Antimicoribal Stewardship

Starter Questions:

What would it take to change the behavior of healthcare practitioners to prescribe antibiotics more responsibly?

Are medical professional societies, such as in the resolution coming before the World Medical Association, up to the task of calling for such changes?

How does our long-term acute care hospitals (that take Medicare patients requiring more than 25 days length of stay) doing on infection control?

Internationally, how can national action plans on antimicrobial resistance be implemented successfully?

Outpatient antibiotic prescriptions trends show decrease since 2011

From 2011-2016, outpatient prescriptions of antibiotics declined by 5% in the United States. Also of note, there was a modest decrease in the ratio of broad- to narrow-spectrum antibiotics prescribed. By drawing upon national data on outpatient antibiotic prescriptions dispensed, and dividing these numbers by census estimates for 2011-2016, researchers found that the prescriptions per 1,000 persons declined from 877 in 2011 to 836 in 2016. Importantly, the largest decrease in antibiotic prescription was among children, with prescriptions for children experiencing a 13% decrease, and adult rates decreasing by 2%. However, the proportions of prescriptions written by nurse practitioners and physician assistants saw an increase in this same period, with more than 25% of all antibiotic prescriptions being written by these health professionals. As a result, the study concludes that adult prescriptions, especially those written by nurse practitioners and physician assistants, are valuable targets for antibiotic stewardship in the coming years, with continued progress for all other groups.

Source: Oxford University Press

US emergency departments found to prescribe more than 2 million unnecessary antibiotics

Published in the journal Pediatrics, researchers have found that more than 2 million unneeded antibiotics are prescribed to children in US emergency departments a year. With the majority of these inappropriate prescriptions originating in non-pediatric emergency departments, the study also found that these non-pediatric emergency departments were also more likely to neglect national guidelines on prescribing for pediatric respiratory infections. Using data from the National Ambulatory Medical Care Survey, the researchers found that out of 29 million annual children's emergency visits, a third of prescriptions for children in non-pediatric emergency departments were for illnesses in which antibiotics were not needed (such as bronchitis), while nearly a quarter of prescriptions for children in pediatric emergency departments were found to be unnecessary. In this study, researchers note that clinicians trained in pediatrics may be more likely to work in pediatric emergency departments, resulting in these pediatric-trained clinicians being more familiar with pediatric-specific antibiotic prescribing guidelines. Moreover, the study notes that in the case of children, patient pressure, through parents’ expectations of antibiotics, could play a role, with researchers concluding that “exposing emergency medicine specialists to pediatric-focused guidelines and antibiotic stewardship initiatives could help improve prescribing in non-pediatric emergency departments.”

Source: Pediatrics

Late-career doctors found to prescribe longer antibiotic courses

Amidst research finding that shorter antibiotic courses are equally as effective as prolonged antibiotic courses, with lower adverse effects and lower risks for antibiotic resistance, one recent study published in Clinical Infectious Diseases finds that physicians nearing the ends of their career are more likely to prescribe longer antibiotic courses. Examining over 10,000 family physicians’ prescribed antibiotic courses in Ontario, Canada, researchers found that more than 33% of these courses exceeded 8 days, with physicians having practiced for more than 25 years, as well as those in large rural areas and those with large pediatric practices being the most likely to prolong antibiotic courses. Quantitatively, the study found that cohorts of physicians at later stages in their career were nearly 50% more likely to prescribe prolonged antibiotics courses than cohorts of physicians at early stages in their career, with physicians at the peak of their career being 25% more likely to prescribe longer doses of antibiotics. Researchers conclude that from these findings, it can be recommended that antibiotic stewardship training and education should start in medical school, rather than waiting until poor prescribing behavior is already established.

Source: Clinical Infectious Diseases

Maryland health professionals demand stronger antibiotics regulations

In a letter to Governor Hogan, Secretary Bartenfelder, and the Maryland General Assembly, over 22 healthcare professionals have urged the support of the Keep Antibiotics Effective Act of 2019. Established in 2017, the original Keep Antibiotics Effective Act of 2017 prevents the administration of antimicrobial drugs to cattle, swine, or poultry in a regular pattern, and requires the Department of Agriculture each year to “collect publicly available data on the use in the State of specified antimicrobial drugs.” In order to keep this Act effective and “ensure that Maryland’s health care professionals will be able to fight infections with antibiotics that work,” these Maryland health care professionals have asked for the support of the Keep Antibiotics Effective Act of 2019, and encourage antibiotic stewardship in patients, as well as communities. The Keep Antibiotics Effective Act of 2019 lays out that antibiotics cannot be used as routine prophylaxis or as standard operating procedure, that antibiotics must be reserved for animals that are sick or will receive surgery, and that reporting will verify compliance with the law and ensure reduction of unnecessary antibiotic use.

Source: MD Keep Antibiotics Working

WHO releases new paper on turning AMR plans into action

Since the adoption of the Global Action Plan on AMR in 2015, more than half of the world’s countries have developed national action plans (NAPs) on tackling antimicrobial resistance (AMR). However, as implementing these plans prove to be difficult, especially for low- and middle-income countries (LMICs), the World Health Organization (WHO) has released a working paper on overcoming barriers in turning AMR NAPs into action, highlighting six key strategies: establishing AMR coordination committee roles and responsibilities, prioritizing AMR activities, getting AMR into government plans and budgeting processes at all levels, engaging stakeholders, tailoring the AMR message for different audiences, and making the case for investment. While these are each important in their own right, the WHO emphasizes that these strategies must be coordinated in a purposeful way to ensure effective implementation.

Source: World Health Organization

An analysis of education and training for antimicrobial stewardship programs in Indian hospitals

To better understand the state of stewardship programs for antimicrobial resistance, one study in India, published in MDPI (Multidisciplinary Digital Publishing Institute), quantitatively and qualitatively examined healthcare professionals from 69 various hospitals. Out of the 60 respondents, it was found that over two thirds received training and education on antimicrobial resistance during their postgraduate or undergraduate training, while 88% received no education or training post-employment regarding antimicrobial stewardship. During the interview of several of these respondents, it was identified that there was a need for greater governmental support in antimicrobial stewardship activities, as well as a lack of antimicrobial stewardship programs in hospitals and postgraduate education and training programs. The researchers conclude that these findings are representative of the fragmented nature of antimicrobial stewardship education and training in India; partly due to a lack of common infrastructure and legal compulsory stewardship on antimicrobial stewardship, there is a currently unmet need for these stewardship programs and activities.

Source: Multidisciplinary Digital Publishing Institute