Quality

Hospitalists Poised to Prevent, Combat Antibiotic-Resistant Pathogens


 

Describing formally for the first time the enormity of the problem of antibiotic resistance and warning of the “potentially catastrophic consequences of inaction,” the Centers for Disease Control and Prevention (CDC) announced in September that more than two million people a year are sickened by infections that are resistant to treatment with antibiotics.

Moreover, the CDC says 23,000 people die as a result.

And because those numbers are based only on the data available—and the agency assumes that many infections are not captured—the CDC says its estimate is a conservative one and the real number is probably higher.

The report is a call to action for hospitalists, who are in an almost ideal position to participate in efforts to prevent infections and control their spread once they’re discovered, says Jean Patel, PhD, deputy director of the office of antimicrobial resistance at the CDC.

“I think it’s a sobering number, and it indicates how far we have to go in combating this problem of antimicrobial resistance,” Dr. Patel says.

The medical community, she adds, cannot expect that new treatments will become available to fight all of these new infections.

“All of the drugs also are going to have some gaps in their range of activity, so there’s no drug coming that’s going to be effective against all the antimicrobial-resistant drugs that we face today,” Dr. Patel explains. “For that reason, we’re sounding the alarm that it’s important to pay attention to infection control and antibiotic stewardship practices.”

The report, “Antibiotic Resistance Threats to the United States, 2013,” creates three categories of antibiotic-resistant pathogens. In the “urgent” tier are Clostridium difficile, which the CDC estimates is responsible for 250,000 infections a year and 14,000 deaths; carbapenem-resistant Enterobacteriaceae, estimated to be responsible for 9,000 drug-resistant infections a year and 600 deaths; and drug-resistant Neisseria gonorrhoeae, at 246,000 drug-resistant infections.

These bacteria are considered an “immediate public health threat that requires urgent and aggressive action.”

There are 12 pathogens in the second category, described as “a serious concern” requiring “prompt and sustained action to ensure the problem does not grow.”

Of particular interest to hospitalists in this group, Dr. Patel says, is methicillin-resistant Staphylococcus aureus (MRSA). The CDC estimates that more than 80,000 severe MRSA infections and more than 11,000 deaths occur in the U.S. every year.

MRSA was not ranked as an “urgent” threat only because the number of infections is actually decreasing, especially in healthcare institutions, and because there are antibiotics that still work on MRSA.

Four “Core Action” Recommendations to Fight Antimicrobial Resistance

Prevent infections. This might be the most obvious way to fight antibiotic-resistance—if there’s no infection, there is no need to worry about one that can’t be treated. Hospitalists can help prevent infection by quickly and effectively treating those who are infected to prevent the spread, washing hands, and promoting effective cleaning habits.

Tracking. The CDC has programs to gather information on antibiotic-resistant infections, causes of infections, and risk factors for infections. With this information, hospitalists can stay aware of the threats. They can also help by remaining vigilant about signs of new resistance and helping to get that information to the CDC.

The CDC is now working on a new module that will collect antimicrobial-susceptibility data that’s generated in hospital labs, Dr. Patel says.

“This will be compiled in a national database and then made available to state and local public health departments that could track antimicrobial resistance trends in their own state,” she says. “We hope those data will then be used to identify new trends in anti-microbial resistance and used to strategize how to prevent resistance from being transmitted locally.”

Antibiotic stewardship. The CDC says prescribing antibiotics only when necessary and tailoring treatment as narrowly as possible might be the most important step in fighting antimicrobial resistance. The CDC estimates that up to half of antibiotic use in humans is unnecessary.

The CDC is working to capture data on antibiotic use in healthcare settings, which will be used for benchmarking antibiotic use among different institutions and regions.

“I think this additional information will really help healthcare institutions measure how well antibiotics are being used in their institutions and make appropriate adjustments,” Dr. Patel says.

New drugs and diagnostic tests. New antibiotics will be needed because, while resistance can be slowed, it cannot be stopped. However, the number of New Drug Application approvals for antibiotics has fallen drastically—nearly 20 from 1980 to 1984, but fewer than five from 2005 to 2012, according to the CDC report.

“If either of those things were to change—for example, if the rate of infections were to increase, or if these isolates were to become more resistant—then we would have to think about changing this from a serious threat to an urgent threat,” Dr. Patel says.

Another infection in the serious category that should be on hospitalists’ radar is drug-resistant Streptococcus pneumoniae. A new vaccine is helping to decrease the number of these infections, but hospitalists should be vigilant about infections that could escape the vaccine and become resistant, Dr. Patel says.

The report estimates as much as $20 billion in excess healthcare costs due to antimicrobial-resistant infections, with $35 billion in lost productivity in 2008 dollars.1

Ketino Kobaidze, MD, assistant professor at the Emory University School of Medicine in Atlanta and a member of the antimicrobial stewardship and infectious disease control committees at Emory University Hospital Midtown, says the sheer numbers are sure to get people to take notice.

“Two million is lots of patients,” she says. “It’s eye-opening, really, for many doctors and patients and society.”

The silver lining, she says, is that the field is moving toward diagnostic tools that will provide quick feedback on the type of infection at work.

It may be that hospitalists have no choice but to give an antibiotic to a patient because of the risk involved in not giving one; however, providers should quickly tailor that treatment to target the specific pathogen when more information is available.

