Antibiotic Use at VA Sites Climbs After Years of Decline

Marcia Frellick

October 27, 2020

Antibiotic use increased across 84 of the nation's largest Department of Veterans Affairs (VA) medical centers this year, reversing years of steady decline, according to new research presented at IDWeek 2020.

Although diagnostic confusion in the early surge of the COVID-19 pandemic may be responsible for some of the increase, said lead author Matthew Goetz, MD, the increase occurred at sites that experienced very little disruption as well as those overwhelmed with cases, indicating stewardship programs may lack resiliency in the current massive upheaval of the healthcare system.

From January through May 2020, the rate of use for all antibiotics at the 84 hospitals was 631 days of therapy per 1000 days patients were in the hospital. That was up 4% from 605 days of therapy in that period in 2019.

A decade ago, Goetz, who is chief of infectious diseases at the VA Greater Los Angeles Healthcare System, and his colleagues developed a dashboard that enabled VA facilities to track their antibiotic use monthly, quarterly, or yearly and compare that to all other VA facilities nationally.

For 10 years, "there has been a steady year-to-year decrease in antimicrobial use," he said. However, this year, "about March or April, we started to see a disturbing trend that antibiotic use appeared to be increasing," Goetz said.

Three Years of Progress Lost

Goetz found that "we were back to rates that were last seen in 2016. So we've lost about 3 years of progress," he said.

Antibiotics prescribed most frequently were those used to treat community-acquired pneumonia and those used to treat the more resistant hospital-associated infections.

Dr Tom Talbot

Tom Talbot, MD, MPH, chief hospital epidemiologist at Vanderbilt University Medical Center in Nashville, Tennessee, and a co-chair for IDWeek 2020, told Medscape Medical News that Goetz's abstract was spotlighted at the conference because of the national scope of the study and its disturbing message that such a large health system was moving in the wrong direction with antibiotic use.

"The study helps illustrate that once we get through this pandemic, the scope of impact on healthcare systems, I think, will be much more expansive than we had thought," he said.

Reasons for the Prescribing

Talbot said there are likely multiple reasons for the increased use. He speculates that the fact that more staff are working from home could play a role. One possibility is that the role of a pharmacist, who used to accompany physicians on rounds and comment on antibiotic choices in real time, cannot easily be replicated in a remote setting.

Another possibility is that as people shied away from receiving care during the pandemic, the patients physicians did see tended to be sicker, which may have contributed to use of more antibiotics.

The study results have pointed out that "[t]he sustainability and infrastructure that we have in place during busy healthcare may have been very stressed and not as resilient as we'd like it to be in times of even greater emergency," he said.

Talbot and Goetz also mentioned the diagnostic confusion that occurred at the beginning of the pandemic, when so much was unknown about the virus. That undoubtedly led some to try broad-spectrum antibiotics.

Goetz said COVID-19 is "an elegant case study of the importance of rapid diagnostics."

He said the next step for research is to find out why some facilities were more resilient than others to changes in antimicrobial utilization.

Researchers will look at the role played by various factors, such as the availability of testing supplies, the supply of personal protective equipment, staffing levels, dissemination of guidelines, provider education regarding prescribing, and facilities' ability to maintain staffing for stewardship programs when providers are being diverted in a crisis.

"We're looking at these questions so we can better design programs that are resistant to future shocks that may occur to the system," Goetz said.

The study was supported by the Veterans Health Administration. Goetz and Talbot have disclosed no relevant financial relationships.

IDWeek 2020: Abstract 181, presented at a press conference on October 23, 2020.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune and Nurse.com and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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