Antibiotics have often been called a modern miracle for good reason as some argue that in a world without effective antibiotics, global life expectancy would drop to approximately 50 years.
William Rosen in his “Modern Cure: The Creation of Antibiotics and the Birth of Modern Medicine” says that in the 80 years or so since antibiotics became widely accessible to the public at large that not only have millions of lives been saved but they've helped create the pharmaceutical industry as we know of it today.
“While antibiotics may have been a success story like no other in the history of medicine, there are also downsides,” says ReAct, an international group that focuses on antibiotic resistance.
Paradise Lost? Misuse and Overuse of Antibiotics
The misuse and overuse of antibiotics are at the core of growing concern over antimicrobial resistance.
“New CDC data states more than half of antibiotic prescribing for selected events in hospitals was not consistent with recommended prescribing practices,” says the Center for Disease Control and Prevention (CDC).
The CDC found antibiotic prescribing was not supported in:
- 79 percent of patients with community-acquired pneumonia
- 77 percent of patients with urinary tract infections (UTIs)
- 47 percent of patients prescribed fluoroquinolone treatment
- 27 percent of patients prescribed intravenous vancomycin antibiotic
“Hospital prescribers and pharmacists can improve antibiotic prescribing by optimizing antibiotic selection, re-assessing antibiotic treatment when the results of diagnostic testing are available, and using the shortest effective duration of therapy,”
says the CDC.
Avoiding Unnecessary or Suboptimal Antibiotic Use
No one is saying that antibiotics are bad for the world, far from it, but it’s how they are being used is the question.
“Antibiotics have transformed the practice of medicine, making once lethal infections readily treatable and making other medical advances, like cancer chemotherapy and organ transplants, possible. Prompt initiation of antibiotics to treat infections reduces morbidity and saves lives, for example, in cases of sepsis,” says the CDC. “However, about 30 percent of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or suboptimal.”
Antibiotics also carry the risk of serious adverse effects, which occur in roughly 20 percent of hospitalized patients who receive them.
“Patients who are unnecessarily exposed to antibiotics are placed at risk for these adverse events with no benefit. The misuse of antibiotics has also contributed to antibiotic resistance, a serious threat to public health,” says the CDC. “The misuse of antibiotics can adversely impact the health of patients who are not even exposed to them through the spread of resistant organisms and Clostridioides difficile (C. difficile).”
Optimizing the use of antibiotics via Antibiotic Stewardship Programs (ASPs) is critical to effectively treat infections, protect patients from harm caused by unnecessary antibiotic use, and combat antibiotic resistance.
Hospital ASPs can increase infection cure rates while reducing:
- Treatment failures
- C. difficile infections
- Adverse effects
- Antibiotic resistance
- Hospital costs and lengths of stay
Core Elements for Hospital Antibiotic Stewardship Programs
While there is no single template to optimize antibiotic prescribing in hospitals, the CDC has identified priorities for the implementation of successful stewardship programs.
“Optimizing the use of antibiotics is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance. Antibiotic stewardship programs can help clinicians improve clinical outcomes and minimize harms by improving antibiotic prescribing,” says the CDC.
Core elements for hospital antibiotic stewardship programs include:
- Hospital Leadership Commitment: Financial, information technology, and human resources needed to be dedicated to the programs.
- Accountability: Leaders or co-leaders, such as a physician and pharmacist, need to be appointed who is responsible for program management and outcomes.
- Pharmacy Expertise: Appoint a pharmacist to lead implementation efforts to improve antibiotic use.
- Action: Implement interventions to improve antibiotic use such as:
o Prioritize actions and categorize them according to infection-based, provider-based, pharmacy-based, microbiology-based, and nursing-based interventions.
o Priority inventions include prospective audit and feedback, preauthorization, and facility-specific treatment recommendation.
o Emphasize the importance of actions focused on the most common indications for hospital antibiotic use: lower respiratory tract infection (e.g., community-acquired pneumonia), UTI, and skin and soft tissue infection.
o Use “antibiotic timeout” as a supplemental intervention, but not as a substitute for prospective audit and feedback.
o An increasing importance placed on the role that nurses in hospital antibiotic stewardship efforts can play.
