Antibiotic Stewardship

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You may have heard, or read, a term over the last few years called “superbug” which refers to bacteria that have become resistant to multiple antibiotics.  It has been a growing concern amongst many U.S. and European health societies due to the ability of these organisms to cause infections providers are increasingly unable to treat.  This causes great harm and even death in some patients.  The goal of this article is to help educate our community on strategies being employed to minimize the risk of these types of infections in our community, and what you and your provider can do to help.

How did we get here?

When I was a child, you could almost bank on my mother taking me to my pediatrician twice yearly because of upper respiratory tract infections.  Although later on, we discovered that it was usually just my seasonal allergies acting up, I could always count on a shot of penicillin and a prescription for an antibiotic to take over the next several days.  Although we could never prove I had an actual “bacterial” infection in my sinuses, that was the standard of care for me in the 1970s.

As time passed, I remember being told by a physician at my undergraduate University health center, the way to tell the difference between a bacterial and viral infection of the sinuses was the color of the discharge…clear meaning viral and colored being bacterial.  As I progressed through my education, I remember talking to my parents in Pennsylvania noting that my mother had a “sniffle” to which she would reply, “I’ll be OK, I’m taking some leftover ampicillin”.  I would tell her that that probably wasn’t a great idea because she probably had a viral infection that would just get better on its own.

Over the years, our profession has overprescribed antibiotics to the point we are seeing quite a few bacteria that are resistant to some of the common drugs we prescribe like a Z-pack and Cipro.  In an adult, it is almost unheard of to try and use penicillin to treat pneumonia because the organisms are resistant.  The FDA has recently placed a Black Box warning on drugs such as Cipro and Levaquin to not be used to treat sinus infections.  We need to be smarter about how we prescribe these drugs so when we really need them, they will treat the infections we have.

What are we doing about combating this problem?

In late 2012, an idea developed about providers being “stewards” in how we prescribe antibiotics for a variety of infections.  That term grew into “antibiotic stewardship”.  Before prescribing an antibiotic, providers should consider many factors such as duration of symptoms, organ system affected, local resistance patterns, etc.  For example, instead of just prescribing a Z-pack for a patient who has had a runny nose for one day, multiple studies have been done that have demonstrated that more than likely the causative organism is viral, and it would be better to wait for a week before prescribing an antibiotic for that patient.  Furthermore, if an antibiotic were to be prescribed, we should pick an antibiotic that targets the most common bacteria this patient is at risk for.

Another example would be a patient that comes in very sick to the hospital with pneumonia, and because they are so sick, they require the breathing machine to help them breathe.  In this particular patient, because they are so sick, we should prescribe antibiotic therapy that covers every possible bacterium this patient could have…in addition to considering their risk for bacterial resistance.  However, as the blood cultures, and other culture data, reveal the causative organism, we should reduce the number of antibiotics to just one that targets that organism.  This way, we reduce the risk of creating resistance in that organism to multiple antibiotics.  We also can reduce the risk of developing a secondary infection known as C. difficile colitis or commonly called C. diff diarrhea due to prolonged use of multiple antibiotics.

The Future

You and your provider should work as a team in deciding what is best for you when visiting the office or hospital.  I’ve always tried to educate patients and their families that there is nothing 100 percent free of risk in medicine.  Every test, drug, etc. is not without risk.  When it comes to Antimicrobial Stewardship, we try to minimize this risk by effectively treating the right bug with the right drug and not automatically prescribing antibiotics for infections that don’t require them.  So, don’t be angry with your provider if they feel as though an antibiotic is not warranted in your case.  When you’re really sick, we want to be able to treat you effectively. In order to “Be Smart about Antibiotics,” we must accept that they aren’t always the answer.

 

JT-Ellis-MD

R.T. Ellis, MD, internal medicine/hospitalist, Baptist Health La Grange

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