15 June 2016

Slowing the Superbug Evolution: Improving Antibiotic Stewardship in the ED

Scientists have warned for years that overuse of antibiotics would eventually lead to bacterial infections against which these “miracle drugs” would be ineffective. A world in which antibiotics are powerless to fight infections seems almost unimaginable. But the threat of untreatable infections is very real, and we’re getting closer to that ominous scenario.

In May, a bacterium that is resistant to an antibiotic of last resort was found in a patient in the U.S. for the first time. The presence of the mcr-1 gene was discovered in an E. coli bacteria cultured from a patient who had been treated for a urinary tract infection on April 26 at an outpatient military facility in Pennsylvania. Tests showed that the E. coli found in this patient were resistant not only to first-line antibiotics but also to colistin, an antibiotic whose use was largely discontinued in the 1970s because of its serious side effects but that is being used again to treat certain dangerous types of superbugs that do not respond to other antibiotics. In this case, the infection was treated successfully with another type of antibiotic. But the authors of a study published on May 26 in Antimicrobial Agents and Chemotherapy wrote that the discovery of the mcr-1 gene in the U.S. “heralds the emergence of a truly pan-drug resistant bacteria.” Dr. Tom Frieden, director of the Centers for Disease Control and Prevention (CDC) warned that this alarming development "is the end of the road for antibiotics unless we act urgently."

23K People Die Each Year From Antibiotic-Resistant Bacterial Infections

The CDC estimates that at least 2 million people in the U.S. become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections. Experts are concerned about the spread of colistin resistance to other bacteria. A CDC media statement explained: “The mcr-1 gene exists on a plasmid, a small piece of DNA that is capable of moving from one bacterium to another, spreading antibiotic resistance among bacterial species,” which could lead to superbugs that could cause untreatable infections.

Exacerbating the problem, the number of F.D.A.-approved antibiotics has decreased steadily in the past two decades, according to an opinion piece in The New York Times by oncologist Ezekiel J. Emanuel, a vice provost at the University of Pennsylvania, and there are relatively few new antibiotics under development. Because antibiotics are taken only for short periods of time, and because any new ones are likely to be prescribed only when no other alternative exists, developing new antibiotics is far less profitable than developing new cancer drugs, for example.

Nearly One-Third of Antibiotic Prescriptions Are Unnecessary

While the popularity of antimicrobial consumer products and widespread use of antibiotics in food-producing animals certainly contribute to the rise of antibiotic-resistant superbugs, the most important factor is overprescribing and misuse of antibiotics. According to a May report on Antibiotic Use in Outpatient Settings by the Pew Charitable Trusts, an analysis of U.S. antibiotic prescribing data from 2010 to 2011 by a panel of CDC representatives and other public health and medical experts found that “Approximately 13 percent of all outpatient office visits in the United States, or about 154 million visits annually, result in an antibiotic prescription; about 30 percent of these, or some 47 million prescriptions, are unnecessary.”

This widespread unnecessary use of antibiotics and the resulting acceleration of superbug evolution are so serious that in March 2015, the White House released a National Action Plan for Combating Antibiotic-Resistant Bacteria. One of its targets is to reduce inappropriate outpatient antibiotic use by 50 percent in outpatient settings and by 20 percent in inpatient settings by 2020. Hitting that target would require a 15% reduction in overall antibiotic prescriptions over the next four years.

EDs Are Uniquely Positioned to Change Antibiotic Use and Slow Resistance

Because of the consistently high patient volume in most emergency departments, overuse of antibiotics in emergency departments (EDs) has been a significant factor in creating this problem, and curbing the inappropriate use of these drugs in EDs – especially in adult patients – will be required to solve it.

According to the Journal of Pharmacy Practice article “Antimicrobial Stewardship in the Emergency Department,” the misuse of antibiotics to treat conditions such as upper respiratory infection, urinary tract infections and cellulitis that are commonly encountered in the ED, both in ambulatory patients and in patients requiring admission to a hospital, has led to increased resistance to drugs commonly used to treat those infections. The author points out that “The ED is uniquely positioned to affect the antimicrobial use and resistance patterns in both ambulatory settings and inpatient settings.”

One of the most prevalent problems has been the widespread use of antibiotics to treat minor acute respiratory tract infections (ARTIs) in ED patients. Many common ARTIs, such as rhinitis, sinusitis, bronchitis, viral pneumonia and influenza, are often caused by viruses and do not require antibiotics. But according to a study published in Antimicrobial Agents and Chemotherapy, an analysis of ED visits between over a 10-year period (2001–2010) found that antibiotics were prescribed in 61% of the 126 million ED visits with a diagnosis of ARTI. During that period, antibiotic use did decrease significantly for antibiotic-inappropriate ARTI patients up to the age of 19. But despite longstanding calls for better antibiotic stewardship, utilization remained stable (and excessive) for antibiotic-inappropriate ARTI in adult ED patients aged 20-64 years, and usage rates of quinolones (a family of synthetic broad-spectrum antibiotic drugs) for ARTI in adult patients increased significantly.

Achieving Effective Antibiotic Stewardship in the ED

Antibiotic stewardship in the ED – as well as in other clinical settings – is essential to curbing inappropriate use of these drugs nationwide. The findings of the panel of experts convened by the Pew Charitable Trusts to analyze antibiotic prescription and include the recommendation that antibiotics should be prescribed only when a bacterial infection is known or suspected, and that healthcare providers need to implement stewardship activities in their practices. The Pew report cites the effectiveness of evidence-based clinical decision support (CDS) in reducing inappropriate antibiotic prescribing for common outpatient infections. 

Another important element of antibiotic stewardship is patient education. In today’s patient-centered healthcare environment, doctors often find themselves in a difficult position when a patient with the flu, a common cold or other another viral disease insists on a prescription for antibiotics. Patients often self-diagnose based on online research, usually via Google or WebMD, or even based on social media conversations. Dr. Catherine Polera, chief medical officer at Sheridan Healthcare's Division of Emergency Services, says these patients often either assume the worst, arrive at an incorrect self-diagnosis, or expect treatment that is contrary to evidence-based quality measures. For example, acute bronchitis is usually caused by a virus and CMS’s Physician Quality Reporting System says it should not be treated with antibiotics, yet many patients with bronchitis insist on a prescription for them. So how can doctors provide the best care in this situation without causing patient dissatisfaction?

Dr. Polera recommends that ED physicians explain their diagnosis to patients and educate them about the illness and treatment best practices in simple, easy-to-understand language. She suggests sharing the medical organizations or regulatory bodies that support your recommended treatment (even referencing Google, if that’s the patient’s preferred source of information), answering patients’ questions and addressing their concerns to build trust in the diagnosis and the prescribed treatment and improve satisfaction with the care. “Time is a scarce resource in any emergency department, but educating patients and helping them understand the validity of your treatment decisions will return a big payoff in patient satisfaction and better outcomes.”

The CDC also recommends displaying appropriate antibiotic use posters in clinical settings to help educate both clinicians and patients.

It’s also important for providers to educate their patients about the severe consequences of inappropriate antibiotic use and the threat of untreatable superbugs. Patients must learn to stop taking antibiotics for granted and thinking of them as a one-size-fits-all default cure for what ails them.

For more information about educating patients about best-practice treatments and managing their expectations, read Dr. Polera’s article “Bridging the Expectation Gap in the ED” in MedPage Today.