The development and widespread use of antibiotics in the early and middle parts of the 20th century transformed medicine,1 turning formerly incurable infections into ailments that could be banished with a short course of therapy. But along with the advent of antibiotics has come antimicrobial resistance, which essentially renders these life-saving drugs ineffective.
According to the US Centers for Disease Control (CDC), more than 2.8 million infections and 35,000 deaths occur every year due to antibiotic-resistant bacteria and fungi.2 Worldwide, the annual number of deaths from these infections tops 700,000. In fact, the World Health Organization (WHO) has declared antimicrobial resistance one of the top 10 threats to global health.3
Driving antimicrobial resistance is the overuse or inappropriate use of antibiotics, both in medicine and in the agriculture industry. The reality that the pharmaceutical and scientific communities have not been able to create new antibiotics quickly enough to replace the drugs to which microbes have become resistant has further compounded this problem. This lack of new therapeutic options, along with the rise in drug-resistant microbes, has created what has been called, “The Perfect Storm”.
The scope of the problem impacts all facets of medicine,4 according to Brian Lee, MD, FAAP, Director of Clinical Sciences at Roche Molecular Systems in Pleasanton, California. Dr. Lee pointed out that the availability of effective antibiotics has allowed advances in the treatment of many other diseases. For example, powerful new cancer drugs have improved patient survival rates, even though they typically wipe out the immune system, because antibiotics can be used to prevent and treat the opportunistic infections to which these patients are vulnerable. In addition, invasive surgeries are possible because patients can be given prophylactic antibiotics to prevent the infections that complicate these procedures. Because so much of clinical care is dependent on the efficacy of antibiotics, resistance has consequences across all medical fields.
Antimicrobial stewardship programs are one important part of the solution
Realizing the seriousness and scope of the problem, entities such as the CDC, WHO, and United Nations have issued action plans to address antibiotic resistance, with a key component being the establishment of hospital antimicrobial stewardship programs.5 These stewardship programs recognize that the appropriate use of antibiotics to optimize patient care can also minimize the undesirable side effects of overuse such as antimicrobial resistance, C difficile infections, and medication toxicity.
What goes into the building of an antimicrobial stewardship program? “The antimicrobial stewardship program is definitely a team effort,” said Dr. Lee. “It usually includes an infectious disease physician and a pharmacist with infectious disease training. One or both of those people are the program lead.” Their role, he stressed, is to implement programs and processes, often working in close collaboration with stakeholders from across the hospital, that will help steer clinicians toward the proper antibiotic choices.
One of the main activities of any antimicrobial stewardship program is a process called prospective audit and feedback. This involves a daily review of all patients on antibiotics in the hospital, prioritizing cases that are most concerning due to the specific illness or type of antibiotic prescribed. The stewardship team will identify opportunities to improve the patient’s antibiotic regimen and will actively reach out to the care team to make suggestions on how the treatment can be adjusted.
Five crucial questions
According to Dr. Lee, the antimicrobial stewardship team focuses on five crucial questions when assessing patients: Does this patient actually need an antibiotic? If so, what is the right antibiotic for his or her clinical situation? What is the right route of administration, oral or intravenous? What is the right dose? And what is the right duration of antibiotic therapy?
These questions are important because they enable the stewardship team to help the care team prescribe more thoughtfully, taking into account patients’ specific characteristics in order to achieve the best clinical outcome. For instance, “IV antibiotics generally require the patient to be in the hospital longer and can have more side effects. In many cases, oral antibiotics can work just as well and allow for earlier discharge,” Dr. Lee said. “In addition, we should always strive to give an antibiotic long enough to cure the infection, but no more than that. Any longer than is necessary exposes the patient to potential harm without additional benefit.”
To address these questions, close collaboration between the stewardship team and front-line prescribers is important. Unfortunately, trying to catch the care team during their rounds or by the traditional hospital paging system can be very time-consuming and prone to miscommunication. This is an area where team collaboration tools similar to those used in other industries can help facilitate the discussions needed to arrive at the right antibiotic choices.
Technology must be optimized to improve antibiotic prescribing
Despite the adoption of electronic medical records (EMR) in many hospitals, the clinical information that the stewardship and care teams need in order to inform prescribing decisions is not always readily accessible. “Electronic medical records (EMR) are not really designed for efficiency,” Dr. Lee lamented. “There are buckets of information siloed into different places.”
Better digital tools would be helpful to bring together key data necessary for clinical decision making in one user-friendly place such as a mobile device. Having such a tool could potentially make an antibiotic stewardship program easier to implement and comply with. These data include not only patient history and laboratory results but also the hospital-based antibiogram (which lists the most effective antibiotics against local bacterial organisms) and treatment guidelines. In many hospitals, these are only available on the hospital intranet or as a paper copy, which may limit timely access. In addition, a mobile digital solution could also enhance these tools by including automated algorithms that essentially bring the stewardship guidance directly to the bedside clinician. “While the care team can always contact the stewardship team to get recommendations, even that can lead to some delays.” Dr. Lee said. “Wouldn’t it be nice to provide that guidance at the fingertips of the care doctors without them having to seek out the stewardship team?”
Antimicrobial resistance is an ongoing pandemic
The current COVID-19 pandemic has highlighted the importance of infectious disease threats, their public health impact, and the need for a coordinated response. Antimicrobial resistance, which has been recognized as a global health threat for well over a decade, deserves no less attention. Without a sustained effort, it is projected that antimicrobial resistance could cause as many as 10 million deaths annually worldwide by the year 2050.3 While this problem requires a multifaceted solution, antimicrobial stewardship is one essential tool currently available in preserving the effectiveness of our current antibiotic armamentarium.4
References:
1. A Brief History of the Antibiotic Era: Lessons Learned and Challenges for the Future. Frontiers in Microbiology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3109405/. Accessed June 9, 2020.
2. More People in the United States Dying from Antibiotic-Resistant Infections than Previously Estimated. U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/media/releases/2019/p1113-antibiotic-resistant.html#:~:text=The%20Centers%20for%20Disease%20Control,the%20United%20States%20each%20year. Accessed June 9, 2020.
3. No Time to Wait: Securing the Future from Drug-Resistant Infections. Interagency Coordination Group on Antimicrobial Resistance. https://www.who.int/docs/default-source/documents/no-time-to-wait-securing-the-future-from-drug-resistant-infections-en.pdf?sfvrsn=5b424d7_6#:~:text=Antimicrobial%20resistance%20is%20a%20global%20crisis.,achieve%20the%20Sustainable%20Development%20Goals. Accessed June 15, 2020.
4. Brian Lee, MD, FAAP, Roche Molecular Systems.
5. The Core Elements of Hospital Antibiotic Stewardship Programs: 2019. U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/antibiotic-use/healthcare/pdfs/hospital-core-elements-H.pdf. Accessed June 9, 2020.
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