Antimicrobial-resistant infections

Clinical question: Has the frequency of sepsis rates, along with administration of antibiotics in U.S. emergency departments (EDs), changed over time?

Background: Prior studies reviewing discharge data from hospitals suggest an increase of sepsis over time; however, little epidemiological research has evaluated the diagnosis of sepsis and antibiotic use in ED settings.

Study design: Retrospective, four-stage probability sample.

Setting: National Hospital Ambulatory Medical Care Survey (NHAMCS).

Synopsis: The NHAMCS includes a sample of all U.S. ED visits, except federal, military, and VA hospitals. According to NHAMCS data, an estimated 1.3 billion visits by adults to U.S. EDs occurred from 1994-2009, or approximately 81 million visits per year. Explicit sepsis was defined by the presence of the following, with ICD-9 codes: septicemia (038), sepsis (995.91), severe sepsis (995.92), or septic shock (785.52). Implicit sepsis was defined as a code indicating infection plus a code indicting organ dysfunction.

In U.S. EDs, explicit sepsis did not become more prevalent from 1994-2009; however, implicitly diagnosed sepsis increased by 7% every two years. There were 260,000 explicit sepsis-related ED visits per year, or 1.23 visits per 1,000 U.S. population. In-hospital mortality was 17% and 9% for the explicit and implicit diagnosis groups, respectively. On review of the explicit sepsis group, only 61% of the patients were found to have received antibiotics in the ED. The rate did increase over the time studied, from 52% in 1994-1997 to 69% in 2006-2009.

The study was limited by the retrospective analysis of data not designed to track sepsis or antibiotic use.

Bottom Line: Explicitly recognized sepsis remained stable in the ED setting from 1994-2009, and early antibiotic use has improved during this time, but there is still much opportunity for improvement.

Citation: Filbin MR, Arias SA, Camargo CA Jr, Barche A, Pallin DJ. Sepsis visits and antibiotic utilization in the U.S. emergency departments. Crit Care Med. 2014;42(3):528-535.

Clinical question: Has the frequency of sepsis rates, along with administration of antibiotics in U.S. emergency departments (EDs), changed over time?

Background: Prior studies reviewing discharge data from hospitals suggest an increase of sepsis over time; however, little epidemiological research has evaluated the diagnosis of sepsis and antibiotic use in ED settings.

Study design: Retrospective, four-stage probability sample.

Setting: National Hospital Ambulatory Medical Care Survey (NHAMCS).

Synopsis: The NHAMCS includes a sample of all U.S. ED visits, except federal, military, and VA hospitals. According to NHAMCS data, an estimated 1.3 billion visits by adults to U.S. EDs occurred from 1994-2009, or approximately 81 million visits per year. Explicit sepsis was defined by the presence of the following, with ICD-9 codes: septicemia (038), sepsis (995.91), severe sepsis (995.92), or septic shock (785.52). Implicit sepsis was defined as a code indicating infection plus a code indicting organ dysfunction.

In U.S. EDs, explicit sepsis did not become more prevalent from 1994-2009; however, implicitly diagnosed sepsis increased by 7% every two years. There were 260,000 explicit sepsis-related ED visits per year, or 1.23 visits per 1,000 U.S. population. In-hospital mortality was 17% and 9% for the explicit and implicit diagnosis groups, respectively. On review of the explicit sepsis group, only 61% of the patients were found to have received antibiotics in the ED. The rate did increase over the time studied, from 52% in 1994-1997 to 69% in 2006-2009.

The study was limited by the retrospective analysis of data not designed to track sepsis or antibiotic use.

Bottom Line: Explicitly recognized sepsis remained stable in the ED setting from 1994-2009, and early antibiotic use has improved during this time, but there is still much opportunity for improvement.

Citation: Filbin MR, Arias SA, Camargo CA Jr, Barche A, Pallin DJ. Sepsis visits and antibiotic utilization in the U.S. emergency departments. Crit Care Med. 2014;42(3):528-535.

Clinical question: Has the frequency of sepsis rates, along with administration of antibiotics in U.S. emergency departments (EDs), changed over time?

Background: Prior studies reviewing discharge data from hospitals suggest an increase of sepsis over time; however, little epidemiological research has evaluated the diagnosis of sepsis and antibiotic use in ED settings.

Study design: Retrospective, four-stage probability sample.

Setting: National Hospital Ambulatory Medical Care Survey (NHAMCS).

Synopsis: The NHAMCS includes a sample of all U.S. ED visits, except federal, military, and VA hospitals. According to NHAMCS data, an estimated 1.3 billion visits by adults to U.S. EDs occurred from 1994-2009, or approximately 81 million visits per year. Explicit sepsis was defined by the presence of the following, with ICD-9 codes: septicemia (038), sepsis (995.91), severe sepsis (995.92), or septic shock (785.52). Implicit sepsis was defined as a code indicating infection plus a code indicting organ dysfunction.

In U.S. EDs, explicit sepsis did not become more prevalent from 1994-2009; however, implicitly diagnosed sepsis increased by 7% every two years. There were 260,000 explicit sepsis-related ED visits per year, or 1.23 visits per 1,000 U.S. population. In-hospital mortality was 17% and 9% for the explicit and implicit diagnosis groups, respectively. On review of the explicit sepsis group, only 61% of the patients were found to have received antibiotics in the ED. The rate did increase over the time studied, from 52% in 1994-1997 to 69% in 2006-2009.

The study was limited by the retrospective analysis of data not designed to track sepsis or antibiotic use.

Bottom Line: Explicitly recognized sepsis remained stable in the ED setting from 1994-2009, and early antibiotic use has improved during this time, but there is still much opportunity for improvement.

Citation: Filbin MR, Arias SA, Camargo CA Jr, Barche A, Pallin DJ. Sepsis visits and antibiotic utilization in the U.S. emergency departments. Crit Care Med. 2014;42(3):528-535.

Clinical question: What are the current prescribing practices for antibiotics used to treat skin and soft tissue infections in the outpatient setting?

Background: Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotic use. Because antibiotic use is associated with bacterial resistance and adverse events, understanding antibiotic prescribing practices is necessary to minimize these types of complications.

Study design: Retrospective cohort.

Setting: Ambulatory care setting in the Denver Health System.

Synopsis: Data from 364 adults and children who presented to an ambulatory setting with a primary diagnosis of skin and soft tissue infection were analyzed using a stepwise multivariate logistic regression in order to determine factors associated with avoidable antibiotic exposure. Among cellulitis cases, 61% of patients were prescribed antibiotics to treat methicillin-resistant Staphylococcus aureus. Avoidable antibiotic exposure occurred in 46% of cases, including use of antibiotics with broad Gram-negative activity (4%), combination therapy (12%), and treatment for ≥10 days (42%). Use of short-course, single-antibiotic treatment approaches consistent with national guidelines would have reduced prescribed antibiotic days by 19%, to 55%.

Bottom line: Avoidable antibiotic exposure frequently occurs in the treatment of uncomplicated skin infections; using short-course, single-antibiotic treatment strategies could significantly reduce total antibiotic use.

Citation: Hurley HJ, Knepper BC, Price CS, Mehler PS, Burman WJ, Jenkins TC. Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med. 2013;126(12):1099-1106.

Clinical question: What are the current prescribing practices for antibiotics used to treat skin and soft tissue infections in the outpatient setting?

Background: Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotic use. Because antibiotic use is associated with bacterial resistance and adverse events, understanding antibiotic prescribing practices is necessary to minimize these types of complications.

Study design: Retrospective cohort.

Setting: Ambulatory care setting in the Denver Health System.

Synopsis: Data from 364 adults and children who presented to an ambulatory setting with a primary diagnosis of skin and soft tissue infection were analyzed using a stepwise multivariate logistic regression in order to determine factors associated with avoidable antibiotic exposure. Among cellulitis cases, 61% of patients were prescribed antibiotics to treat methicillin-resistant Staphylococcus aureus. Avoidable antibiotic exposure occurred in 46% of cases, including use of antibiotics with broad Gram-negative activity (4%), combination therapy (12%), and treatment for ≥10 days (42%). Use of short-course, single-antibiotic treatment approaches consistent with national guidelines would have reduced prescribed antibiotic days by 19%, to 55%.

Bottom line: Avoidable antibiotic exposure frequently occurs in the treatment of uncomplicated skin infections; using short-course, single-antibiotic treatment strategies could significantly reduce total antibiotic use.

