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.
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:
“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.
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:
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:
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.
Microbiology laboratory testing and staff can play a crucial role in optimal antibiotic prescribing.
The CDC says that microbiology laboratory staff can:
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).
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:
o Improving diagnostic accuracy
o Tailoring of therapy to culture results
o Optimizing the duration of treatment to ensure compliance with guidelines
Microbiology labs, in consultation with the stewardship program, can help implement the following interventions for common-based and other infections:
“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: