BLOG: Optimize antibiotic stewardship

November 1, 2013

Now is the time to dedicate resources in the inpatient and outpatient world to optimize antimicrobial stewardship.

On September 16th, the Centers for Disease Control and Prevention (CDC) released the first-ever summary (relative to the sea of literature out there, 113 pages is quite the summary) of antibiotic resistance that pose the greatest risk to humankind.

The term antibiotic includes agents that kill bacteria. The term antimicrobial is more inclusive, including bacteria, fungus, viruses, parasites, etc…  Since this document addresses a fungal issue (Candida), the term antimicrobial applies. However, the authors stated the term “bacteria” will include candida for simplicity.  What? 

This is really quite an inspirational document from the leaders at the CDC. It was written so that non-clinicians can grasp the concepts at stake. They cite the following statistics specific to the U.S.:

·       2,049.442 illnesses/yr attributed to resistant bacteria and fungus (most occur in the community)

o   23,000 deaths/yr (most in hospitals and nursing homes)

·       250,000 illnesses/yr attributed to Clostridium difficile (not really a resistance problem, but associated with antibiotic use)

o   14,000 deaths/yr

·       Up to $20 billion in excess direct healthcare costs

o   Lost productivity $35 billion/year (2008 dollars)

·       Up to 50% of all antibiotics are not needed or not effective as prescribed

Here are the infections with freshly highlighted targets on their backs. They are categorized by importance based on eight factors (clinical and economic impact, incidence, 10 yr projected incidence, transmissibility, availability of effective antibiotics and barriers to prevention):

Urgent Threats

·       Clostridium difficile

·       Carbapenem-resistant Enterobacteriaceae (CRE)

·       Drug-resistant Neisseria gonorrhoeae

Serious Threats

·       Multidrug-resistant Acinetobacter

·       Drug-resistant Campylobacter

·       Fluconazole-resistant Candida (a fungus)

·       Extended spectrum β-lactamase producing Enterobacteriaceae (ESBLs)

·       Vancomycin-resistant Enterococcus (VRE)

·       Multidrug-resistant Pseudomonas aeruginosa

·       Drug-resistant Non-typhoidal Salmonella

·       Drug-resistant Salmonella Typhi

·       Drug-resistant Shigella

·       Methicillin-resistant Staphylococcus aureus (MRSA)

·       Drug-resistant Streptococcus pneumoniae

·       Drug-resistant tuberculosis

Concerning Threats

·       Vancomycin-resistant Staphylococcus aureus (VRSA)

·       Erythromycin-resistant Group A Streptococcus

·       Clindamycin-resistant Group B Streptococcus

The document provides an actual break down of number of cases and deaths/year. And there are fantastic resources for individual, hallway adorning microbe posters on addressing the specific organisms above. There are lots of pictures and bulleted items. Be sure to review all of these eighteen organisms and assess whether your patient population is vulnerable to these and if you are prepared for the four action items listed next.

 Healthcare professionals should take action, as in now, with the following:

·       Prevent infections and prevent the spread of resistance

·       Track resistant bacteria

·       Improve antibiotic use through stewardship

·       Promote development of new antibiotics as well as diagnostic tests for resistant bacteria

Given that I am a pharmacist in a hospital, my major focus is on antibiotic stewardship.  Antibiotics are like aluminum in the rain forest at this point (not a renewable resource), due to financial and clinical constraints in the pharmaceutical world. As the surge in resistant organisms continues, now is the time to dedicate resources in the inpatient and outpatient world to optimize antimicrobial stewardship. Make a pitch to your senior management, again if necessary. California has mandated such action and hopefully the remainder of the country will follow.  If we continue to ignore it, it will not just go away, it will fester.

Dr Harper graduated from the University of Florida with her doctor of pharmacy and then went on to complete a pharmacy residency at Buffalo General Hospital in Buffalo, N.Y.  She then became a clinical coordinator/clinical manager at Millard Fillmore Gates in Buffalo, NY; Roosevelt Hospital in New York City, N.Y.; Chippenham Hospital in Richmond, Va.; and Vail Valley Medical Center in Vail, Colo., before coming to Poudre Valley Hospital in 2007.  In addition to being the clinical coordinator at Poudre Valley Hospital, she also is the residency program director for post graduate year-1 pharmacists.