Citation: Hurley HJ, Knepper BC, Price CS, Mehler PS, Burman WJ, Jenkins TC. Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med. 2013;126(12):1099-1106.

Clinical question: What are the current prescribing practices for antibiotics used to treat skin and soft tissue infections in the outpatient setting?

Background: Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotic use. Because antibiotic use is associated with bacterial resistance and adverse events, understanding antibiotic prescribing practices is necessary to minimize these types of complications.

Study design: Retrospective cohort.

Setting: Ambulatory care setting in the Denver Health System.

Synopsis: Data from 364 adults and children who presented to an ambulatory setting with a primary diagnosis of skin and soft tissue infection were analyzed using a stepwise multivariate logistic regression in order to determine factors associated with avoidable antibiotic exposure. Among cellulitis cases, 61% of patients were prescribed antibiotics to treat methicillin-resistant Staphylococcus aureus. Avoidable antibiotic exposure occurred in 46% of cases, including use of antibiotics with broad Gram-negative activity (4%), combination therapy (12%), and treatment for ≥10 days (42%). Use of short-course, single-antibiotic treatment approaches consistent with national guidelines would have reduced prescribed antibiotic days by 19%, to 55%.

Bottom line: Avoidable antibiotic exposure frequently occurs in the treatment of uncomplicated skin infections; using short-course, single-antibiotic treatment strategies could significantly reduce total antibiotic use.

Citation: Hurley HJ, Knepper BC, Price CS, Mehler PS, Burman WJ, Jenkins TC. Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med. 2013;126(12):1099-1106.

By Mark Shen, MD

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: Is a short course (less than four weeks) of antibiotics effective for the treatment of acute osteomyelitis and septic arthritis?

Background: The optimal duration of treatment for acute bone and joint infections in children has not been assessed adequately in prospectively designed trials. Historically, intravenous (IV) antibiotics in four- to six-week durations have been recommended, although the evidence for this practice is limited. There is widespread variation in both the route of administration (oral vs. IV) and duration of this treatment.

Study design: Prospective cohort study.

Setting: Two children’s hospitals in Australia.

Synopsis: Seventy children ages 17 and under who presented to two tertiary-care children’s hospitals with osteomyelitis or septic arthritis were enrolled. Primary surgical drainage was performed for patients with septic arthritis. Intravenous antibiotics were administered for at least three days, and until clinical symptoms improved and the C-reactive protein levels had stabilized. Patients then were transitioned to oral antibiotics and discharged to complete a minimum of three weeks of therapy.

Fifty-nine percent of patients were converted to oral antibiotics by day three, 86% by day five of therapy. Based on clinical and hematologic assessment, 83% of patients had oral antibiotics stopped at the three-week followup and remained well through the 12-month follow-up period.

This study essentially involved prospective data collection for a cohort of children receiving standardized care. Although the results suggest that a majority of children can be treated with a three-week course of oral antibiotics, the results would have been further strengthened by an explicit protocol with well-defined criteria for the oral to IV transition and cessation of antibiotic therapy. Additional limitations include pathogens and antibiotic choices that might not be applicable to North American populations.

Bottom line: After initial intravenous therapy, a three-week course of oral antibiotics can be effective for acute osteomyelitis and septic arthritis in children.

Citation: Jagodzinski NA, Kanwar R, Graham K, Bache CE. Prospective evaluation of a shortened regimen of treatment for acute osteomyelitis and septic arthritis in children. J Pediatr Orthop. 2009;29(5):518-525.

By Mark Shen, MD

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: Is a short course (less than four weeks) of antibiotics effective for the treatment of acute osteomyelitis and septic arthritis?

Background: The optimal duration of treatment for acute bone and joint infections in children has not been assessed adequately in prospectively designed trials. Historically, intravenous (IV) antibiotics in four- to six-week durations have been recommended, although the evidence for this practice is limited. There is widespread variation in both the route of administration (oral vs. IV) and duration of this treatment.

Study design: Prospective cohort study.

Setting: Two children’s hospitals in Australia.

Synopsis: Seventy children ages 17 and under who presented to two tertiary-care children’s hospitals with osteomyelitis or septic arthritis were enrolled. Primary surgical drainage was performed for patients with septic arthritis. Intravenous antibiotics were administered for at least three days, and until clinical symptoms improved and the C-reactive protein levels had stabilized. Patients then were transitioned to oral antibiotics and discharged to complete a minimum of three weeks of therapy.

Fifty-nine percent of patients were converted to oral antibiotics by day three, 86% by day five of therapy. Based on clinical and hematologic assessment, 83% of patients had oral antibiotics stopped at the three-week followup and remained well through the 12-month follow-up period.

This study essentially involved prospective data collection for a cohort of children receiving standardized care. Although the results suggest that a majority of children can be treated with a three-week course of oral antibiotics, the results would have been further strengthened by an explicit protocol with well-defined criteria for the oral to IV transition and cessation of antibiotic therapy. Additional limitations include pathogens and antibiotic choices that might not be applicable to North American populations.

Bottom line: After initial intravenous therapy, a three-week course of oral antibiotics can be effective for acute osteomyelitis and septic arthritis in children.

Citation: Jagodzinski NA, Kanwar R, Graham K, Bache CE. Prospective evaluation of a shortened regimen of treatment for acute osteomyelitis and septic arthritis in children. J Pediatr Orthop. 2009;29(5):518-525.

By Mark Shen, MD

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: Is a short course (less than four weeks) of antibiotics effective for the treatment of acute osteomyelitis and septic arthritis?

Background: The optimal duration of treatment for acute bone and joint infections in children has not been assessed adequately in prospectively designed trials. Historically, intravenous (IV) antibiotics in four- to six-week durations have been recommended, although the evidence for this practice is limited. There is widespread variation in both the route of administration (oral vs. IV) and duration of this treatment.

Study design: Prospective cohort study.

Setting: Two children’s hospitals in Australia.

Synopsis: Seventy children ages 17 and under who presented to two tertiary-care children’s hospitals with osteomyelitis or septic arthritis were enrolled. Primary surgical drainage was performed for patients with septic arthritis. Intravenous antibiotics were administered for at least three days, and until clinical symptoms improved and the C-reactive protein levels had stabilized. Patients then were transitioned to oral antibiotics and discharged to complete a minimum of three weeks of therapy.

Fifty-nine percent of patients were converted to oral antibiotics by day three, 86% by day five of therapy. Based on clinical and hematologic assessment, 83% of patients had oral antibiotics stopped at the three-week followup and remained well through the 12-month follow-up period.

This study essentially involved prospective data collection for a cohort of children receiving standardized care. Although the results suggest that a majority of children can be treated with a three-week course of oral antibiotics, the results would have been further strengthened by an explicit protocol with well-defined criteria for the oral to IV transition and cessation of antibiotic therapy. Additional limitations include pathogens and antibiotic choices that might not be applicable to North American populations.

Bottom line: After initial intravenous therapy, a three-week course of oral antibiotics can be effective for acute osteomyelitis and septic arthritis in children.

Citation: Jagodzinski NA, Kanwar R, Graham K, Bache CE. Prospective evaluation of a shortened regimen of treatment for acute osteomyelitis and septic arthritis in children. J Pediatr Orthop. 2009;29(5):518-525.

Clinical question: Is once-weekly intravenous dalbavancin as effective as conventional therapy for the treatment of acute bacterial skin infections?

Background: Acute bacterial skin infections are common and often require hospitalization for intravenous antibiotic administration. Treatment covering gram-positive bacteria usually is indicated. Dalbavancin is effective against gram-positives, including MRSA. Its long half-life makes it an attractive alternative to other commonly used antibiotics, which require more frequent dosing.

Study design: Phase 3, double-blinded RCT.

Setting: Multiple international centers.

Synopsis: Researchers randomized 1,312 patients with acute bacterial skin and skin-structure infections with signs of systemic infection requiring intravenous antibiotics to receive dalbavancin on days one and eight, with placebo on other days, or several doses of vancomycin with an option to switch to oral linezolid. The primary endpoint was cessation of spread of erythema and temperature of ≤37.6°C at 48-72 hours. Secondary endpoints included a decrease in lesion area of ≥20% at 48-72 hours and clinical success at end of therapy (determined by clinical and historical features).

Results of the primary endpoint were similar with dalbavancin and vancomycin-linezolid groups (79.7% and 79.8%, respectively) and were within 10 percentage points of noninferiority. The secondary endpoints were similar between both groups.

Limitations of the study were the early primary endpoint, lack of noninferiority analysis of the secondary endpoints, and cost-effective analysis.

