In this article a pharmacist with advanced training in infectious diseases and antimicrobial stewardship identifies five ways to defend your antibiogram and protect your patients by using antibiotics wisely.
Authored By: Timothy Gauthier, Pharm.D., BCPS-AQ ID
[Last Updated: 21 May 2019]
Antimicrobial resistance is a major threat to human health worldwide. In one report it is estimated by 2050 the number of deaths attributable to antimicrobial resistance will exceed 10,000,000 . This is estimated to be more deaths than will be caused by cancer at that time.
People are taking antimicrobial drug resistance seriously and one way that institutions seek to identify the drug resistance challenges that they face is through developing institutional antibiograms. Institutional antibiograms help us to understand our local resistance patterns since they provide cumulative data on drug resistance for a given time period (commonly a year). In assessing cumulative institutional antibiogram data a healthcare professional may wonder what part they can play in trying to stop the progression of worsening antimicrobial resistance rates.
Identifying changes in resistance patterns over time that are the result of a specific practice change is an incredibly challenging thing to do and in many instances it is totally impossible (e.g., low number of patient cases or isolates in a given time period can prevent any meaningful analysis). Despite this, there are worthwhile actions healthcare professionals can take to fight back against the progression of antimicrobial resistance. To do this with limited data it is helpful to start by accepting one thing as a truth: the more we use antibiotics, the more we will lose antibiotics. As stated by thought leader and infectious diseases physician Dr. Brad Spellberg “There is no evidence that taking antibiotics beyond the point at which a patient’s symptoms are resolved reduces antibiotic resistance… to the contrary, specifically for pneumonia, studies have shown that longer courses of therapy result in more emergence of antibiotic resistance, which is consistent with everything we know about natural selection, the driver of antibiotic resistance” . Combine this with the notion that every single dose of an antimicrobial drug puts patients at risk for adverse drug reactions or Clostridioides difficile infection and reducing antimicrobial drug use can be a meaningful mechanism for defending your antibiogram from becoming worse while protecting your patients from becoming harmed.
With the conceptual piece in place, healthcare providers may now wonder what specific actions they can take. Here, I identify and discuss five such activities. These were selected based upon my perception of overall clinical relevance. There are of course many other examples not discussed here.
1. Treat carbapenems and the new beta-lactam/ beta-lactamase inhibitor combinations like they are more precious than gold
Carbapenems are drugs such as meropenem (Merrem), ertapenem (Invanz), and imipenem-cilastatin (Primaxin). New beta-lactam/ beta-lactamase inhibitor (BL/BLI) combinations are drugs such as ceftazidime-avibactam (Avycaz), ceftolozane-tazobactam (Zerbaxa), and meropenem-vaborbactam (Vabomere).
When these drugs are not options, the next line of agents tends to be more toxic (e.g., colistin) and/or less effective (e.g., tigecycline). Additionally carbapenem resistant organisms have been associated with death rates in the 50% range .
While toxicity is always on the radar with antibiotics, with carbapenems and BL/BLIs, reducing unnecessary use is more about attempting to reduce the risk of developing local isolates that are resistant to these drugs. To protect your antibiogram, only use carbapenems or BL/BLIs when you really need to. In doing this, assess every carbapenem or BL/BLI patient you are caring for every single day and determine if it is still needed.
2. Make sure antibiotic surgical prophylaxis is ordered and processed correctly
One of the most common reasons hospitals and outpatient care centers expose patients to antibiotics is for surgical prophylaxis. Ensuring orders are placed in such a way that the patient does not receive the wrong drug, dose, or number of doses can help with overall antibiotic use while ensuring the lowest risk to the patient.
An article published in JAMA Surgery just last month investigating the benefits of surgical prophylaxis beyond 24 hours postoperatively found that not only do extended durations not reduce surgical site infections, they actually raise the odds of acute kidney injury and C. difficile infection in a duration-dependent fashion . The authors specifically note that every day matters when it comes to surgical prophylaxis.
3. Embrace the slogan “Symptom Free Pee, Let It Be!”
This slogan comes from the Association of Medical Microbiology and Infectious Disease Canada, where there is a campaign focusing on the management of asymptomatic bacteriuria (ASB) in long-term care residents and elderly patients in acute care.
When a patient does not have symptoms of a urinary tract infection (UTI) it may not even be necessary to send a urine culture (NOTE: smelly urine, cloudy urine, pyuria, or a positive urinalysis are NOT symptoms of UTI). If a urine culture is sent and results as positive and the patient is without symptoms, that is called ASB. ASB rarely requires antibiotic therapy. If we can identify ASB and avoid giving unnecessary antibiotics for it, then that is going to be a win for reducing antibiotic pressure on bacteria and a win for avoiding unnecessary antibiotic exposure for the patient.
ASB is such an important issue that the Infectious Diseases Society of America has a guideline solely devoted to the topic. You can check out their update published in 2019 here.
4. Embrace the slogan “Snort, Sniffle, Sneeze, No Antibiotics Please!”
This slogan comes from the Centers for Disease Control and Prevention (CDC) and is at least 10 years old. There is a short simple video about it here.
A large number of upper respiratory illnesses (e.g., acute bronchitis) are caused by viruses and in turn will not be treated by antibiotics. In fact not only will antibiotics not help a viral infection, patients may actually be harmed by adverse events that antibiotics put them at risk for. If we want to preserve the antibiotics we use in the outpatient setting for future bacterial infections, then it is important to avoid using them inappropriately for viral infections (even if a patient is demanding one).
This simple slogan may serve as a tool for educating your peers or patients about when (and when not) to use antibiotics.
5. Reach for a fluoroquinolone only under specific circumstances when other safer drugs are not an option
While many current healthcare providers may have learned in school that “ciprofloxacin is first line for UTI”, today we know that is not the case at all. Fluoroquinolones have been flagged for numerous debilitating toxicities, most recently aortic rupture. A summary of the toxicities is here. In addition to this, the fluoroquinoones are closely tied to collateral damage of antibiotic drug use. Not only are they associated with C. difficile infections, but they also are associated with resistance to themselves and resistance to other drugs (e.g., MRSA) . Reducing fluoroquinolone use may avoid their collateral damage.
It should be noted that the FDA has specifically come out and stated that fluoroquinolones should only be used when risks outweigh potential benefits if treating acute sinusitis, acute bronchitis or uncomplicated urinary tract infections.
Antimicrobial resistance is a problem that people face across the world each day. It is here. It is real. It is important.
New antibiotic development is largely unimpressive and the progression of antimicrobial resistance is a cause for substantial concern. I wonder what my young children will have available to them when they are adults or what I may have available to myself should I become an elderly patient with a drug-resistant bacterial infection. It is truly frightening to consider the notion that we are entering or have entered a second pre-antibiotic era.
For the time being, I hope people will take the opportunity to do what they can to preserve antibiotics for the future, including the things mentioned here.
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