By Gary Evans, Medical Writer
Infection preventionists (IPs) are playing key roles in antibiotic stewardship programs, which are now in place in most U.S. hospitals and making some hard-earned progress against a horde of multidrug-resistant bacteria.
“More and more it is important that infection preventionists work with people who are leading antibiotic stewardship efforts in hospitals. That is a collaboration that can directly impact the amount of antibiotic use occurring,” says Lauri Hicks, DO, a medical epidemiologist at the Centers for Disease Control and Prevention (CDC).
Misuse and overuse of antibiotics has led to emerging multidrug-resistant pathogens, including some pan-resistant strains that are impervious to the full formulary. However, discriminate use of antibiotics through stewardship programs combined with infection prevention efforts can stop the emergence and transmission of resistant bugs.
“There is a real synergy between antibiotic stewardship programs and infection prevention and control,” says Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC, president of the Association for Professionals in Infection Control and Epidemiology.
“They are both interested in the common goal of keeping patients safe and improving patient outcomes. There are studies that show the more effective an infection control program is, particularly in terms of hand hygiene, the better the results of the stewardship program.”
Likewise, an effective antibiotic stewardship program can enhance infection control efforts, particularly when outbreaks are occurring or there are recurrent Clostridioides difficile (C. diff) infections.
“IP surveillance efforts overlap with the antibiotic stewardship program,” Hoffmann says. “They provide data on where you are at with antimicrobial resistance, particularly with C. diff. Antibiotic stewardship programs have to have that data in order to see their effectiveness.”
IPs are also known for their interactions with multiple disciplines, from environmental services to nurses and physicians.
“Regardless of the setting, IPs work with a really diverse population of healthcare providers,” she says. “They are working directly with the frontline providers, the nurses who often make the call to the clinicians for the antibiotics.”
This access can translate to insight and education, including using CDC definitions to verify that the patient has an infection that warrants antibiotic treatment.
“They can create a number of interventions to help with [stewardship], including antibiotic time outs and knowing the [CDC] core measures,” Hoffmann says. “There are a variety of things that they can do with the frontline providers that benefit antibiotic stewardship.”
Most hospitals using core measures
Although much work remains, the CDC recently published a report1 citing a dramatic increase from 2014 to 2017 in the number of hospitals adopting all seven of the recommended core elements of antibiotic stewardship programs. Of 4,992 hospitals responding to the CDC’s National Healthcare Safety Network (NHSN) survey in 2017, 3,816 (76%) reported uptake of all the core elements. As outlined in the CDC report, the core elements of a drug stewardship program are summarized as follows:
- Leadership Commitment: Dedicate necessary resources.
- Accountability: A single leader is responsible for program.
- Drug Expertise: A pharmacist leader works to improve antibiotic use.
- Action: Follow-through evaluation after, for example, a set period of initial treatment.
- Tracking: Monitor drug prescribing and resistance patterns.
- Reporting: Regularly disseminate antibiotic use and resistance data to staff.
- Education: Teach clinicians about resistance and optimal prescribing.
Although the core elements are more widely implemented and there are signs that antibiotic use is decreasing, it is difficult to directly tie stewardship efforts to reductions in drug-resistant healthcare-associated infections.
“We are seeing some improvements in some of these infections, but it is probably multifactorial,” Hicks says. “There’s a major effort to improve infection prevention at the same time as the efforts to improve antibiotic use. We will be tracking the changes specifically in C. diff over time, both in hospitals and community settings. That is a really important infection to give us a sense [of] where there are opportunities to improve use.”
C. diff, which kills about 15,000 patients annually, frequently emerges after the administration of antibiotics used for other infections disrupts the commensal bacteria in the gut. As a result, antibiotic stewardship programs tempering the use of the drugs have been heavily emphasized in recent years. The CDC previously reported a 20% reduction in C. diff from 2016 to 2017.2 That put the agency back on track to reach an overall reduction goal - from a baseline of 2015 - of 30% in C. diff infections by 2020.3 The surveillance data were reported by NHSN hospitals. (See Hospital Infection Control & Prevention, May 2019.)
With care moving out across the continuum, the CDC has published antibiotic stewardship core measures for outpatient settings.4 Drug-resistant pathogens respect no borders, so the CDC has also developed antibiotic stewardship core elements for resource-limited countries.5 Globally, antibiotic use is - literally - all over the map, as some countries lack drugs while others use them indiscriminately.
“For example, in some countries, healthcare providers earn a large portion of their income by selling prescription drugs, leading to inappropriate or irrational antibiotic prescribing,” the CDC notes. Of course, patients who develop drug-resistant infections may travel to other regions, as has been demonstrated with several high-threat pathogens cited by the CDC.
The CDC will publish a new report on antibiotic-resistant threats in the coming months, updating the 2013 report that classified the pathogens in descending threat levels as “urgent” (i.e., C. diff); “serious” (i.e., multidrug-resistant Acinetobacter); and “concerning” (clindamycin-resistant Group B Streptococcus).6
“We are seeing improvements in a number of healthcare-associated infections, and there will be some more information released later this fall in that antibiotic-resistant threats report,” Hicks says.
Despite the progress, the challenge is still staggering. In its new report, the CDC estimates that 30% of antibiotics prescribed in U.S. doctors’ offices and emergency departments each year are unnecessary.
“Antibiotic prescribing nationally has improved, with a 5% decrease from 2011 to 2016, but more progress needs to be made,” the CDC notes. “In 2016, 270 million antibiotic prescriptions were written in the United States. That’s enough antibiotic courses for five out of every six Americans to receive an antibiotic prescription.”