Bottom line: Once-weekly dalbavancin appears to be similarly efficacious to intravenous vancomycin in the treatment of acute bacterial skin infections in terms of outcomes within 48-72 hours of therapy and might provide an alternative to continued inpatient hospitalization for intravenous antibiotics in stable patients.

Citation: Boucher HW, Wilcox M, Talbot GH, Puttagunta S, Das AF, Dunne MW. Once-weekly dalbavancin versus daily conventional therapy for skin infection. N Engl J Med. 2014;370(23):2169-2179.

Clinical question: Is once-weekly intravenous dalbavancin as effective as conventional therapy for the treatment of acute bacterial skin infections?

Background: Acute bacterial skin infections are common and often require hospitalization for intravenous antibiotic administration. Treatment covering gram-positive bacteria usually is indicated. Dalbavancin is effective against gram-positives, including MRSA. Its long half-life makes it an attractive alternative to other commonly used antibiotics, which require more frequent dosing.

Study design: Phase 3, double-blinded RCT.

Setting: Multiple international centers.

Synopsis: Researchers randomized 1,312 patients with acute bacterial skin and skin-structure infections with signs of systemic infection requiring intravenous antibiotics to receive dalbavancin on days one and eight, with placebo on other days, or several doses of vancomycin with an option to switch to oral linezolid. The primary endpoint was cessation of spread of erythema and temperature of ≤37.6°C at 48-72 hours. Secondary endpoints included a decrease in lesion area of ≥20% at 48-72 hours and clinical success at end of therapy (determined by clinical and historical features).

Results of the primary endpoint were similar with dalbavancin and vancomycin-linezolid groups (79.7% and 79.8%, respectively) and were within 10 percentage points of noninferiority. The secondary endpoints were similar between both groups.

Limitations of the study were the early primary endpoint, lack of noninferiority analysis of the secondary endpoints, and cost-effective analysis.

Bottom line: Once-weekly dalbavancin appears to be similarly efficacious to intravenous vancomycin in the treatment of acute bacterial skin infections in terms of outcomes within 48-72 hours of therapy and might provide an alternative to continued inpatient hospitalization for intravenous antibiotics in stable patients.

Citation: Boucher HW, Wilcox M, Talbot GH, Puttagunta S, Das AF, Dunne MW. Once-weekly dalbavancin versus daily conventional therapy for skin infection. N Engl J Med. 2014;370(23):2169-2179.

Clinical question: Is once-weekly intravenous dalbavancin as effective as conventional therapy for the treatment of acute bacterial skin infections?

Background: Acute bacterial skin infections are common and often require hospitalization for intravenous antibiotic administration. Treatment covering gram-positive bacteria usually is indicated. Dalbavancin is effective against gram-positives, including MRSA. Its long half-life makes it an attractive alternative to other commonly used antibiotics, which require more frequent dosing.

Study design: Phase 3, double-blinded RCT.

Setting: Multiple international centers.

Synopsis: Researchers randomized 1,312 patients with acute bacterial skin and skin-structure infections with signs of systemic infection requiring intravenous antibiotics to receive dalbavancin on days one and eight, with placebo on other days, or several doses of vancomycin with an option to switch to oral linezolid. The primary endpoint was cessation of spread of erythema and temperature of ≤37.6°C at 48-72 hours. Secondary endpoints included a decrease in lesion area of ≥20% at 48-72 hours and clinical success at end of therapy (determined by clinical and historical features).

Results of the primary endpoint were similar with dalbavancin and vancomycin-linezolid groups (79.7% and 79.8%, respectively) and were within 10 percentage points of noninferiority. The secondary endpoints were similar between both groups.

Limitations of the study were the early primary endpoint, lack of noninferiority analysis of the secondary endpoints, and cost-effective analysis.

Bottom line: Once-weekly dalbavancin appears to be similarly efficacious to intravenous vancomycin in the treatment of acute bacterial skin infections in terms of outcomes within 48-72 hours of therapy and might provide an alternative to continued inpatient hospitalization for intravenous antibiotics in stable patients.

Citation: Boucher HW, Wilcox M, Talbot GH, Puttagunta S, Das AF, Dunne MW. Once-weekly dalbavancin versus daily conventional therapy for skin infection. N Engl J Med. 2014;370(23):2169-2179.

Overuse of antibiotics is fueling antimicrobial resistance, posing a threat to people around the world and prompting increased attention to antibiotic stewardship practices. Good stewardship requires hospitals and clinicians to adopt coordinated interventions that focus on reducing inappropriate antibiotic prescribing while remaining focused on the health of patients.

Although it can seem overwhelming to physicians with busy workloads and sick patients to engage in these practices, not addressing the issue of responsible antibiotic prescribing is putting patients at risk.

“We know development of resistance is complicated,” 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 CDC’s division of Healthcare Quality Promotion. Dr. Srinivasan is one of the authors of a recent CDC report on antibiotic prescribing practices across the U.S. “Nonetheless, we know that overuse of antibiotics leads to increases in resistance. We also know that if we can improve the way we prescribe them, we can reduce antibiotic resistance.”

The CDC recommends that hospitals adopt, at a minimum, the following antibiotic stewardship checklist:

• Commit leadership: Dedicate necessary human, financial, and information technology resources.
• Create accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
• Provide drug expertise: Appoint a single pharmacist leader to support improved prescribing.
• Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
• Track: Monitor prescribing and antibiotic resistance patterns.
• Report: Regularly report to staff on prescribing and resistance patterns, as well as steps to improve.
• Educate: Offer education about antibiotic resistance and improving prescribing practices.
• Work with other healthcare facilities to prevent infections, transmission, and resistance.

These practices are not just the domain of infectious disease clinicians, either, 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. In 1992, Dr. Fishman helped establish an antibiotic stewardship program at Penn, working with infectious disease staff to identify and adopt best practices tailored to their needs.

Their efforts have shown promise in improving the health of their patients, he says, and many institutions that adopt stewardship programs typically see cost savings, too.

“These programs do usually end up decreasing drug costs but also increasing the quality of care,”

Dr. Fishman says. “If you can cut out 30% of unnecessary drugs, you cut drug costs. To me, that meets the true definition of value in healthcare.”

In one study that looked at stewardship-related cost reduction, primarily among larger healthcare settings, the average annual savings from reduced inappropriate antibiotic prescribing ranged from $200,000 to $900,000.

The recent CDC report, to which Dr. Srinivasan contributed, was published March 4 in Vital Signs. The study found that as many as a third of antibiotics prescribed are done so inappropriately. According to experts, hospitals and other healthcare institutions need to develop processes and standards to assist physicians in efforts to be responsible antibiotic prescribers.

“Sometimes, when you’re focusing on other issues, antibiotics are a bit of an afterthought,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at University of Michigan Medical School in Ann Arbor.

“If there is not a checklist of processes [and] things are not accounted for in a systematic way, it doesn’t happen.”

Dr. Flanders and colleague Sanjay Saint, MD, MPH, the University of Michigan George Dock Collegiate professor of internal medicine and associate chief of medicine at the VA Ann Arbor Healthcare System, recently published an article in the Journal of the American Medical Association Internal Medicine in which they recommend the following:

• Antimicrobial stewardship programs, which aim to develop guidelines and implement programs that help optimize antibiotic use among hospitalized patients, should partner with front-line clinicians to tackle the problem.
• Clinicians should better document aspects of antibiotic use that can be shared with other providers caring for the same patient throughout his or her hospital stay and after discharge.
• Clinicians should take an “antibiotic time-out” after 48-72 hours of a patient’s use of antibiotics to reassess the use of these drugs.
• Treatment and its duration should be in line with evidence-based guidelines, and institutions should work to clearly identify appropriate treatment duration.
• Improved diagnostic tests should be available to physicians.
• Target diagnostic error by working to improve how physicians think when considering whether to provide antibiotics.
• Develop performance measures that highlight common conditions in which antibiotics are overprescribed, to shine a brighter light on the problem.

“I think we can make a lot of progress,” Dr. Flanders says. “The problem is complex; it developed over decades, and any solutions are unlikely to solve the problem immediately. But there are several examples of institutions and hospitals making significant inroads in a short period of time.” —KAT

Overuse of antibiotics is fueling antimicrobial resistance, posing a threat to people around the world and prompting increased attention to antibiotic stewardship practices. Good stewardship requires hospitals and clinicians to adopt coordinated interventions that focus on reducing inappropriate antibiotic prescribing while remaining focused on the health of patients.

