A recent CDC study found that nearly a third of antibiotics might be inappropriately prescribed.1 The report also found wide variation in antibiotic prescribing practices for patients in similar treatment areas in hospitals across the country.
Across the globe, antibiotic resistance has become a daunting threat. Some public health officials have labeled it a crisis, and improper prescribing and use of antibiotics is at least partly to blame, experts say.
“We’re dangerously close to a pre-antibiotic era where we don’t have antibiotics to treat common infections,” says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. “We are seeing more and more infections, usually hospital-based, caused by bacterial resistance to most, if not all, of the antibiotics that we have.”
It’s an issue hospitalists around the country are championing.
“I think for a long time there’s been a misperception that antibiotic stewardship is at odds with hospitalists, who are managing very busy patient loads and managing inpatient prescribing,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the division of Healthcare Quality Promotion at the CDC. Dr. Srinivasan is one of the authors of the new CDC study.
But “they have taken that ball and run with it,” says Dr. Srinivasan, who has worked with the Society of Hospital Medicine to address antibiotic resistance issues.
The goals of the study, published in the CDC’s Vital Signs on March 4, 2014, were to evaluate the extent and rationale for the prescribing of antibiotics in U.S. hospitals, while demonstrating opportunities for improvement in prescribing practices.
—Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System
Study authors analyzed data from the Truven Health MarketScan Hospital Drug Database and the CDC’s Emerging Infection Program and, using a model based on the data, demonstrated that a 30% reduction in broad-spectrum antibiotics use would decrease Clostridium difficile infection (CDI) by 26%. Overall antibiotic use would drop by 5%.
According to the CDC, antibiotics are among the most frequent causes of adverse drug events among hospitalized patients in the U.S., and complications like CDI can be deadly. In fact, 250,000 hospitalized patients are infected with CDI each year, resulting in 14,000 deaths.
“We’re really at a critical juncture in healthcare now,” Dr. Fishman says. “The field of stewardship has evolved mainly in academic tertiary care settings. The CDC report is timely because it highlights the necessity of making sure antibiotics are used appropriately in all healthcare settings.”
Take a Break
One of the ways in which hospitalists have addressed the need for more appropriate antibiotic prescribing in their institutions is the practice of an “antibiotic time-out.”
“After some point, when the dust settles at about 48-72 hours, you can evaluate the patient’s progress, evaluate their studies, [and] you may have culture results,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at the University of Michigan Medical School in Ann Arbor. At that point, physicians can decide whether to maintain a patient on the original antibiotic, alter the duration of treatment, or take them off the treatment altogether.
Dr. Flanders and a colleague published an editorial in the Journal of the American Medical Association Internal Medicine that coincided with the CDC report.2 A 2007 study published in Clinical Infectious Diseases found that the choice of antibiotic agent or duration of treatment can be incorrect in as many as half of all cases in which antibiotics are prescribed.3