspecialty clinics, retail and urgent care clinics and dental clinics. The Joint Commission recently adopted antibiotic stewardship standards for hospitals, effective January 2017, that align with the CDC’s core elements.
The CDC’s Core Elements are:
- Commitment: Demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety.
- Action for policy and practice: Implement at least one policy or practice to improve antibiotic prescribing, assess its effectiveness and modify as needed.
- Tracking and reporting: Monitor antibiotic prescribing practices and offer regular feedback to clinicians, or have clinicians assess their own prescribing practices.
- Education and expertise: Provide educational resources and expertise to clinicians and patients on antibiotic prescribing.
In Arkansas, the Arkansas Hospital Association, Arkansas Association of Health-System Pharmacists and the Arkansas Department of Health are addressing the problem with their Pharmacist-Led Collaborative. This collaboration created a shared learning community of 22 hospitals that have established the core elements of an antimicrobial stewardship program in their facilities.
There is no one-size-fits-all stewardship program because each facility is different in terms of size, location and resources. Here are four key elements to consider:
- Implement an antibiotic stewardship program slowly. It can feel overwhelming so start small and identify one thing to do now. For example, display commitment posters in your clinic lobby and exam rooms. They serve as a reminder of accountability and are great conversation starters 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. Many patients diagnosed with common bacterial infections in doctors’ offices, EDs and hospital-based clinics are not receiving the most appropriate antibiotic. In 2010 and 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 treated with antibiotics received recommended first-line drugs based on established practice guidelines.
- Implement a policy of “watchful waiting” when appropriate. Antibiotics are frequently prescribed for noninfectious or nonbacterial syndromes. Provide symptomatic relief with a clear plan for follow up if infection symptoms do not improve. Delaying antibiotic prescriptions is another evidence-based approach that can safely decrease antibiotic use when used in accordance with clinical practice guidelines.
- Track and report antibiotic This is key to guiding your practice and measuring improvement. Potential sources of data include existing quality measures data, automatic electronic medical record extraction or manual periodic chart review. Providing individual antibiotic prescribing reports is an effective way to ensure adherence to evidence-based treatment guidelines.
Antibiotic stewardship requires commitment to change and thoughtful efforts to improve outcomes. It continues to be one the most important strategies in fighting antibiotic resistance, and keeping our patients safe and our communities healthy.
More information on core elements at: https://www.cdc.gov/mmwr/volumes/65/rr/rr6506a1.htm