Changing the antibiotic mindset of docs, patients

Education, better use data, research

In addition to calling for federal regulation requiring antimicrobial stewardship, a position paper by leading infectious disease groups recommended several other measures to preserve remaining antibiotic efficacy.

Monitor antimicrobial stewardship in ambulatory healthcare settings.

More ID doctors, pharmacists, and other clinicians are needed to monitor and oversee ambulatory settings' antimicrobial stewardship programs. Also, these settings should integrate clinical decision support technology into electronic health records and into e-prescribing mechanisms, the position paper states.

"All of these changes, listed in the position paper, are necessary for the evolution of care in and out of a hospital setting that involves antibiotics and infectious diseases," says Thomas G. Slama, MD, FIDSA, president, IDSA, and clinical professor of medicine at the Indiana University School of Medicine in Indianapolis, IN.

The involvement of ID physicians and clinicians trained in infectious diseases is crucial to these programs' success, he says.

Just like heart disease patients see a cardiologist for their care, patients with high-risk infectious diseases need to see an ID expert, he adds.

Educate clinicians and the public about antimicrobial resistance and antimicrobial stewardship.

Education is lacking for patients and medical trainees on this critical issue, emphasizes Jason G. Newland, MD, MEd, director of the antibiotic stewardship program and associate professor of pediatrics at the University of Missouri-Kansas City (MO) School of Medicine, Children's Mercy Hospitals & Clinics.

"We don't teach families and society how to use these drugs," he says. "I've had people come to me and say, 'I need a z-pack.' They know they usually go to the physician's office and get a drug they think will make them feel better."

What physicians need to do is tell patients: "You don't need this. I know you are coughing up green stuff, but you're going to be fine."

But doctors infrequently do not do this because they know that if a patient wants an antibiotic from them and does not get it, the patient might go to another doctor who will make the prescription, Newland says.

"What we need to do is educate families and patients, saying, 'This is why we're not going to use these drugs.'"

Norwegian countries have done a good job of making antibiotics a less-prescribed and requested drug, he notes.

"The resistance rates are super low," Newland says. "What I've been told is the families will go to a doctor and if the doctor gives them an antibiotic they see it as a negative thing."

Patient education materials about antibiotics are available on the Centers for Disease Control and Prevention "Get Smart" website including brochures and pamphlets for hand out. (http://1.usa.gov/JnHc2t)

"Up until now the Get Smart program focused on pediatric populations, but they are expanding it to address the issue of antibiotic use in the adult population, as well," says Neil Fishman, MD, associate chief medical officer at the University of Pennsylvania Health System in Philadelphia, PA.

"The campaign addresses the use of antibiotics for bronchitis, the common cold, and sinusitis, which all are diseases most often caused by viruses, so antibiotics are not effective in treatment."

In addition, clinician education on antimicrobial stewardship should be reinforced during internships and residencies.

"Outpatient medicine is a dilution of inpatient medicine, and most doctors do what they saw or were taught as trainees," Slama says. "So if you change the process in the hospital, then the doctors will change their practices when they go into the community."

When health systems first begin clinician education about antimicrobial stewardship, they might use guidelines and formularies, spot auditing of antibiotic use, individual clinician teaching, and grand round teaching at the bedside with infectious disease physicians, he suggests.

"We need to have a formal curriculum during the time they're seeing patients," Newland adds. "Antimicrobial stewardship needs to be brought into the fabric of those settings, which is the best time for learning."

Collect antimicrobial use data and make it readily available for inpatient and outpatient settings.

The United States is lacking readily available data for tracking and benchmarking antimicrobial use, and such data are critical to antimicrobial monitoring, the position paper says.

Also, antimicrobial use data can be used as part of an incentive-based payment system.

While antibiograms tell part of the story, more data are needed to give clinicians and health systems a complete picture of antimicrobial resistance in their hospitals and communities, Newland says.

"We also need to set up standards and to do this we have to improve decisions about what appropriate use is," he adds. "Antimicrobial stewardship is a 20-year-old field, and it's just now that people are beginning to recognize it because of resistance problems."

Increase research on antimicrobial stewardship.

"Most physicians and health care providers understand that resistance is a growing problem," Fishman says. "But it's difficult to think beyond the single patient they're taking care of."

Antimicrobials are different from other drugs prescribed because they have an ecological impact, he adds.

"Antimicrobials are the only drugs where use in one individual can impact the ability to use the drug in another individual," Fishman says.

Research into how antimicrobial stewardship affects the ecological impact is needed.

"To date there has been only a single multicenter study that looked at the impact of antimicrobial stewardship, and it was just published," Fishman says. "Most research has focused on specific types of interventions during outbreaks of infections with resistant organisms and these were only in single institutions or single units of individual hospitals."

Research in antimicrobial stewardship today is where infection control research was 15-20 years ago, he adds.

"There's a lot of work that needs to be done," he says. "The big problem is there's not an obvious or ready funding source for this research, and the National Institutes of Health has not put out grants for this type of research that we're calling for."

Reference

  1. 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 Cont Hosp Epi, Vol. 33, No.4, Special Topic Issue: Antimicrobial Stewardship (April 2012), pp. 322-327