Despite numerous advances in medicine and health care, the rates of antimicrobial resistance or drug resistant infections are increasing all over the world. They are expected to cause 10 million deaths annually by 2050, exceeding other major causes of death such as cancer and diabetes. Per a recent report by the Centers for Disease Control and Prevention, about 2 million infections occurring each year are caused by antimicrobial resistant bacteria and they result in about 23,000 deaths annually. Upon the recommendations of the Presidential Council of Advisors on Science and Technology, the White House released the National Action Plan for Combating Antimicrobial Resistant Bacteria in March 2015. US hospitals are now required by the Center for Medicare and Medicaid Services to have an antimicrobial stewardship program.
Last year, the CDC issued a checklist of Core Elements for Antimicrobial Stewardship in Hospitals that are essential to a successful program. The seven elements are:
- Leadership Commitment: Dedicating necessary human, financial and information technology resources
- Accountability: Appointing a single leader responsible for program outcomes. Experience with successful programs show that a physician leader is effective
- Drug Expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use.
- Action: Implementing at least one recommended action, such as systemic evaluation of ongoing treatment need after a set period of initial treatment (i.e. “antibiotic time out” after 48 hours)
- Tracking: Monitoring antibiotic prescribing and resistance patterns
- Reporting: Regular reporting information on antibiotic use and resistance to doctors, nurses and relevant staff
- Education: Educating clinicians about resistance and optimal prescribing
The obvious need of the hour is to reduce our antimicrobial (a.k.a. anti-infective, antibiotic) use. Against this backdrop, two recently published studies give us additional confidence that we can move the meter.
Study #1 is the Surveillance and Correction of Unnecessary Antibiotic Therapy (SCOUT) performed by Drs. Pablo Sanchez and Joseph Cantey in the Parkland Health and Hospital System neonatal intensive care unit, a 90-bed level III NICU with approximately 1400 admissions annually. Physician services are provided by the UT Southwestern Medical Center. After collecting and analyzing antibiotic usage data from October 2011 to November 2012, the study team implemented shorter duration of antibiotics for three conditions. They got buy-in from the neonatology faculty members for this initiative. They limited duration of empiric antibiotics for suspected infection to 48 hours using a ‘hard stop’ in the electronic medical record, and limited treatment duration for pneumonia and for culture-negative sepsis to five days each. In the 9-month intervention period from October 2013 to June 2014, there were no adverse safety outcomes for the neonates, and the overall antimicrobial usage reduced by 27%, from 343∙2 days of therapy per 1000 patient-days during the baseline period to 252∙2 days of therapy per 1000 patient-days (p<0∙0001). These data are shown in the picture for this blogpost. This study is impressive in that there haven’t been any prospective studies published on antimicrobial stewardship in neonatal intensive care units prior to this. Most of these newborn are low birth weight and very low birth weight and they have very complex medical conditions. The study was funded by the Gerber Foundation. (Reference: Reducing unnecessary antibiotic use in the neonatal intensive care unit (SCOUT): a prospective interrupted time-series study. Cantey JB, Wozniak PS, Pruszynski JE, Sánchez PJ. Lancet Infect Dis. 2016 Jul 21. [Epub ahead of print])
Study #2 is the Use of Behavioral Economics to Improve Treatment of Acute Respiratory Infections (BEARI). This cluster randomized controlled trial was done by Dr. Jason Doctor and team with funding by the National Institute on Aging. They enrolled 47 primary clinics from Northwestern University, Brigham and Women’s Hospital, Massachusetts General Hospital, AltaMed Health Services in Los Angeles and The Children’s Clinic in Long Beach, CA. The condition targeted was acute respiratory infections that generally do not require treatment with antibiotics. They used three interventions in the study – 1. ‘Suggested alternatives’ wherein the electronic medical record had a pop up alert suggesting alternatives to antibiotics, 2. ‘Accountable justification’ wherein the clinicians were asked to provide a free-text justification for why they want to prescribe an antibiotic, and 3. ‘Peer comparison’ in which the clinicians got email reports of how their antibiotic prescribing patterns compared with those of their peers. They randomized 248 clinicians to receive 0, 1, 2, or 3 interventions for 18 months between November 2011 and April 2014. They found that the average antibiotic prescribing rate reduced significantly from 24.1% at the beginning of intervention to 13.1% at the end of intervention. The decrease was most pronounced for two of the interventions – accountable justification and peer comparison, and the decrease was statistically not significant for the intervention in which alternatives were suggested. The most impressive aspects of this study are that it was well grounded in behavioral theories, and that it was done in the outpatient setting where it is more challenging to implement antimicrobial stewardship interventions. The study team compensated each clinician $1200 for participation in the study, which may dilute the generalizability of findings. (Reference: Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial. Meeker D, Linder JA, Fox CR, Friedberg MW, Persell SD, Goldstein NJ, Knight TK, Hay JW, Doctor JN. JAMA. 2016 Feb 9;315(6):562-70.)