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Opinions & Essays

Antibiotic Stewardship: A Call to Action

Prescribing antibiotics only when needed is the single most important action providers can take to contain antibiotic-resistant infections.

"The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself; and by exposing his microbes to non-lethal quantities of the drug, make them resistant."   - Alexander Fleming, Nobel Lecture, December 11, 1945  

There is no question that for the past 70 years, morbidity and mortality from infectious diseases has been drastically reduced or eradicated due to the use of antimicrobial drugs. Yet, as prophesized by Alexander Fleming 70 years ago, widespread use of these medications has created an environment for bacterial organisms to inevitably adapt and evolve, making numerous antibiotics less effective as means of disease remedy.

The unnecessary use of antibiotics has many downsides, among them creating risk for adverse drug events, incurring higher (but unnecessary) costs, and most importantly, increasing the number of drug-resistant infections at the patient and population level.1 Every year, more than 2 million people become infected with drug-resistant bacteria, causing approximately 23,000 deaths annually. It is imperative that providers and patients alike accurately perceive the significance of this issue. We need a "call to action" to contain the existing resistance and to prevent the development of any new resistance.

Overprescribed Without Cause
While these drugs are quite commonly issued, the Centers for Disease Control and Prevention (CDC) reports that "up to 50% of the time, antibiotics are not optimally prescribed, often done so when not needed, [with] incorrect dosing or duration."1

For example, when patients in the U.S. present with upper respiratory infections and acute bronchitis (which are viral in etiology), more than 50% of them will be prescribed antibiotics-unnecessarily!

In primary care settings in particular, the "overprescription" of antibiotics can often be attributed to: providers who are faced with high patient expectations; a lack of awareness on the part of both patients and providers about resistance patterns; and lack of knowledge on the part of both patients and providers about the severity of the growing resistance problem.1,2

What is Antibiotic Stewardship?
There is a tremendous need going forward to use antibiotics fittingly in every case, which includes choosing the right antibiotics, administering them the correct way, and prescribing them only when needed to treat infectious disease. The CDC refers to this notion as antibiotic stewardship, and it is considered perhaps the single most important action providers can take to slow and contain antibiotic-resistant infections.

In the primary care setting, the antibiotic stewardship initiative has the potential to improve patient outcomes. A body of research exists that supports methods such as provider and/or patient education, the establishment of treatment guidelines, the use of delayed prescribing, communications skills training, and the use of laboratory testing as considerably effective interventions.1,3

SEE ALSO: Grand Valley State University Working to Eliminate E coli "Superbug"

Try Delayed Prescribing
With the majority of antibiotic prescriptions being written in the outpatient setting, primary care and family practice offices are an ideal location to begin instituting improved prescribing practice standards.

Delayed prescribing was found to be one of the most significant interventions. This is when the provider asks the patient to wait a short period of time (24 to 48 hours) after the initial clinical visit to determine if an antibiotic is really warranted for the symptom presentation. This involves either writing a post-dated prescription and re-contacting the patient after being examined in the office; or providing the patient with a prescription and verbal orders to fill it only after a specified length of time has passed and the symptoms have not improved.4

One Close Call Already
Unless we all become vocal practitioners of antibiotic stewardship, we soon may be reaching the end of the road for antibiotics in medicine. May 2016 brought this reality to light as a "superbug" first made an appearance in the United States.

E. coli bacteria carrying the mcr-1gene was found in the urine sample of a female patient in Pennsylvania, who presented with urinary tract infection (UTI) symptoms and who had not traveled outside the U.S. in the recent past. The mcr-1 gene makes bacteria resistant to a drug called colistin, a "last-resort" antibiotic which is normally reserved for use only in desperate cases, due to the intensity of renal damage that it causes.5,6

The mcr-1 gene exists on a plasmid, a small piece of DNA that is capable of moving from one bacterium to another-which means it could spread antibiotic resistance among bacterial species. The CDC and federal partners have been hunting for this gene in the U.S. ever since its emergence in China in 2015.5,6

Despite some media reports, an investigation by the Pennsylvania State Health Department finally did conclude that the bacteria found in the woman's urine sample was not resistant to all antibiotics (referred to as a pan-resistant infection). The presence of the mcr-1 gene, however, and its ability to share its colistin-resistance with other bacteria (such as carbapenem-resistant Enterobacteriaceae, or CRE), raises the risk that pan-resistant bacteria could develop.6

Embrace the "Call to Action"
The case described above can be seen as a close call, for the moment. The thought that a type of bacteria could evolve into a bug so "super" it could resist all known antibiotics is simply terrifying.

Health care providers must take action to ensure that antibiotics will still be available and effective when we need them the most. These drugs not only need to be taken correctly; they need to be prescribed correctly.  Without the embracement of antibiotic stewardship, we may soon be return to an era where there are no antibiotics-an impending reality which Andrew Fleming cautioned against in 1945.

Shannon L. Joy currently works as a nurse practitioner in palliative care medicine at Magee-Women's Hospital, University of Pittsburgh Medical Center (UPMC) in Pittsburgh, PA. She was inspired to write this article while working in the hospital's adult intensive care unit.

References

1. Centers for Disease Control and Prevention (CDC). Antibiotic/antimicrobial resistance. 2016. https://www.cdc.gov/drugresistance/

2. Ackerman SL, Gonzales R, Stahl MS, Metlay JP. One size does not fit all: evaluating an intervention to reduce antibiotic prescribing for acute bronchitis. BMC Health Services Research. 2013;13(462):1-9. 

3. Drekonja D, Filice G, Greer N, Olson A, MacDonald R, Wilt TJ. Antimicrobial stewardship programs in outpatient settings: A systematic review. Washington (DC): Department of Veterans Affairs (US); 2014. http://www.ncbi.nlm.nih.gov/books/NBK274571/

4. Centers for Disease Control and Prevention (CDC). Delayed prescribing practices for healthcare professionals. 2015. http://www.cdc.gov/getsmart/community/improving-prescribing/interventions/delayed-prescribing-practices.html

5. Sun LH, Dennis B. The superbug that doctors have been dreading just reached the U.S. The Washington Post; May 26, 2016. https://www.washingtonpost.com/news/to-your-health/wp/2016/05/26/the-superbug-that-doctors-have-been-dreading-just-reached-the-u-s/

6. Centers for Disease Control and Prevention (CDC). Discovery of first mcr-1 gene in E. coli bacteria found in a human in United States. May 2016. http://www.cdc.gov/media/releases/2016/s0531-mcr-1.html

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