Let's Get Smart about Antibiotic Prescribing

Antibiotics are commonly prescribed by a wide range of clinicians. Data suggest that up to 50% of prescribed antibiotics are “unnecessary” or “inappropriate”. The decision to prescribe starts with two key questions:

1) Is an infection present?

2) Is an antibiotic needed for this condition?

Once these decisions are made, the next important step is choosing the correct antibiotic for the infection at hand, the correct dose, route, interval, and duration. As such, errors in prescribing can occur at any of these decision points. Infectious diseases specialists refer to this as “inappropriate prescribing”, which is closely associated with antibiotic resistance, adverse patient outcomes (i.e. adverse drug reactions and C. difficile associated diarrhea), morbidity, and mortality. Breaking the cycle of “inappropriate” prescribing is challenging and critical for optimal patient outcomes.

Antimicrobial stewardship program (ASPs) are healthcare institutional programs aimed at promoting judicious antibiotic prescribing. ASPs have gained recent attention through White House policies designed to address multidrug resistant bacterial infections in the United States.

Multidrug resistance was first addressed in 2014 by President Obama in his State of the Union Address as a growing threat to the safety of our citizens. He convened at the President’s Council of Advisors on Science and Technology (PCAST) on antimicrobial resistance. Ultimately, the White House and the Centers for Disease Prevention and Control (CDC) hosted over 150 stake holders in June 2015 to discuss strategies for halting antibiotic resistance. One of the primary proposals of the council was to draft legislation requiring all US healthcare facilities to develop ASPs by 2020 in an attempt to reduce “inappropriate prescribing” by 30%, thus, improving antibiotic use is now on the national public health agenda.

November 16-22, 2015 is the CDC’s Get Smart about Antibiotics Week. We hope to use our 2008 established ASPs and the CDC’s platform to enlighten clinicians, patients, and families about the role of antimicrobial stewardship. Although it is humbling to hear President Obama supporting our mission nationally, we have learned that attitudes, culture, and practice changes start locally.

Just like the infectious diseases that we aim to cure, improved prescribing can be “contagious” with the right message:

Clinicians vary in their knowledge and confidence in antibiotic prescribing. In our experience, the educational message needs to be tailored to the prescribing audience, from medical students, residents, fellows, to mature clinicians, and allied health professionals (NPs, PAs).

A multi-disciplinary team is needed to tackle the challenge of improving prescribing throughout the hospital system. No one group can do this alone. Infectious diseases physicians and pharmacists usually lead the charge, but there are many champions throughout the facility, including microbiologists, hospitalists, nurses, residents, and PAs.

Data speaks louder than any opponent. A coordinated ASPs team can aggregate meaningful data, such as local prescribing patterns and susceptibility data, to share with prescribers. ASPs can adapt national guidelines for specific infections to meet the needs of local prescribers, patients, pathogens, as well as the hospital formulary of agents (the inventory of antimicrobial drugs that each hospital has in stock).

Education is very important but not enough on its own. According to several studies, education without reinforcement is unlikely to have larger or sustained effects on prescribing. We have found that partnering education with simple prescribing tools (e.g. prescribing algorithms, electronic applications) and other activities (auditing and detailing to prescribers) can have real impact on the appropriateness of antibiotics used throughout the hospital.

We hope that prescribers reflect on their individual roles in addressing “inappropriate prescribing.” We suggest the following:

1) Be a good role model. Do not take or prescribe antibiotics when not needed (i.e. for a viral infection).

2) Receive and recommend the Influenza vaccine to avert viral syndromes for which inappropriate antibiotics are often prescribed.

3) Use local susceptibility data to make informed antibiotic prescribing choices.

4) Keep antibiotic durations short when possible, especially for syndromes such as pneumonia and urinary tract infections where information is mounting to support shorter courses.

5) Champion ASPs with your colleagues and patients.

Let’s get smart about antibiotic prescribing. This is a meaningful way to impact the care for current and future generations of patients.

Belinda Ostrowsky M.D., M.P.H. is Director of Montefiore Health System’s Antibiotic Stewardship Program, organized to foster judicious antimicrobial use toward better patient care and safety; improved clinical outcomes; reduced resistance; and fewer healthcare-acquired infections. She is also an Associate Professor of Clinical Medicine, Department of Medicine (Infectious Diseases) at Albert Einstein College of Medicine. Her background includes a specialty in infections and public health at a Harvard-affiliated teaching hospital and assignments to the Center for Disease Control and Prevention’s Epidemic Intelligence Service and the Westchester County Department of Health. Dr. Ostrowsky is helping to oversee a 64-hospital effort to reform antibiotic use.

Priya Nori M.D. is an attending physician in the Infectious Disease department of Montefiore Health System and an assistant professor at Albert Einstein College of Medicine. Dr. Nori is a director of the Montefiore-Einstein Antimicrobial Stewardship Program at Wakefield. Her research currently focuses on educational tools for improving antibiotic prescribing in medical providers and antimicrobial stewardship with an emphasis on improving evidence-based antibiotic prescribing in medical providers. She is very involved in residency and fellow education and curriculum development in the area of Infectious Diseases. Dr. Nori’s numerous awards include the American Medical Women’s Association Glasgow-Rubin Achievement Award, Alpha Omega Alpha, and the Barbara Zucker Traveling Fellowship in Clinical Infectious Diseases.