“Two million is lots of patients. It’s eye-opening, really, for many doctors and patients and society.”

—Ketino Kobaidze, MD, assistant professor, Emory University School of Medicine, Atlanta, member, antimicrobial stewardship and infectious disease control committees, Emory University Hospital Midtown

“The most important thing, I think, for hospital medicine and medicine anywhere, is to follow up with whatever you’re ordering and notice right away what happens with these tests. If it’s positive or negative, redirect your care,” Dr. Kobaidze says. “Time is really an important issue here.

“As hospitalists, we need to be extremely cautious not to give them something they don’t need.”

Dr. Kobaidze was particularly struck by gonorrhea being listed in the “urgent” threat category.

“It was so easy to treat before,” she says. “It was nothing, piece of cake. This makes me a little bit concerned.”

Robert Orenstein, DO, an infectious disease expert at Mayo Clinic, praises the report and says hospitalists have a key role to play.

“I think this has a clear impact on hospitalists, who are the primary caregivers of many of these ill patients,” he says. “We need to educate them and build systems that target antimicrobials to the infecting agents and limit their use. Hospitalists are also the people who can help protect patients from the spread of these in the hospital by following appropriate infection prevention guidelines and educating their colleagues of the importance of this.”

He also stresses the importance of being aware of threats within your specific region.

“Many of these MDROs [multi-drug resistant organisms] have regional prevalence,” he says. “And it’s important to know which bugs are in your region so you can work with your institution and public health to tackle these.”


Tom Collins is a freelance writer in South Florida.

Stubborn Bugs

The CDC has created three levels of threats posed by antibiotic-resistant pathogens:

Urgent Threats

  • Clostridium difficile: 14,000 deaths a year; not yet resistant to antibiotics used, but spreads rapidly; stronger strain emerged in 2000.
  • Carbapenem-resistant Enterobacteriaceae (CRE): 600 deaths a year; some resistant to nearly all antibiotics, including carbapenems, considered the antibiotics of last resort.
  • Drug-resistant Neisseria gonorrhoeae: 246,000 drug-resistant infections a year; easily transmitted; showing resistance to the antibiotics used for treatment, including cefixime, ceftriaxone, azithromycin, and tetracycline.

Serious Threats

  • Multidrug-resistant Acinetobacter: 7,300 multidrug-resistant infections a year; about 63% of these bacteria considered multidrug-resistant, meaning at least three different classes of antibiotic no longer cure the infections.
  • Drug-resistant Campylobacter: 310,000 drug-resistant infections a year; showing resistance to ciprofloxacin and azithromycin; these infections sometimes last longer.
  • Fluconazole-resistant Candida (a fungus): 46,000 infections among hospitalized patients per year; showing increasing resistance to first and second line antifungal treatments.
  • Extended spectrum Beta-lactamase-producing Enterobacteriaceae (ESBLs): 26,000 drug-resistant infections a year; some are resistant to nearly all penicillins and cephalosporins, requiring use of last-resort carbapenems, leading to greater resistance to carbapenems.
  • Vancomycin-resistant Enterococccus (VRE): 20,000 drug-resistant infections a year; often cause infections among very sick hospitalized patients; some strains resistant to vancomycin, a last-resort treatment.
  • Multidrug-resistant Pseudomonas aeruginosa: 6,700 multidrug-resistant infections a year; some strains found to be resistant to nearly all, or all, antibiotics.
  • Drug-resistant nontyphoidal Salmonella: 100,000 drug-resistant infections a year; showing resistance to ceftriaxone, ciprofloxacin, and multiple classes of drugs.
  • Drug-resistant Salmonella Typhi: 3,800 drug-resistant infections a year; showing resistance to ceftriaxone, azithromycin, and ciprofloxacin.
  • Drug-resistant Shigella: 27,000 drug-resistant infections a year; high resistance to traditional first-line drugs and now showing resistance to alternatives such as ciprofloxacin and azithromycin.
  • Methicillin-resistant Staphylococcus aureus (MRSA): 80,461 severe infections a year; resistance to methicillin and related antibiotics (nafcillin, oxacillin) and to cephalosporins.
  • Drug-resistant Streptococcus pneumoniae: 1.2 million drug-resistant infections a year; has developed resistance to drugs in the penicillin and erythromycin groups and to less commonly used drugs.
  • Drug-resistant tuberculosis: 1,042 drug-resistant infections a year; resistance to drugs used for standard therapy; some TB is multidrug-resistant and resistant to fluoroquinolone and second line injectables like amikacin, kanamycin, and capreomycin.

Concerning Threats

  • Vancomycin-resistant Staphylococcus aureus (VRSA): 13 cases since 2002; resistance to vancomycin leaves few or no treatment options.
  • Erythromycin-resistant Group A Streptococcus: 1,300 drug-resistant infections a year; resistance to clindamycin and macrolides.
  • Clindamycin-resistant Group B Streptococcus: 7,600 drug-resistant infections a year; has developed resistance to clindamycin, erythromycin, and azithromycin; recently, the first cases of resistance to vancomycin have been detected.

Reference

  1. Roberts RR, Hota B, Ahmed I, et al. Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. Clin Infect Dis. 2009;49(8):1175-1184.

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