Transcript Bugs,Drugs and Stewardship

Waleed Albert , MD,FACP
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First antibiotic prescribed in the late 1930
Between 1944 and 1972 ,life expectancy
increased by 8 years
In 1969, the US Surgeon General William
Stewart told congress” it was time to close the
books on Infectious Disease”
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1950-1960 most classes of antibiotics were
developed.
1999 new class of antibiotics ( Oxazolidiones)
introduced to market
Currently we have over 100 antibiotic
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Used when not indicated
Wrong antibiotic (drug-bug mismatch)
Long course of antibiotic when it is not
indicated or beneficial
Wrong dose
Broad spectrum antibiotic for susceptible
bacteria , failure to de-escalate
30-50% of antibiotics prescribed are
unnecessary
 Rise of Clostridium difficile infection
 Drug Reaction
 Increase resistance to antibiotics
 Cost
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CDC
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500,000 Clostridium difficile infections
every year
◦ 150,000 deaths
◦ Estimated$1billion in additional cost
Carbapenem Resistant Enterobacteriaceae
◦ 9,000 infections every year
◦ 600 deaths every year
◦ Resistant to almost all antibiotics
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Extended Spectrum Beta-Lactamase ( ESBL)
producing Enterobacteriaceae
◦ 26,000 infections every year
◦ 1,700 deaths every year
CDC
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Multidrug resistant Acinetobacter
◦ 7,300 infections every year
◦ 500 deaths
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Vancomycin Resistant Enterococcus
◦ 20,000 infections every year
◦ 1,300 deaths
Resistant Streptococcus pneumoniae
◦ 1,200,000 infections every year
◦ 7,000 deaths every year
◦ $96,000,000 additional cost
CDC
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CDC estimates 2013:
$ 20 billion/year is the cost to treat
infections caused by resistant bacteria.
$ 35 billion/year in lost productivity.
CDC
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CAP is a widespread and serious affliction
◦ First year medical students are free of the disease
◦ Interns and first year residents are severely
afflicted…life-long habit difficult to break
◦ CAP is supported by a well organized group of
antibiotic pushers
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Antibiotics Anonymous
◦ Self help group, available 24 hours, will talk you
through the urge to prescribe more than two
antibiotics, other abuses
Lockwood et al,NEJM P465-466,1974
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September 2014 , the President Executive
order which calls for Department of Health
and Human Services (DHHS) to promote
implementation of robust ASP across health
care facilities
March 2015 , White House issued its National
Action Plan for Combating Antibiotic
Resistant Bacteria , with goals to slow the
emergence and spread of resistant bacteria
and to strengthen antibiotic stewardship in
inpatient, outpatient and long term settings.
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A program dedicated to improving
antibiotic use
CDC 7 Key elements of an antibiotic
stewardship program
◦ Leadership commitment
◦ Accountability
◦ Drug expertise
◦ Action
◦ Tracking
◦ Reporting
◦ Education
CDC
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Leadership commitment: Dedicate necessary
human,financial, and information technology
resources
Accountability: Appoint a single leader responsible
for program outcomes who is accountable to an
executive level or patient quality focused hospital
committee
Drug Expertise: Appoint a single pharmacist leader
responsible for working to improve antibiotic use
Action: Implement at least one recommended action
Tracking: Monitor process measures, impact on
patients ,antibiotic use and resistance
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Reporting: Report the information of tracking
on regular basis to providers , nurses and
other staff
Education: Educate clinicians about disease
management ,resistance, and optimal
prescribing
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Basic: System wide Interventions including
Prior approval, documentation of indication
and duration, antibiotic allergy assessment,
standardize order forms
Intermediate: Patient Specific Interventions
including post prescription review,
automatic IV TO PO conversion, dose
adjustment, dose optimization for bacteria
with reduced susceptibility, alerts for
duplicate therapy, automatic stop orders(
prophylactic antibiotic empiric therapy,
protocols for sepsis
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Advanced: Diagnosis and Infection Specific
Interventions Including real time ,rapid
diagnostics(flu , MRSA) ,biomarkers ,timely
and appropriate culture collection and
transport , realize opportunities to improve
antibiotic use for different situations( CAP ,
UTI , skin infections , CDI , culture
contaminants)
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Lack of defined guidelines
Difficult to implement and track outcome
Interventions
◦ Provider and /or Patient Education
◦ Provider Feedback
◦ Guidelines
◦ Delayed Prescribing
◦ Communication Skills Training *
◦ Restrictions
◦ Rapid /Specific Laboratory Tests
(PCT,antigen,PCR) *
◦ Financial Incentives
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All of the bacteria in our body collectively
weighs about 4 pounds
The average office desk has 400 times more
bacteria than a toilet
There are more bacteria in your mouth than
there are people in the world
Cell phones have 18 times more bacteria than
toilet handle
A clean mouth has between 1000 and 100000
bacteria on each tooth
Chocolate has antibacterial effect on the mouth
and protects against tooth decay
A dollar bill has 3000 type of bacteria