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Colistin Resistance Reinforces Antibiotic Stewardship Efforts


 

In 2015, researchers in China announced they had found for the first time a bacterial gene conferring resistance to colistin. The gene was present in samples from agricultural animals and in 1% of tested patients.1 Colistin, an antibiotic from the 1950s, is rarely prescribed; it is often considered an antibiotic of last resort.

In May 2016, the U.S. Department of Defense announced this gene, called mcr-1, had been found in E. coli isolated from the urine of a patient in Pennsylvania presenting with symptoms of a urinary tract infection.2 Subsequent surveillance also found mcr-1 E. coli in a pig.

The news has been met with grave concern by public health officials, scientists, infectious disease specialists, and countless physicians around the U.S. It has also served as a reminder that good antibiotic stewardship is a national, if not international, imperative.

“The recent discovery of a plasmid-borne colistin resistance gene, mcr-1, heralds the emergence of truly pan-drug resistant bacteria,” the authors of the recent U.S. study, from the Walter Reed National Military Medical Center, wrote in their opening sentence.

In November 2015, the Society of Hospital Medicine (SHM) launched an antibiotic stewardship campaign, “Fight the Resistance,” in partnership with the Centers for Disease Control and Prevention (CDC). Hospitalists around the country have taken the lead on confronting the issue head on.

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Eric Howell, MD, MHM

When the CDC and the White House called for action last year, “SHM jumped in with both feet,” says Eric Howell, MD, MHM, SHM’s senior physician advisor, chief of the Division of Hospital Medicine at Johns Hopkins Bayview, and professor of medicine at Johns Hopkins University in Baltimore. The “Fight the Resistance” campaign calls for the nation’s 44,000 hospitalists to commit to responsible antibiotic-prescribing practices.

“While it’s extremely alarming, leading up to this, we knew there was a crisis of antibiotic resistance,” says Megan Mack, MD, a hospitalist and clinical instructor in the University of Michigan Health System in Ann Arbor. “We know more antibiotic use is not the answer, stronger is not the answer. We need to be peeling back antibiotic use, honing when we need them, narrowing how we use them as much as possible, and keeping the duration as short as possible.”

Dr. Mack is first author of a new study in the Journal of Hospital Medicine that examines hospitalist-driven antibiotic stewardship efforts in five hospitals around the country.3

The Institute for Healthcare Improvement, with the CDC, recruited Dr. Mack and her study coauthors, hospitalists Jeff Rohde, MD, and Scott Flanders, MD, MHM, to participate.

“We were interested in the opportunity to put into place interventions in five different hospitals and to be able to share our successes and our barriers, which we did twice monthly,” Dr. Mack says.

Each hospital in the collaborative, which included teaching and non-teaching community hospitals and academic medical centers, focused on its own data and tailored its stewardship interventions to three strategies shown to be quality indicators of successful stewardship programs.

These strategies included:

  • Enhanced documentation with regard to antimicrobial prescribing and use
  • Improved quality and accessibility of guidelines for common infections
  • Adoption of a 72-hour antibiotic timeout to reassess a patient’s antibiotic treatment plan once culture results were available

Each hospital used its own particular antibiotic stewardship practice data to educate and inform its physicians, which Dr. Mack says was important to the success of interventions because it was “concrete and realistic.”

The study found that in two hospitals, complete antibiotic documentation in patient records increased to 51% from 4% and to 65% from 8%. It also recorded 726 antibiotic timeouts, resulting in 218 antibiotic treatment adjustments or discontinuations. It also found several barriers to improved antibiotic stewardship.

“[Hospitalists] are stretched for time. We’re constantly being pulled in multiple directions,” Dr. Mack says. “We are bombarded daily with quality improvement initiatives and with constantly meeting metrics deemed to be priorities, so we tried interventions that were easily incorporated into daily workflow.”

The team learned that workflow integration was a requirement for success. For instance, Dr. Mack suggests building antibiotic prescribing into hospitalists’ electronic health records, with automatic stop dates that must be overridden by a physician. “It’s too easy to overlook it, and 10 days later, your patient is still on vancomycin.”

The experience, she says, made her fellow physicians in the collaborative realize that, despite some skepticism, good antimicrobial stewardship can be achieved without significant disruption.

“If we don’t change our practice patterns, there are not enough antibiotics in the pipeline to mitigate the effects,” of resistance, says Dr. Howell, who was not involved in the study. “We can’t stop resistance, but we can change our practice patterns so we slow the rate of resistance and give ourselves time to develop new therapies to treat infections.”

This includes behavioral changes hospitalists can easily incorporate, Dr. Howell says, which align with the strategies assessed in Dr. Mack’s study. These include rethinking the treatment time course, antibiotic timeouts, and adhering to prescribing guidelines.

Hospitalists, he says, are well-positioned to lead antibiotic stewardship efforts.

“We’re quality improvement experts … and there are not enough infectious disease physicians in the country to roll out antibiotic stewardship programs, so there is space for hospitalists,” Dr. Howell explains. “In every hospital, we are prescribing these medications, so we own the problem.” TH


Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

  1. Liu YY, Wang Y, Walsh TR, et al. Emergence of plasmid-mediated colistin resistance mechanism MCR-1 in animals and human beings in China: a microbiological and molecular biological study. Lancet Infect Dis. 2016;16(2):161-168. doi:10.1016/S1473-3099(15)00424-7.
  2. McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: First report of mcr-1 in the USA. Antimicrob Agents Chemother. 2016;60(7):4420-4421.
  3. Mack MR, Rohde JM, Jacobsen D, et al. Engaging hospitalists in antimicrobial stewardship: Lessons from a multihospital collaborative [published online ahead of print on April 30, 2016]. J Hosp Med. doi:10.1002/jhm.2599.

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