Antibiotics are vital to the practice of modern medicine. They make many things that we take for granted today possible. But, like anything else, too much of a good thing, can be bad.
Over the last several decades, over-prescribing has played a large role in an increase of antibiotic-resistant strains of bacteria. The CDC says as many as half of all antibiotic prescriptions in the United States are unnecessary. Misusing antibiotics allows the most resistant types of bacteria to survive, giving them the opportunity to reproduce, with each generation becoming more resistant.
Changing the way antibiotics are used, and making sure they’re used appropriately, is the goal for the Antibiotic Stewardship Program at the Hospital of the University of Pennsylvania, led by Keith Hamilton, MD, an assistant professor of Clinical Medicine and infectious disease physician. Formed in 1992 by associate chief medical officer Neil Fishman, HUP’s program is one of the oldest—if not the oldest—programs of its kind in the nation.
As part of the system-wide antibiotic stewardship efforts, each Penn hospital has its own team responsible for overseeing safe use of these critical drugs. The stewardship team at PPMC, led by Amanda Binkley, PharmD, AAHIVP and Christo Cimino, PharmD, BCPS, Judith O’Donnell, MD, and Naasha Talati, MD, recently wrapped up its Antibiotic Stewardship Week, which gives faculty and staff across the hospital a chance to focus on the issue and learn more about what can be done to prevent to over-prescription of antimicrobial drugs. Activities to promote learning included a table with games and educational materials set up outside of the cafeteria. Amanda Binkley, PharmD, AAHIVP, clinical pharmacy specialist in Infectious Disease, said the effort was a huge success.
“It wasn’t just clinicians stopping by,” Binkley said. “A significant number of patients and patients’ families stopped by to inquire about mechanisms which they can implement and ways they can help curb antibiotic utilization.”
Patient involvement in antibiotic prescription is one thing that Hamilton said has increased in recent years.
“Patients are becoming more informed consumers,” he said. “The stewardship effort really is a collaboration. Patients are learning to ask when antibiotics are appropriate.”
Though Antibiotic Stewardship Week is over for 2016, the team’s work to manage responsible antibiotic use goes on all year. Hamilton said one of the big ways prescriptions are managed across the system is through prior approval, meaning prescribers need authorization to prescribe certain antibiotics. Those medications may be restricted for a number of reasons, including a special need to preserve their usefulness.
The teams at each hospital also review all antibiotic prescriptions and follow patients to ensure the proper use. This review gives them a chance to spot any prescriptions that might not be necessary and intervene, if appropriate. Binkley said at PPMC, the majority of care providers are appreciative and heed their recommendations.
Similarly, members of the Antibiotic Stewardship teams also lead the Infectious Disease Transition Service (IDTS), which monitors patients discharged on intravenous antibiotics. After discharge, IDTS team members will monitor them to make sure no errors are made during transition.
IDTS started at HUP and recently won a grant from the Penn Center for Health Care Innovation to create dashboard which will help clinicians better manage transitions. Hamilton said most patients who are discharged with antibiotics are prescribed oral medications, but up to 15 percent require intravenous antibiotics. Because those drugs special care, these patients are tracked more closely. IDTS helps the stewardship team know when these patients have appointments, results of recent lab work, current dosage, and other vital clinical information.
The new system will also help the stewardship team track a large swath of macro-level metrics surrounding antibiotic use. With this data, they’ll be able to spot trends in what drugs are being prescribed for, which drugs are more successful treating certain types of infections, and so on. All of that information will better allow the stewardship team to manage appropriate use.
They also serve as resident antibiotics experts, providing valuable feedback and recommendations to physicians and pharmacy staff who want to make sure they are in line with best practices for antimicrobials. Binkley said the team has a pager and is always available to help prescribers make the best choices. Members of the teams regularly round with physicians as well.
“One of us will actually go to the floors on more complicated cases and have face to face discussions with physicians about their patients and discuss the best options,” Hamilton said.
In his 2014 TED Talk, Ramanan Laxminarayan, director of the Center for Disease Dynamics, Economics & Policy, likened antibiotics to other finite resources like oil. We can reduce usage and vastly prolong the usefulness of the drugs, or we can create new antibiotics—the “drill, baby, drill” option, as he calls it — which would ease the problem in the short term, but without a fundamental change in the way the drugs are prescribed, we’d likely face a very similar problem in the future.
It’s an idea echoed by Hamilton who said that it’s possible that one day we may have a perfect solution for infections, but until that day, it’s crucial that we all take responsibility for making sure the antibiotics we have will be useful as far into the future as possible.