Although it can seem overwhelming to physicians with busy workloads and sick patients to engage in these practices, not addressing the issue of responsible antibiotic prescribing is putting patients at risk.

“We know development of resistance is complicated,” 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 CDC’s division of Healthcare Quality Promotion. Dr. Srinivasan is one of the authors of a recent CDC report on antibiotic prescribing practices across the U.S. “Nonetheless, we know that overuse of antibiotics leads to increases in resistance. We also know that if we can improve the way we prescribe them, we can reduce antibiotic resistance.”

The CDC recommends that hospitals adopt, at a minimum, the following antibiotic stewardship checklist:

• Commit leadership: Dedicate necessary human, financial, and information technology resources.
• Create accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
• Provide drug expertise: Appoint a single pharmacist leader to support improved prescribing.
• Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
• Track: Monitor prescribing and antibiotic resistance patterns.
• Report: Regularly report to staff on prescribing and resistance patterns, as well as steps to improve.
• Educate: Offer education about antibiotic resistance and improving prescribing practices.
• Work with other healthcare facilities to prevent infections, transmission, and resistance.

These practices are not just the domain of infectious disease clinicians, either, 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. In 1992, Dr. Fishman helped establish an antibiotic stewardship program at Penn, working with infectious disease staff to identify and adopt best practices tailored to their needs.

Their efforts have shown promise in improving the health of their patients, he says, and many institutions that adopt stewardship programs typically see cost savings, too.

“These programs do usually end up decreasing drug costs but also increasing the quality of care,”

Dr. Fishman says. “If you can cut out 30% of unnecessary drugs, you cut drug costs. To me, that meets the true definition of value in healthcare.”

In one study that looked at stewardship-related cost reduction, primarily among larger healthcare settings, the average annual savings from reduced inappropriate antibiotic prescribing ranged from $200,000 to $900,000.

The recent CDC report, to which Dr. Srinivasan contributed, was published March 4 in Vital Signs. The study found that as many as a third of antibiotics prescribed are done so inappropriately. According to experts, hospitals and other healthcare institutions need to develop processes and standards to assist physicians in efforts to be responsible antibiotic prescribers.

“Sometimes, when you’re focusing on other issues, antibiotics are a bit of an afterthought,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at University of Michigan Medical School in Ann Arbor.

“If there is not a checklist of processes [and] things are not accounted for in a systematic way, it doesn’t happen.”

Dr. Flanders and colleague Sanjay Saint, MD, MPH, the University of Michigan George Dock Collegiate professor of internal medicine and associate chief of medicine at the VA Ann Arbor Healthcare System, recently published an article in the Journal of the American Medical Association Internal Medicine in which they recommend the following:

• Antimicrobial stewardship programs, which aim to develop guidelines and implement programs that help optimize antibiotic use among hospitalized patients, should partner with front-line clinicians to tackle the problem.
• Clinicians should better document aspects of antibiotic use that can be shared with other providers caring for the same patient throughout his or her hospital stay and after discharge.
• Clinicians should take an “antibiotic time-out” after 48-72 hours of a patient’s use of antibiotics to reassess the use of these drugs.
• Treatment and its duration should be in line with evidence-based guidelines, and institutions should work to clearly identify appropriate treatment duration.
• Improved diagnostic tests should be available to physicians.
• Target diagnostic error by working to improve how physicians think when considering whether to provide antibiotics.
• Develop performance measures that highlight common conditions in which antibiotics are overprescribed, to shine a brighter light on the problem.

“I think we can make a lot of progress,” Dr. Flanders says. “The problem is complex; it developed over decades, and any solutions are unlikely to solve the problem immediately. But there are several examples of institutions and hospitals making significant inroads in a short period of time.” —KAT

Overuse of antibiotics is fueling antimicrobial resistance, posing a threat to people around the world and prompting increased attention to antibiotic stewardship practices. Good stewardship requires hospitals and clinicians to adopt coordinated interventions that focus on reducing inappropriate antibiotic prescribing while remaining focused on the health of patients.

Although it can seem overwhelming to physicians with busy workloads and sick patients to engage in these practices, not addressing the issue of responsible antibiotic prescribing is putting patients at risk.

“We know development of resistance is complicated,” 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 CDC’s division of Healthcare Quality Promotion. Dr. Srinivasan is one of the authors of a recent CDC report on antibiotic prescribing practices across the U.S. “Nonetheless, we know that overuse of antibiotics leads to increases in resistance. We also know that if we can improve the way we prescribe them, we can reduce antibiotic resistance.”

The CDC recommends that hospitals adopt, at a minimum, the following antibiotic stewardship checklist:

• Commit leadership: Dedicate necessary human, financial, and information technology resources.
• Create accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
• Provide drug expertise: Appoint a single pharmacist leader to support improved prescribing.
• Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
• Track: Monitor prescribing and antibiotic resistance patterns.
• Report: Regularly report to staff on prescribing and resistance patterns, as well as steps to improve.
• Educate: Offer education about antibiotic resistance and improving prescribing practices.
• Work with other healthcare facilities to prevent infections, transmission, and resistance.

These practices are not just the domain of infectious disease clinicians, either, 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. In 1992, Dr. Fishman helped establish an antibiotic stewardship program at Penn, working with infectious disease staff to identify and adopt best practices tailored to their needs.

Their efforts have shown promise in improving the health of their patients, he says, and many institutions that adopt stewardship programs typically see cost savings, too.

“These programs do usually end up decreasing drug costs but also increasing the quality of care,”

Dr. Fishman says. “If you can cut out 30% of unnecessary drugs, you cut drug costs. To me, that meets the true definition of value in healthcare.”

In one study that looked at stewardship-related cost reduction, primarily among larger healthcare settings, the average annual savings from reduced inappropriate antibiotic prescribing ranged from $200,000 to $900,000.

The recent CDC report, to which Dr. Srinivasan contributed, was published March 4 in Vital Signs. The study found that as many as a third of antibiotics prescribed are done so inappropriately. According to experts, hospitals and other healthcare institutions need to develop processes and standards to assist physicians in efforts to be responsible antibiotic prescribers.

“Sometimes, when you’re focusing on other issues, antibiotics are a bit of an afterthought,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at University of Michigan Medical School in Ann Arbor.

“If there is not a checklist of processes [and] things are not accounted for in a systematic way, it doesn’t happen.”

Dr. Flanders and colleague Sanjay Saint, MD, MPH, the University of Michigan George Dock Collegiate professor of internal medicine and associate chief of medicine at the VA Ann Arbor Healthcare System, recently published an article in the Journal of the American Medical Association Internal Medicine in which they recommend the following:

• Antimicrobial stewardship programs, which aim to develop guidelines and implement programs that help optimize antibiotic use among hospitalized patients, should partner with front-line clinicians to tackle the problem.
• Clinicians should better document aspects of antibiotic use that can be shared with other providers caring for the same patient throughout his or her hospital stay and after discharge.
• Clinicians should take an “antibiotic time-out” after 48-72 hours of a patient’s use of antibiotics to reassess the use of these drugs.
• Treatment and its duration should be in line with evidence-based guidelines, and institutions should work to clearly identify appropriate treatment duration.
• Improved diagnostic tests should be available to physicians.
• Target diagnostic error by working to improve how physicians think when considering whether to provide antibiotics.
• Develop performance measures that highlight common conditions in which antibiotics are overprescribed, to shine a brighter light on the problem.

“I think we can make a lot of progress,” Dr. Flanders says. “The problem is complex; it developed over decades, and any solutions are unlikely to solve the problem immediately. But there are several examples of institutions and hospitals making significant inroads in a short period of time.” —KAT

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.

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

Dr. Flanders, a past president of SHM who has worked extensively with the CDC and the Institute for Healthcare Improvement, was behind the development of the time-out strategy. Dr. Srinivasan says the clinical utility of the method was “eye-opening.”

The strategy, which has taken hold among hospital groups the CDC has worked with, has demonstrated that stewardship and patient management are not at odds, Dr. Srinivasan says. Despite patient sign-outs and hand-offs, the time-out strategy allows any clinician to track a patient’s antibiotic status and reevaluate the treatment plan.

Having a process is critical to more responsible prescribing practices, Dr. Flanders says. He attributes much of the variability in antibiotics prescribing among similar departments at hospitals across the country to a lack of standards, though he noted that variability in patient populations undoubtedly plays a role.

Lack of Stats

The CDC report showed up to a threefold difference in the number of antibiotics prescribed to patients in similar hospital settings at hospitals across the country. The reasons for this are not known, Dr. Fishman says.