- Tracking: Monitor antibiotic prescribing, the impact of interventions, and other important outcomes like C. difficile infection and resistance patterns.
- Reporting: Regularly reporting information on antibiotic use and resistance to prescribers, pharmacists, nurses, and hospital leadership.
- Education: Educate prescribers, pharmacists, and nurses about adverse reactions from antibiotics, antibiotic resistance, and optimal prescribing.
The Role of Microbiology Testing in Optimal Antibiotic Prescribing
Microbiology laboratory testing and staff can play a crucial role in optimal antibiotic prescribing.
The CDC says that microbiology laboratory staff can:
- Guide the proper use of tests and the flow of results as part of “diagnostic stewardship”.
- Help optimize empiric antibiotic prescribing by creating and interpreting a facility cumulative antibiotic resistance report or antibiogram. Laboratory and stewardship personnel can work collaboratively to present data from lab reports in a way that supports optimal antibiotic use and is consistent with hospital guidelines.
- Guide discussions on the potential implementation of rapid diagnostic tests and new antibacterial susceptibility test interpretive criteria (e.g., antibiotic breakpoints) that might impact antibiotic use. Microbiology labs and stewardship programs can work together to optimize the use of such tests and the communication of results.
- Collaborate with stewardship program personnel to develop guidance for clinicians when changes in laboratory testing practices might impact clinical decision-making.
- Hospitals, where microbiology services are contracted to an external organization, should ensure that information is available to inform stewardship efforts.
Facility-specific guidelines should address diagnostic approaches, such as when to send diagnostic samples and what tests to perform, including indications for rapid diagnostics and non-microbiologic tests (e.g. imaging, procalcitonin).
Common Infection-Based Interventions
More than half of all antibiotics given to treat active infections in hospitals are prescribed for three infections where there are important opportunities to improve use: lower respiratory tract infection (e.g. community-acquired pneumonia), UTIs, and skin and soft tissue infection.
“Optimizing the duration of therapy can be especially important because many studies show infections are often treated for longer than guidelines recommend and data demonstrate that each additional day of antibiotics increases the risk of patient harm,” says the CDC.
Interventions have focused on:
- Community-acquired pneumonia:
o Improving diagnostic accuracy
o Tailoring of therapy to culture results
o Optimizing the duration of treatment to ensure compliance with guidelines
- UTIs: Many patients who are prescribed antibiotics for UTIs have asymptomatic bacteriuria that generally does not need to be treated. Successful stewardship interventions focus on avoiding obtaining unnecessary urine cultures and avoiding treatment of patients who are asymptomatic unless there are specific reasons to treat. For patients who need treatment, interventions can focus on ensuring patients receive appropriate therapy based on local susceptibilities for the recommended duration.
- Skin and Soft Tissue Infection: Interventions have focused on ensuring patients with uncomplicated infections do not receive antibiotics with overly broad spectra (e.g. unnecessary coverage for methicillin-resistant Staphylococcus aureus (MRSA) and gram-negative pathogens) and prescribing the correct route, dosage, and duration of treatment.
Microbiology Labs and Provider-Based Interventions
Microbiology labs, in consultation with the stewardship program, can help implement the following interventions for common-based and other infections:
- Selective reporting of antimicrobial susceptibility testing results: Tailoring hospital susceptibility reports to show antibiotics that are consistent with hospital treatment guidelines or recommended by the stewardship program.
- Comments in microbiology reports: for example, to help providers know which pathogens might represent colonization or contamination.
“Experts suggest that daily reviews of antibiotic selection, until a definitive diagnosis and treatment duration are established, can optimize treatment,” says the CDC.
Four key questions can be used for provider-led reviews of antibiotics:
- Does this patient have an infection that will respond to antibiotics?
- Have proper cultures and diagnostic tests been performed?
- Can antibiotics be stopped or improved by narrowing the spectrum (also referred to as “de-escalation”) or changing from intravenous to oral?
- How long should the patient receive the antibiotic(s), considering both the hospital stay and any post-discharge therapy?