Given the situation, there is building momentum for a regulation requiring antibiotic stewardship to be adopted by the Centers for Medicare & Medicaid Services (CMS), which proposed a rule in 2016 that remains in limbo. Earlier this year, the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria urged the CMS to move the proposed rule to “immediate finalization.”7
“There is a critical need for mandatory, not voluntary, implementation of antibiotic stewardship programs in our nation’s hospitals,” the panel stated.
The Joint Commission adopted an antimicrobial stewardship standard in 2017,8 but it appears a CMS regulation would be needed for the CDC to meet a 2020 goal to have programs in 100% of hospitals.
“The high percent of hospitals that are complying with all of the core elements have a lot do to with the accreditation requirements put in place in 2017,” Hicks says. “There are some other accreditation organizations out there [taking action] and I think that will also help. In terms of the CMS, we are hopeful that there will be a regulatory requirement at some point. There is a requirement for nursing homes to have antibiotic stewardship programs.”
We asked Hicks to address a few of the specific findings in the new CDC report in the following interview, which has been edited for length and clarity.
HIC: The report found that antibiotics are often unnecessarily prescribed for respiratory illnesses, such as the common cold and bronchitis. You cite a 25% level of inappropriate prescriptions in hospital emergency departments (EDs). What do you think is happening there?
Hicks: There are some cross-cutting issues that apply to all settings, and the ED is not immune to that. There is a lot of concern about meeting patient expectations among physicians and nurse practitioners. We often hear from these different healthcare providers that there is pressure to prescribe even in situations where they know that antibiotics are unneeded. What is challenging about the ED setting in particular is that, obviously, there isn’t an established clinician-patient relationship. The clinician may not know what the likelihood of follow-up is if that patient takes a turn for the worse. If they have uncertainty about whether the patient needs an antibiotic, they may err on the side of prescribing because there is less of a relationship and less certainty about patient follow-up. There is the potential there to lead to unnecessary [antibiotic] use because of fear of missing something or diagnostic uncertainty.
HIC: You also report that fluoroquinolones, a known driver for C. diff, were often unnecessarily prescribed for urinary tract infections and respiratory conditions in 2014 data. Are you seeing any improvements in this trend?
Hicks: Yes, and I think some of the changes we are starting to see in fluoroquinolone prescribing are probably because there are concerns that they can potentially lead to consequences like C. diff. The other reason [for curtailed use of fluoroquinolones] are the FDA’s warnings about potential adverse events. There was a warning not too long ago about the potential for aortic aneurisms and rupture in older adults in particular. That is a rare, but a very serious, consequence. C. diff is one reason we are seeing the fluoroquinolone decline, and there is also increased awareness of these adverse events.
HIC: You report that most adult patients need about five days of antibiotic therapy for community-acquired pneumonia, yet 70% of patients receive almost 10 days of therapy.
Hicks: It is interesting because we see that [10-day] duration of therapy whether we are talking about hospitalized patients or those in outpatient settings and nursing homes. I think this goes back to the perception that giving something and giving more of it is better than not giving something and giving less. We are hoping to shift that paradigm. We need to because we now know that giving more [antibiotics] is not necessarily safer. It also takes some effort when the patient is being discharged from a hospital to identify how many days of therapy they have been on, and decide how many days of therapy they should [continue]. A lot of courses of therapy happen after hospitalization. We are recommending that at the time of discharge, there is a reevaluation of both the duration and the selection of the antibiotic.
HIC: The report notes that azithromycin is not a recommended treatment for common pediatric infections but was being prescribed in 18% of cases reviewed. What is the disconnect there?
Hicks: Macrolides like fluoroquinolones and azithromycin are both what we consider broad-spectrum antibiotics. There can be a perception that they may be effective because they target many organisms. Azithromycin was also very effectively marketed for many years. In the case of azithromycin use in kids - there are very few indications for it. In fact, what we are finding is that sometimes kids are getting azithromycin when it is not even the first-line recommended drug, which could potentially lead to treatment failure. We are very concerned that there is this misperception that it is better because it is broader. In the case of a lot of the common conditions we are treating in kids, the better first-line agent is amoxicillin. There are a lot of beliefs and behaviors that we need to work on to change prescribing. The reason why azithromycin is not recommended typically is because of concern for antibiotic resistance among the most common types of bacteria that cause ear infections.
- CDC. Antibiotic Use in the United States, 2018 Update: Progress and Opportunities. 2019. Available at: https://bit.ly/2NjuYU5.
- CDC. HAI Data: National Data for Acute Care Hospitals, Year 2017. Available at: https://bit.ly/2UX3SD7.
- Department of Health and Human Services. Prevent Health Care-Associated Infections: National Targets and Metrics. Available at: https://bit.ly/2I7t4V0.
- CDC. The Core Elements of Outpatient Antibiotic Stewardship. 2016;1-33. Available at: https://bit.ly/2NKC5oZ.
- CDC. The Core Elements of Human Antibiotic Stewardship Programs in Resource-Limited Settings: National and Hospital Levels. 2018;1-25. Available at: https://bit.ly/2keOJAc.
- CDC. Antibiotic Resistance Threats in the United States, 2013. Available at: https://bit.ly/2FqISgr.
- Presidential Advisory Council on Combating Antibiotic Resistant Bacteria. Letter to the HHS. April 8, 2019. Available at: https://bit.ly/2m5fxmR.
- The Joint Commission. Approved: New Antimicrobial Stewardship Standard Joint Commission Perspectives July 2016;36(7)1-8. Available at: https://bit.ly/2hMxS0e.