“The main reason we don’t know is we don’t have a good mechanism in the U.S. right now to monitor antibiotics use,” he explains. “We don’t have a way for healthcare facilities to benchmark their use.”

Without good strategies to monitor and develop more responsible antibiotics prescription practices, Dr. Flanders believes many physicians find themselves trapped by the “chagrin” of not prescribing.

“Patients often enter the hospital without a clear diagnosis,” he says. “They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

“We know delays increase mortality, and that’s not an acceptable option.”

Patients often enter the hospital without a clear diagnosis. They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

 

—Scott Flanders, MD, FACP, MHM, professor of internal medicine, director of hospital medicine, University of Michigan Medical School, Ann Arbor, past president, SHM

Beyond the Bedside

Many physicians fail to consider the bigger societal implications when prescribing antibiotics for sick patients in their charge, because their responsibility is, first and foremost, to that individual. But, Dr. Srinivasan says, “good antibiotic stewardship is beneficial to the patient lying in the bed in front of you, because every day we are confronted with C. diff. infections, adverse drug events, all of these issues.”

Strategies and processes help hospitalists make the best decision for their patients at the time they require care, while providing room for adaptation and the improvements that serve all patients.

Some institutions use interventions like prospective audit and feedback monitoring to help physicians become more responsible antibiotic prescribers, says Dr. Fishman, who worked with infectious disease specialists at the University of Pennsylvania in the early 1990s to develop a stewardship program there.

“In our institution, we see better outcomes—lower complications—usually associated with a decreased length of stay, at least in the ICU for critically ill patients—and increased cure rates,” he says.

Stewardship efforts take investment on the part of the hospital. Dr. Fishman cited a recent study at the Children’s Hospital of Pennsylvania that looked at whether a particular education strategy the hospital implemented actually led to improvements.⁴

“It was successful in intervening in this problem [of inappropriate prescribing] in pediatricians, but it did take ongoing education of both healthcare providers and patients,” he says, noting that large financial and time investments are necessary for the ongoing training and follow-up that is necessary.

And patients need to be educated, too.

“It takes a minute to write that prescription and probably 15 or 20 minutes not to write it,” Dr. Fishman says. “We need to educate patients about potential complications of antibiotics use, as well as the signs and symptoms of infection.”

The CDC report is a call to action for all healthcare providers to consider how they can become better antibiotic stewards. There are very few new antibiotics on the market and little in the pipeline. All providers must do what they can to preserve the antibiotics we currently have, Dr. Fishman says.

“There is opportunity, and I think hospitalists are up to the challenge,” Dr. Flanders says. “They are doing lots of work to improve quality across lots of domains in their hospitals. I think this is an area where attention is deserved.”

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

References

1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vital signs: improving antibiotic use among hospitalized patients. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm?s_cid=mm6309a4_w. Accessed August 31, 2014.
2. Flanders SA, Saint S. Why does antrimicrobial overuse in hospitalized patients persist? JAMA Internal Medicine online. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1838720. Accessed August 31, 2014.
3. Dellit TH, Owens RC, McGowan JE, et al. Clinical Infectious Diseases online. Available at: http://cid.oxfordjournals.org/content/44/2/159.full. Accessed August 31, 2014.
4. Gerber JS, Prasad PA, Fiks A, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA. 2013;309(22):2345-2352.

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.

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

Dr. Flanders, a past president of SHM who has worked extensively with the CDC and the Institute for Healthcare Improvement, was behind the development of the time-out strategy. Dr. Srinivasan says the clinical utility of the method was “eye-opening.”

The strategy, which has taken hold among hospital groups the CDC has worked with, has demonstrated that stewardship and patient management are not at odds, Dr. Srinivasan says. Despite patient sign-outs and hand-offs, the time-out strategy allows any clinician to track a patient’s antibiotic status and reevaluate the treatment plan.

Having a process is critical to more responsible prescribing practices, Dr. Flanders says. He attributes much of the variability in antibiotics prescribing among similar departments at hospitals across the country to a lack of standards, though he noted that variability in patient populations undoubtedly plays a role.

Lack of Stats

The CDC report showed up to a threefold difference in the number of antibiotics prescribed to patients in similar hospital settings at hospitals across the country. The reasons for this are not known, Dr. Fishman says.

“The main reason we don’t know is we don’t have a good mechanism in the U.S. right now to monitor antibiotics use,” he explains. “We don’t have a way for healthcare facilities to benchmark their use.”

Without good strategies to monitor and develop more responsible antibiotics prescription practices, Dr. Flanders believes many physicians find themselves trapped by the “chagrin” of not prescribing.

“Patients often enter the hospital without a clear diagnosis,” he says. “They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

“We know delays increase mortality, and that’s not an acceptable option.”

Patients often enter the hospital without a clear diagnosis. They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

 

—Scott Flanders, MD, FACP, MHM, professor of internal medicine, director of hospital medicine, University of Michigan Medical School, Ann Arbor, past president, SHM

Beyond the Bedside

Many physicians fail to consider the bigger societal implications when prescribing antibiotics for sick patients in their charge, because their responsibility is, first and foremost, to that individual. But, Dr. Srinivasan says, “good antibiotic stewardship is beneficial to the patient lying in the bed in front of you, because every day we are confronted with C. diff. infections, adverse drug events, all of these issues.”

Strategies and processes help hospitalists make the best decision for their patients at the time they require care, while providing room for adaptation and the improvements that serve all patients.

Some institutions use interventions like prospective audit and feedback monitoring to help physicians become more responsible antibiotic prescribers, says Dr. Fishman, who worked with infectious disease specialists at the University of Pennsylvania in the early 1990s to develop a stewardship program there.

“In our institution, we see better outcomes—lower complications—usually associated with a decreased length of stay, at least in the ICU for critically ill patients—and increased cure rates,” he says.

Stewardship efforts take investment on the part of the hospital. Dr. Fishman cited a recent study at the Children’s Hospital of Pennsylvania that looked at whether a particular education strategy the hospital implemented actually led to improvements.⁴

“It was successful in intervening in this problem [of inappropriate prescribing] in pediatricians, but it did take ongoing education of both healthcare providers and patients,” he says, noting that large financial and time investments are necessary for the ongoing training and follow-up that is necessary.

And patients need to be educated, too.

“It takes a minute to write that prescription and probably 15 or 20 minutes not to write it,” Dr. Fishman says. “We need to educate patients about potential complications of antibiotics use, as well as the signs and symptoms of infection.”

The CDC report is a call to action for all healthcare providers to consider how they can become better antibiotic stewards. There are very few new antibiotics on the market and little in the pipeline. All providers must do what they can to preserve the antibiotics we currently have, Dr. Fishman says.

“There is opportunity, and I think hospitalists are up to the challenge,” Dr. Flanders says. “They are doing lots of work to improve quality across lots of domains in their hospitals. I think this is an area where attention is deserved.”

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

References

1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vital signs: improving antibiotic use among hospitalized patients. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm?s_cid=mm6309a4_w. Accessed August 31, 2014.
2. Flanders SA, Saint S. Why does antrimicrobial overuse in hospitalized patients persist? JAMA Internal Medicine online. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1838720. Accessed August 31, 2014.
3. Dellit TH, Owens RC, McGowan JE, et al. Clinical Infectious Diseases online. Available at: http://cid.oxfordjournals.org/content/44/2/159.full. Accessed August 31, 2014.
4. Gerber JS, Prasad PA, Fiks A, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA. 2013;309(22):2345-2352.

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.

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

Dr. Flanders, a past president of SHM who has worked extensively with the CDC and the Institute for Healthcare Improvement, was behind the development of the time-out strategy. Dr. Srinivasan says the clinical utility of the method was “eye-opening.”

The strategy, which has taken hold among hospital groups the CDC has worked with, has demonstrated that stewardship and patient management are not at odds, Dr. Srinivasan says. Despite patient sign-outs and hand-offs, the time-out strategy allows any clinician to track a patient’s antibiotic status and reevaluate the treatment plan.

Having a process is critical to more responsible prescribing practices, Dr. Flanders says. He attributes much of the variability in antibiotics prescribing among similar departments at hospitals across the country to a lack of standards, though he noted that variability in patient populations undoubtedly plays a role.

Lack of Stats

The CDC report showed up to a threefold difference in the number of antibiotics prescribed to patients in similar hospital settings at hospitals across the country. The reasons for this are not known, Dr. Fishman says.

