There are many stories of patients who suffer when we make errors prescribing antibiotics. 75-year-old Bob Totsch from Coshocton, Ohio, went in for heart bypass surgery with every expectation of a good outcome.
Instead, he developed a surgical site infection caused by MRSA. Given a variety of antibiotics, he developed the deadly diarrheal infection C. difficile, went into septic shock, and died.
A tragic story and, probably, a preventable death.
Today, we’ve published a report about the need to improve antibiotic prescribing in hospitals. Antibiotic resistance is one of the most urgent health threats facing us today. Antibiotics can save lives.
But when they’re not prescribed correctly, they put patients at risk for preventable allergic reactions, resistant infections, and deadly diarrhea. And they become less likely to work in the future.
About half of hospital patients receive an antibiotic during the course of their stay. But doctors in some hospitals prescribe three times more antibiotics than doctors in other hospitals, even though patients were receiving care in similar areas of each hospital.
Among 26 medical-surgical wards, there were 3-fold differences in prescribing rates of all antibiotics, including antibiotics that place patients at high risk for developing Clostridium difficile infections (CDI).
CDC has estimated that there are about 250,000 CDIs in hospitalized patients each year resulting in 14,000 deaths.
We estimate that a 30% reduction in use of broad-spectrum antibiotics could result in a 26% reduction in CDI. High-risk antibiotics include fluoroquinolones, β-lactam antibiotics with β−lactamase inhibitors, and extended-spectrum cephalosporins. CDI reductions of this magnitude would likely have additional positive ripple effects in reducing exposure and transmission of C. difficile between patients throughout the health care system and community.
Among the six most common patient-location types, critical care units reported higher rates of antibiotic prescribing than ward locations, although the difference in prescribing rates (between the top 10% and bottom 10% of reporters) within any one patient-location type was highest (3-fold) among combined medical/surgical wards.
When limiting the comparison to assessing prescribing within a similar patient-care location (e.g., 26 medical/surgical wards), rates of prescribing for specific antibiotic classes varied even more: 8-fold for fluoroquinolones, 6-fold for antipseudomonal agents, and 3-fold for both broad-spectrum agents (antibiotics considered high risk for subsequent CDI), and vancomycin.
CDC recommends that every hospital in the country have an effective antibiotic stewardship program, and has developed guidance to assist hospitals in starting or expanding stewardship programs to improve antibiotic prescribing practices. Central to this guidance are seven core elements that have been critical to the success of hospital antibiotic stewardship programs:
- Leadership commitment: Dedicate necessary human, financial, and IT resources.
- Accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
- Drug expertise: Appoint a single pharmacist leader to support improved prescribing.
- Act: Implement at least one prescribing improvement action, such as requiring reassessment within 48 hours to review drug choice, dose, and duration.
- Track: Monitor prescribing and antibiotic resistance patterns.
- Report: Regularly report to staff on these prescribing and resistance patterns, and recommend steps to improve.
- Educate: Offer education about antibiotic resistance and improving prescribing practices.
In addition, hospitals should work with other health care facilities in the area to prevent infections, transmission, and resistance.
Given the proven benefit of these programs and the urgent need to address the growing problem of antibiotic resistance, CDC recommends that all hospitals make it a top priority to implement an antibiotic stewardship program.
Our new guide and checklist can help hospitals make a major step forward in protecting these endangered resources and providing better patient care.
Tom Frieden, MD, MPH (@DrFriedenCDC) is Director of the Centers for Disease Control and Prevention.