COMMENTARY

Antimicrobial Stewardship Is Vital to Avoid a Return to the Preantibiotic Era

Neil O. Fishman, MD

Disclosures

March 30, 2010

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Hello, my name is Neil Fishman. I am President of the Society for Healthcare Epidemiology of America and the Director of Healthcare Epidemiology, Infection Prevention and Control for the University of Pennsylvania Health System. I am here today to speak to you about Antimicrobial Stewardship as part of the CDC Expert Commentary series on Medscape.

Antimicrobial resistance is one of the most pressing problems and greatest challenges that healthcare providers will confront during the coming decade. As bacteria and other micro-organisms are becoming more resistant to antimicrobials, our current therapeutic options are dwindling and research and development of new antibiotics is lagging. For the first time since the discovery and introduction of penicillin in the 1940s, we are dangerously close to a return to the pre-antibiotic era.

While MRSA has become the bacterial poster child for antimicrobial resistance, other organisms pose a greater threat during the next 10 years. The CDC studied rates of resistance in healthcare-associated infections that were reported to the National Healthcare Safety Network during 2006 and 2007, and described their findings in Infection Control and Hospital Epidemiology in 2008.[1] While a slight downward trend in MRSA was noted, the resistance trends in gram-negative organisms were alarming. This group of bacteria accounted for nearly 32% of reported bacteria.

Enzymes that confer resistance, such as extended-spectrum beta-lactamases and Klebsiella pneumoniae carbapenemases are spreading among all Enterobacteriaciae at an alarming pace. Some studies describe a 20-35% rate of resistance of E. coli to fluoroquinolones in the United States.[2] Unfortunately, there are no drugs in clinical development to address this problem. Since it is likely that this trend will accelerate and since it takes at least 8-10 years to bring a drug to market, the management of infectious diseases will be increasingly challenging as the decade progresses.

Antimicrobial resistance is a complex problem that demands multidimensional solutions. The infectious diseases and healthcare epidemiology communities are working to address resistance, and much of the cutting edge science in this area will be presented this week at the 5th Decennial International Conference on Healthcare Associated Infections being held in Atlanta, GA. A maximally effective program to battle resistance must address the transmission of resistant organisms and the lack of effective antimicrobial agents, as well as the overuse and abuse of antibiotics.

The Society for Healthcare Epidemiology of America (or SHEA) has focused on preventing transmission of these organisms throughout the hospital and particularly as a cause of healthcare-associated infections. Practical recommendations to assist you in your practice can be found in the Compendium of Strategies to Prevent Healthcare Associated Infections that is available on our Website. Additionally, the SHEA Research Committee has identified gaps in our knowledge that must be answered to help optimize prevention strategies, and is working to answer these critical questions. The Infectious Diseases Society of America is lobbying to eliminate nontherapeutic use of antibiotics in animals and also has focused on the dwindling human antibiotic armamentarium through its Bad Bugs, No Drugs campaign and its more recent 10 x '20 effort. IDSA has challenged the pharmaceutical industry to develop 10 new antibiotics by the year 2020, and is working to make this a reality. Overuse and abuse will hasten the evolution of resistance to these new agents.

The goals of antimicrobial stewardship are to ensure the proper use of antibiotics in order to reduce or stabilize resistance, to optimize clinical outcomes and to decrease the risk of adverse events such as Clostridium difficile infection. SHEA and IDSA published Guidelines for Antimicrobial Stewardship in 2007,[3] but there has not been widespread uptake of the initiatives that were recommended. While this document focused on the composition and implementation of stewardship programs, there are many simple steps you can take in your practices and hospitals to improve antibiotic use without a complex infrastructure. For example:

  • Never treat viral syndromes such as acute bronchitis with antibiotics, even when patients demand therapy

  • Use fluoroquinolones cautiously. Not only is fluoroquinolone resistance rising at an alarming rate, but this group of drugs causes resistance to many other antibiotics and is associated with the new more virulent strain of C. difficile we are seeing in the United States

  • Antibiotics used for surgical prophylaxis should rarely be given for more than 24 hours; post-operative doses are not required in many cases.

  • Refine your antibiotic choice once culture data is available and always use the drug with the narrowest spectrum

  • Double coverage is rarely necessary once antimicrobial susceptibilities are known

Antibiotic resistance is no longer confined to large hospitals. We are seeing increasing rates of resistance in the community, so it is now more critical than ever that we embrace these concepts to prolong the efficacy of our current antibiotics while we await new more effective agents. SHEA is committed to the goals of antimicrobial stewardship, to the research needed to define the most effective interventions and to educating the next generation of stewards. We are also working with the CDC to develop practical implementation tools to move antimicrobial stewardship out of the enclave of the academic medical center to the community where the majority of antibiotics are prescribed. Look for the launch of Get Smart for Healthcare in the near future.

I will end by asking everyone to avoid mural dyslexia or "failure to read the handwriting on the wall." Antimicrobial resistance is a very real problem that extends to every segment of the healthcare community. We are seeing more and more infections caused by bacteria with limited susceptibilities or that are resistant to all antibiotics. It is unlikely that new antibiotics will be available in the near future, so we must take the necessary measures to preserve our current supply. Failure to do so will guarantee a return to the pre-antibiotic era.

Web Resources

Infectious Diseases Society of America. Bad bugs, no drugs: patient stories. Available at: http://www.idsociety.org/badbugsnodrugspatientstories.htm Accessed March 29, 2010.

Infectious Diseases Society of America. Action alert: urge Congress to pass legislation to spur antibiotic discovery. Available at: http://www.capwiz.com/idsociety/issues/alert/?alertid=7478136 Accessed March 29, 2010.

Infectious Diseases Society of America. Action alert: tell Congress to pass the STAAR Act! Available at: http://www.capwiz.com/idsociety/issues/alert/?alertid=14750026 Accessed March 29, 2010.

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