“The main reason we don’t know is we don’t have a good mechanism in the U.S. right now to monitor antibiotics use,” he explains. “We don’t have a way for healthcare facilities to benchmark their use.”

Without good strategies to monitor and develop more responsible antibiotics prescription practices, Dr. Flanders believes many physicians find themselves trapped by the “chagrin” of not prescribing.

“Patients often enter the hospital without a clear diagnosis,” he says. “They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

“We know delays increase mortality, and that’s not an acceptable option.”

Patients often enter the hospital without a clear diagnosis. They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

 

—Scott Flanders, MD, FACP, MHM, professor of internal medicine, director of hospital medicine, University of Michigan Medical School, Ann Arbor, past president, SHM

Beyond the Bedside

Many physicians fail to consider the bigger societal implications when prescribing antibiotics for sick patients in their charge, because their responsibility is, first and foremost, to that individual. But, Dr. Srinivasan says, “good antibiotic stewardship is beneficial to the patient lying in the bed in front of you, because every day we are confronted with C. diff. infections, adverse drug events, all of these issues.”

Strategies and processes help hospitalists make the best decision for their patients at the time they require care, while providing room for adaptation and the improvements that serve all patients.

Some institutions use interventions like prospective audit and feedback monitoring to help physicians become more responsible antibiotic prescribers, says Dr. Fishman, who worked with infectious disease specialists at the University of Pennsylvania in the early 1990s to develop a stewardship program there.

“In our institution, we see better outcomes—lower complications—usually associated with a decreased length of stay, at least in the ICU for critically ill patients—and increased cure rates,” he says.

Stewardship efforts take investment on the part of the hospital. Dr. Fishman cited a recent study at the Children’s Hospital of Pennsylvania that looked at whether a particular education strategy the hospital implemented actually led to improvements.⁴

“It was successful in intervening in this problem [of inappropriate prescribing] in pediatricians, but it did take ongoing education of both healthcare providers and patients,” he says, noting that large financial and time investments are necessary for the ongoing training and follow-up that is necessary.

And patients need to be educated, too.

“It takes a minute to write that prescription and probably 15 or 20 minutes not to write it,” Dr. Fishman says. “We need to educate patients about potential complications of antibiotics use, as well as the signs and symptoms of infection.”

The CDC report is a call to action for all healthcare providers to consider how they can become better antibiotic stewards. There are very few new antibiotics on the market and little in the pipeline. All providers must do what they can to preserve the antibiotics we currently have, Dr. Fishman says.

“There is opportunity, and I think hospitalists are up to the challenge,” Dr. Flanders says. “They are doing lots of work to improve quality across lots of domains in their hospitals. I think this is an area where attention is deserved.”

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

References

1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vital signs: improving antibiotic use among hospitalized patients. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm?s_cid=mm6309a4_w. Accessed August 31, 2014.
2. Flanders SA, Saint S. Why does antrimicrobial overuse in hospitalized patients persist? JAMA Internal Medicine online. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1838720. Accessed August 31, 2014.
3. Dellit TH, Owens RC, McGowan JE, et al. Clinical Infectious Diseases online. Available at: http://cid.oxfordjournals.org/content/44/2/159.full. Accessed August 31, 2014.
4. Gerber JS, Prasad PA, Fiks A, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA. 2013;309(22):2345-2352.

Clinical question

Does stopping antibiotic treatment after cholecystectomy for mild to moderate acute calculous cholecystitis affect outcomes?

Bottom line

Stopping antibiotic treatment after cholecystectomy for mild to moderate acute cholecystitis does not increase postoperative infection rates compared with a strategy of 5 days of postoperative antibiotics. (LOE = 1b)

Reference

Regimbeau JM, Fuks D, Pautrat K, et al, for the FRENCH Study Group. Effect of postoperative antibiotic administration on postoperative infection following cholecystectomy for acute calculous cholecystitis. JAMA 2014;312(2):145-154.

Study design

Randomized controlled trial (nonblinded)

Funding source

Government

Allocation

Concealed

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Using concealed allocation, these investigators randomized 414 adult patients who presented to an emergency department with mild or moderate acute calculous cholecystitis requiring cholecystectomy into 2 groups: (1) continue taking antibiotics or (2) stop taking antibiotics during the postoperative period. Those with severe cholecystitis, defined as concomitant dysfunction of other organ systems, were excluded, as were those with acute pancreatitis, cholangitis, biliary peritonitis, or cirrhosis. All study patients received amoxicillin plus clavulanic acid 3 times a day from admission to day of surgery. The treatment group continued the same antibiotic regimen for 5 days after surgery, while the nontreatment group received no further antibiotics. The 2 groups were well balanced, with a mean age of 56 years and mean duration of preoperative antibiotics of 2 days. Approximately half the patients in each group had mild cholecystitis. For the primary outcome of postoperative surgical site or distant site infections at 4 weeks, there was no significant difference detected between the 2 groups in either the intention-to-treat or per-protocol analyses (intention-to-treat: 17% for nontreatment vs 15% for antibiotic group; per-protocol: 13% for both groups). This held true when the outcomes were analyzed according to severity of cholecystitis or duration of preoperative antibiotic use.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does stopping antibiotic treatment after cholecystectomy for mild to moderate acute calculous cholecystitis affect outcomes?

Bottom line

Stopping antibiotic treatment after cholecystectomy for mild to moderate acute cholecystitis does not increase postoperative infection rates compared with a strategy of 5 days of postoperative antibiotics. (LOE = 1b)

Reference

Regimbeau JM, Fuks D, Pautrat K, et al, for the FRENCH Study Group. Effect of postoperative antibiotic administration on postoperative infection following cholecystectomy for acute calculous cholecystitis. JAMA 2014;312(2):145-154.

Study design

Randomized controlled trial (nonblinded)

Funding source

Government

Allocation

Concealed

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Using concealed allocation, these investigators randomized 414 adult patients who presented to an emergency department with mild or moderate acute calculous cholecystitis requiring cholecystectomy into 2 groups: (1) continue taking antibiotics or (2) stop taking antibiotics during the postoperative period. Those with severe cholecystitis, defined as concomitant dysfunction of other organ systems, were excluded, as were those with acute pancreatitis, cholangitis, biliary peritonitis, or cirrhosis. All study patients received amoxicillin plus clavulanic acid 3 times a day from admission to day of surgery. The treatment group continued the same antibiotic regimen for 5 days after surgery, while the nontreatment group received no further antibiotics. The 2 groups were well balanced, with a mean age of 56 years and mean duration of preoperative antibiotics of 2 days. Approximately half the patients in each group had mild cholecystitis. For the primary outcome of postoperative surgical site or distant site infections at 4 weeks, there was no significant difference detected between the 2 groups in either the intention-to-treat or per-protocol analyses (intention-to-treat: 17% for nontreatment vs 15% for antibiotic group; per-protocol: 13% for both groups). This held true when the outcomes were analyzed according to severity of cholecystitis or duration of preoperative antibiotic use.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does stopping antibiotic treatment after cholecystectomy for mild to moderate acute calculous cholecystitis affect outcomes?

Bottom line

Stopping antibiotic treatment after cholecystectomy for mild to moderate acute cholecystitis does not increase postoperative infection rates compared with a strategy of 5 days of postoperative antibiotics. (LOE = 1b)

Reference

Regimbeau JM, Fuks D, Pautrat K, et al, for the FRENCH Study Group. Effect of postoperative antibiotic administration on postoperative infection following cholecystectomy for acute calculous cholecystitis. JAMA 2014;312(2):145-154.

Study design

Randomized controlled trial (nonblinded)

Funding source

Government

Allocation

Concealed

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Using concealed allocation, these investigators randomized 414 adult patients who presented to an emergency department with mild or moderate acute calculous cholecystitis requiring cholecystectomy into 2 groups: (1) continue taking antibiotics or (2) stop taking antibiotics during the postoperative period. Those with severe cholecystitis, defined as concomitant dysfunction of other organ systems, were excluded, as were those with acute pancreatitis, cholangitis, biliary peritonitis, or cirrhosis. All study patients received amoxicillin plus clavulanic acid 3 times a day from admission to day of surgery. The treatment group continued the same antibiotic regimen for 5 days after surgery, while the nontreatment group received no further antibiotics. The 2 groups were well balanced, with a mean age of 56 years and mean duration of preoperative antibiotics of 2 days. Approximately half the patients in each group had mild cholecystitis. For the primary outcome of postoperative surgical site or distant site infections at 4 weeks, there was no significant difference detected between the 2 groups in either the intention-to-treat or per-protocol analyses (intention-to-treat: 17% for nontreatment vs 15% for antibiotic group; per-protocol: 13% for both groups). This held true when the outcomes were analyzed according to severity of cholecystitis or duration of preoperative antibiotic use.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Which criteria identify ambulatory patients with exacerbations of mild to moderate COPD who do not need antibiotics?

