Resistant bugs a top CDC priority, will CMS follow?
The antibiotic pipeline is really on life support’
Reducing the threat of antibiotic-resistant pathogens will be a top priority for the Centers for Disease Control and Prevention over the next few years, and there appears to be sufficient political will to put incentives behind the effort, a CDC official said recently in San Francisco at the IDWeek 2013 conference.
"Antimicrobial resistance is going to be a major priority in the next few years," said Denise Cardo, MD, director of the CDC’s Division of Healthcare Quality Promotion. "It is bipartisan — both sides of Congress think it is an important issue."
Delivering the annual Society for Healthcare Epidemiology of America (SHEA) lecture, Cardo also told IDWeek attendees that "antimicrobial stewardship is going to be a major focus."
In that regard, a recent CDC report on the challenge of drug-resistant pathogens concluded that "perhaps the single most important action needed to greatly slow down the development and spread of antibiotic-resistant infections is to change the way antibiotics are used. Up to half of antibiotic use in humans and much of antibiotic use in animals is unnecessary and inappropriate and makes everyone less safe."1
The continuing erosion of antibiotic efficacy poses a particular danger to vulnerable patient populations undergoing chemotherapy for cancer, dialysis for renal failure, and surgery for organ transplants — for which the ability to treat secondary infections is crucial, the CDC warned.
"Efforts to prevent such threats build on the foundation of proven public health strategies: immunization, infection control, protecting the food supply, antibiotic stewardship, and reducing person-to-person spread through screening, treatment and education," Tom Frieden, MD, MPH, CDC director, writes in a foreword to the report.
Add to that list the very real possibility of Center for Medicare and Medicaid Services (CMS) regulation as the issue continues to gain momentum. At IDWeek, a past-president of the Infectious Diseases Society of America (IDSA) reiterated a call for the CMS to require antibiotic stewardship programs as a provision for reimbursement.
"If we align the economic self-interest of the provider with the interest of society we are more likely to succeed," said Brad Spellberg, MD, an infectious disease physician at Harbor-UCLA Medical Center in Los Angeles.
A CMS requirement for antibiotic stewardship would transform the system, raising the possibility that ID docs could partner with CMS to create national benchmarking of antibiotic use in a pay for performance plan, Spellberg noted.
"If we could achieve public reporting of antibiotic use that would enable national benchmarking, we could begin to [link] payments to providers and health care systems," he said. "And I guarantee you when physician and health care systems feel the pain of penalties in reimbursement it will help reinforce behaviors that we want to reinforce."
Infection preventionists part of team
The IDSA and SHEA have previously called for a CMS regulation aligning appropriate antibiotic use with financial incentives. Along with the Pediatric Infectious Diseases Society, they issued a position paper calling for the CMS to require the creation of a multidisciplinary antimicrobial stewardship teams in hospitals and other health care settings.2As proposed, the physician-directed team would include a pharmacist, a clinical microbiologist, and an infection preventionist. (See Hospital Infection Control & Prevention, May 2012)
Stewardship is critical because the development of new antibiotics is hindered by a variety of obstacles and disincentives.
"The antibiotic pipeline is really on life support at this point," Spellberg said. "We need economic incentives to lure industry back into this business."
In the coming decade there will likely be a shift from the traditional business model that Big Pharma has used specifically for antibiotics, going more to a defense contractor public-private partnership model, he predicted. In addition, the Limited Population Antibiotic Drug Proposal supported by IDSA would streamline the development of antibiotics desperately needed to treat the most serious bacterial infections.
"We need to change the clinical development program to get drugs that we really need rather than continuing to shunt drugs in what are perceived to be large markets, but for which there really isn’t a current medical need," he said. "And I’m speaking for example, of skin infections, where drug after drug has been approved. We have more skin drugs than we know what to do with and not enough drugs in other areas."
- Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2013: http://1.usa.gov/15yIo29
- Policy Statement on Antimicrobial Stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS) Infect Con Hosp Epi 2012;(Special Topic Issue: Antimicrobial Stewardship)33:322-327