Background: The Anthonisen criteria (increased dyspnea, sputum volume, sputum purulence) are commonly used to identify which patients with COPD exacerbations would benefit from antibiotics. These criteria, however, were derived in patients with severe COPD. It is unknown whether these criteria are predictive in patients with mild to moderate COPD.

Study design: Multivariate logistic regression analysis of placebo group of a double-blinded RCT.

Setting: Multicenter, ambulatory, primary care clinics in Spain.

Synopsis: The original RCT enrolled 310 ambulatory patients with exacerbations of mild to moderate COPD and tested the efficacy of amoxicillin/clavulanate. Clinical failure without antibiotics was 19.9% compared to 9.5% with antibiotics (P=0.022). Here they analyzed the 152 patients from the placebo group to identify factors associated with increased risk of clinical failure. Only increased sputum purulence (OR 6.1, CI 1.5-25; P=0.005) or C-reactive protein (CRP) >40 mg/L (OR 13.4, CI 4.5-38.8, P<0.001) were independently associated with increased risk of failure. Presence of both predicted a 63.7% failure without antibiotics.

The study did not define “increased sputum purulence,” but this is similar to real-life clinical practice. Placebo effect cannot be ruled out, but correlation of the objective measures with the clinical assessments suggests that the clinical assessments were accurate. The study did not have a protocol for administering co-medications such as steroids and inhalers. Despite these limitations, the criteria of increased sputum purulence and CRP >40 mg/L identified COPD patients likely to have a clinical failure without antibiotics.

Bottom line: Patients with exacerbations of mild to moderate COPD who do not have increased sputum purulence or CRP >40 mg/L can be safely managed without antibiotics.

Citation: Maravitlles M, Moravas A, Hernandez S, Bayona C, Llor C. Is it possible to identify exacerbations of mild to moderate COPD that do not require antibiotic treatment? Chest. 2013;144(5):1571-1577.

Clinical question: Which criteria identify ambulatory patients with exacerbations of mild to moderate COPD who do not need antibiotics?

Background: The Anthonisen criteria (increased dyspnea, sputum volume, sputum purulence) are commonly used to identify which patients with COPD exacerbations would benefit from antibiotics. These criteria, however, were derived in patients with severe COPD. It is unknown whether these criteria are predictive in patients with mild to moderate COPD.

Study design: Multivariate logistic regression analysis of placebo group of a double-blinded RCT.

Setting: Multicenter, ambulatory, primary care clinics in Spain.

Synopsis: The original RCT enrolled 310 ambulatory patients with exacerbations of mild to moderate COPD and tested the efficacy of amoxicillin/clavulanate. Clinical failure without antibiotics was 19.9% compared to 9.5% with antibiotics (P=0.022). Here they analyzed the 152 patients from the placebo group to identify factors associated with increased risk of clinical failure. Only increased sputum purulence (OR 6.1, CI 1.5-25; P=0.005) or C-reactive protein (CRP) >40 mg/L (OR 13.4, CI 4.5-38.8, P<0.001) were independently associated with increased risk of failure. Presence of both predicted a 63.7% failure without antibiotics.

The study did not define “increased sputum purulence,” but this is similar to real-life clinical practice. Placebo effect cannot be ruled out, but correlation of the objective measures with the clinical assessments suggests that the clinical assessments were accurate. The study did not have a protocol for administering co-medications such as steroids and inhalers. Despite these limitations, the criteria of increased sputum purulence and CRP >40 mg/L identified COPD patients likely to have a clinical failure without antibiotics.

Bottom line: Patients with exacerbations of mild to moderate COPD who do not have increased sputum purulence or CRP >40 mg/L can be safely managed without antibiotics.

Citation: Maravitlles M, Moravas A, Hernandez S, Bayona C, Llor C. Is it possible to identify exacerbations of mild to moderate COPD that do not require antibiotic treatment? Chest. 2013;144(5):1571-1577.

Clinical question: Which criteria identify ambulatory patients with exacerbations of mild to moderate COPD who do not need antibiotics?

Background: The Anthonisen criteria (increased dyspnea, sputum volume, sputum purulence) are commonly used to identify which patients with COPD exacerbations would benefit from antibiotics. These criteria, however, were derived in patients with severe COPD. It is unknown whether these criteria are predictive in patients with mild to moderate COPD.

Study design: Multivariate logistic regression analysis of placebo group of a double-blinded RCT.

Setting: Multicenter, ambulatory, primary care clinics in Spain.

Synopsis: The original RCT enrolled 310 ambulatory patients with exacerbations of mild to moderate COPD and tested the efficacy of amoxicillin/clavulanate. Clinical failure without antibiotics was 19.9% compared to 9.5% with antibiotics (P=0.022). Here they analyzed the 152 patients from the placebo group to identify factors associated with increased risk of clinical failure. Only increased sputum purulence (OR 6.1, CI 1.5-25; P=0.005) or C-reactive protein (CRP) >40 mg/L (OR 13.4, CI 4.5-38.8, P<0.001) were independently associated with increased risk of failure. Presence of both predicted a 63.7% failure without antibiotics.

The study did not define “increased sputum purulence,” but this is similar to real-life clinical practice. Placebo effect cannot be ruled out, but correlation of the objective measures with the clinical assessments suggests that the clinical assessments were accurate. The study did not have a protocol for administering co-medications such as steroids and inhalers. Despite these limitations, the criteria of increased sputum purulence and CRP >40 mg/L identified COPD patients likely to have a clinical failure without antibiotics.

Bottom line: Patients with exacerbations of mild to moderate COPD who do not have increased sputum purulence or CRP >40 mg/L can be safely managed without antibiotics.

Citation: Maravitlles M, Moravas A, Hernandez S, Bayona C, Llor C. Is it possible to identify exacerbations of mild to moderate COPD that do not require antibiotic treatment? Chest. 2013;144(5):1571-1577.

While not a new phenomenon, antimicrobial resistance is an alarming and, arguably, still underappreciated public health problem. A mere 70 years after the introduction of antibiotics, we face the distinct possibility of a future without effective antibiotics for some infections. Such a reality will render select surgical operations, cancer chemotherapy, and organ transplants exceedingly dangerous.

The scarcity of new antimicrobial agents and the paucity of new agents in the drug development pipeline limit treatment options, particularly for patients with infections caused by multidrug-resistant organisms. Annually, multidrug resistant organisms cause an estimated 25,000 deaths in Europe and 12,000 deaths in the United States. In response to this threat, the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) was established and published their report with 17 recommendations.

Respiratory tract infections are one of the most common symptoms presenting to primary care. Overprescribing in this setting is rampant, driven largely by patient expectations and clinician need for expediency and desire to receive "high marks" for satisfaction. Available evidence has suggested that delayed antibiotic prescribing is effective. But what is the best method to delay antibiotic prescribing?

Researchers in the United Kingdom evaluated the comparative effectiveness of four different strategies of delayed antibiotic prescribing for patients not needing antibiotics right away:

• Recontact: Patients were asked to contact the office and leave a message for a clinician to prescribe an antibiotic.

• Postdated prescription: The prescription could be filled only after a certain date.

• Wait/Request: Patients were instructed to wait but could request an antibiotic from the front office.

• Delayed use: Patients received antibiotics but were asked to wait to use them.

A "no prescription" arm was added later in the trial. The primary outcome was symptom severity measured at the end of each day during days 2-4 of a two-week symptom diary. Secondary outcomes included antibiotic use and side effects.

No differences were observed between the four strategies with respect to symptom control. Antibiotic use did not differ significantly between strategies and the lowest use was reported in the no prescription arm. No significant differences were observed between groups in patient satisfaction. Complications were slightly higher in the no antibiotic group (2.5%), compared with the delayed groups (1.4%).

Delayed prescribing is associated with less than 40% of patients using an antibiotic. Given the current crisis with multidrug resistance, we should feel obligated to try one of the proposed strategies for delayed antibiotic prescription if patients do not need one right away.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

While not a new phenomenon, antimicrobial resistance is an alarming and, arguably, still underappreciated public health problem. A mere 70 years after the introduction of antibiotics, we face the distinct possibility of a future without effective antibiotics for some infections. Such a reality will render select surgical operations, cancer chemotherapy, and organ transplants exceedingly dangerous.

The scarcity of new antimicrobial agents and the paucity of new agents in the drug development pipeline limit treatment options, particularly for patients with infections caused by multidrug-resistant organisms. Annually, multidrug resistant organisms cause an estimated 25,000 deaths in Europe and 12,000 deaths in the United States. In response to this threat, the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) was established and published their report with 17 recommendations.

Respiratory tract infections are one of the most common symptoms presenting to primary care. Overprescribing in this setting is rampant, driven largely by patient expectations and clinician need for expediency and desire to receive "high marks" for satisfaction. Available evidence has suggested that delayed antibiotic prescribing is effective. But what is the best method to delay antibiotic prescribing?

Researchers in the United Kingdom evaluated the comparative effectiveness of four different strategies of delayed antibiotic prescribing for patients not needing antibiotics right away:

• Recontact: Patients were asked to contact the office and leave a message for a clinician to prescribe an antibiotic.

• Postdated prescription: The prescription could be filled only after a certain date.

• Wait/Request: Patients were instructed to wait but could request an antibiotic from the front office.

• Delayed use: Patients received antibiotics but were asked to wait to use them.

A "no prescription" arm was added later in the trial. The primary outcome was symptom severity measured at the end of each day during days 2-4 of a two-week symptom diary. Secondary outcomes included antibiotic use and side effects.

No differences were observed between the four strategies with respect to symptom control. Antibiotic use did not differ significantly between strategies and the lowest use was reported in the no prescription arm. No significant differences were observed between groups in patient satisfaction. Complications were slightly higher in the no antibiotic group (2.5%), compared with the delayed groups (1.4%).

Delayed prescribing is associated with less than 40% of patients using an antibiotic. Given the current crisis with multidrug resistance, we should feel obligated to try one of the proposed strategies for delayed antibiotic prescription if patients do not need one right away.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

While not a new phenomenon, antimicrobial resistance is an alarming and, arguably, still underappreciated public health problem. A mere 70 years after the introduction of antibiotics, we face the distinct possibility of a future without effective antibiotics for some infections. Such a reality will render select surgical operations, cancer chemotherapy, and organ transplants exceedingly dangerous.

The scarcity of new antimicrobial agents and the paucity of new agents in the drug development pipeline limit treatment options, particularly for patients with infections caused by multidrug-resistant organisms. Annually, multidrug resistant organisms cause an estimated 25,000 deaths in Europe and 12,000 deaths in the United States. In response to this threat, the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) was established and published their report with 17 recommendations.

Respiratory tract infections are one of the most common symptoms presenting to primary care. Overprescribing in this setting is rampant, driven largely by patient expectations and clinician need for expediency and desire to receive "high marks" for satisfaction. Available evidence has suggested that delayed antibiotic prescribing is effective. But what is the best method to delay antibiotic prescribing?

Researchers in the United Kingdom evaluated the comparative effectiveness of four different strategies of delayed antibiotic prescribing for patients not needing antibiotics right away:

• Recontact: Patients were asked to contact the office and leave a message for a clinician to prescribe an antibiotic.

• Postdated prescription: The prescription could be filled only after a certain date.

• Wait/Request: Patients were instructed to wait but could request an antibiotic from the front office.

• Delayed use: Patients received antibiotics but were asked to wait to use them.

A "no prescription" arm was added later in the trial. The primary outcome was symptom severity measured at the end of each day during days 2-4 of a two-week symptom diary. Secondary outcomes included antibiotic use and side effects.

No differences were observed between the four strategies with respect to symptom control. Antibiotic use did not differ significantly between strategies and the lowest use was reported in the no prescription arm. No significant differences were observed between groups in patient satisfaction. Complications were slightly higher in the no antibiotic group (2.5%), compared with the delayed groups (1.4%).

Delayed prescribing is associated with less than 40% of patients using an antibiotic. Given the current crisis with multidrug resistance, we should feel obligated to try one of the proposed strategies for delayed antibiotic prescription if patients do not need one right away.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

A Centers for Disease Control and Prevention (CDC) report this month on antibiotic stewardship highlights the need for continued attention and improvement around the topic, says a hospitalist who has studied the issue.

The CDC announcement, "Antibiotic Rx in Hospitals: Proceed with Caution," circulated in its monthly report, CDC Vital Signs, urged hospital leaders to adopt at least a basic stewardship program and "work with other healthcare facilities to prevent infections, transmission, and resistance."

David Rosenberg, MD, MPH, FACP, SFHM, chief of the division of hospital medicine at North Shore University Hospital's department of medicine in Manhasset, N.Y., says the alert can serve as a spotlight.

"While we all agree that this is an important topic, there's a certain amount of inertia around it," Dr. Rosenberg says. "When the CDC comes out with statements like this, it really helps drive this forward. It really should be viewed as a call to action."

The CDC alert highlights the variability of antibiotic use. It notes that doctors in some hospitals prescribed three times as many antibiotics as doctors at others. The disparity in treatment standards makes stewardship a broad issue to tackle, Dr. Rosenberg says.

"It's not a simple fix," he adds. "You have to do it one piece at a time. How are you going to manage urinary-tract infections? How are you going to manage pneumonias? How are you going to manage bloodstream infections? We want ultimately to integrate the approach into the day-to-day practice of hospitalists, but there's a lot of data you need in a very organized format to inform those decisions. Stewardship programs organize the information in a way that can influence and change practice."

Visit our website for more information on antibiotic stewardship.

A Centers for Disease Control and Prevention (CDC) report this month on antibiotic stewardship highlights the need for continued attention and improvement around the topic, says a hospitalist who has studied the issue.

The CDC announcement, "Antibiotic Rx in Hospitals: Proceed with Caution," circulated in its monthly report, CDC Vital Signs, urged hospital leaders to adopt at least a basic stewardship program and "work with other healthcare facilities to prevent infections, transmission, and resistance."

David Rosenberg, MD, MPH, FACP, SFHM, chief of the division of hospital medicine at North Shore University Hospital's department of medicine in Manhasset, N.Y., says the alert can serve as a spotlight.

"While we all agree that this is an important topic, there's a certain amount of inertia around it," Dr. Rosenberg says. "When the CDC comes out with statements like this, it really helps drive this forward. It really should be viewed as a call to action."

The CDC alert highlights the variability of antibiotic use. It notes that doctors in some hospitals prescribed three times as many antibiotics as doctors at others. The disparity in treatment standards makes stewardship a broad issue to tackle, Dr. Rosenberg says.

"It's not a simple fix," he adds. "You have to do it one piece at a time. How are you going to manage urinary-tract infections? How are you going to manage pneumonias? How are you going to manage bloodstream infections? We want ultimately to integrate the approach into the day-to-day practice of hospitalists, but there's a lot of data you need in a very organized format to inform those decisions. Stewardship programs organize the information in a way that can influence and change practice."

Visit our website for more information on antibiotic stewardship.

A Centers for Disease Control and Prevention (CDC) report this month on antibiotic stewardship highlights the need for continued attention and improvement around the topic, says a hospitalist who has studied the issue.

The CDC announcement, "Antibiotic Rx in Hospitals: Proceed with Caution," circulated in its monthly report, CDC Vital Signs, urged hospital leaders to adopt at least a basic stewardship program and "work with other healthcare facilities to prevent infections, transmission, and resistance."

David Rosenberg, MD, MPH, FACP, SFHM, chief of the division of hospital medicine at North Shore University Hospital's department of medicine in Manhasset, N.Y., says the alert can serve as a spotlight.

"While we all agree that this is an important topic, there's a certain amount of inertia around it," Dr. Rosenberg says. "When the CDC comes out with statements like this, it really helps drive this forward. It really should be viewed as a call to action."

The CDC alert highlights the variability of antibiotic use. It notes that doctors in some hospitals prescribed three times as many antibiotics as doctors at others. The disparity in treatment standards makes stewardship a broad issue to tackle, Dr. Rosenberg says.

"It's not a simple fix," he adds. "You have to do it one piece at a time. How are you going to manage urinary-tract infections? How are you going to manage pneumonias? How are you going to manage bloodstream infections? We want ultimately to integrate the approach into the day-to-day practice of hospitalists, but there's a lot of data you need in a very organized format to inform those decisions. Stewardship programs organize the information in a way that can influence and change practice."

Visit our website for more information on antibiotic stewardship.