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From Medscape Infectious Diseases Conquering Antibiotic Overuse An Expert Interview With the CDC Laura A. Stokowski, RN, MS Authors and Disclosures Posted: 11/30/2010 Physician Rating: ( 23 Votes ) Rate This Article: Print This Email this Share INFORMATION FROM INDUSTRY The changing landscape of nursing is creating new opportunities The University of Phoenix College of Nursing can provide you with the academically relevant information needed to pursue new opportunities. Discover the opportunities Addressing Antibiotic Overuse Editor's Note: The serious and pervasive problem of antibiotic overuse in our society must be attacked on many fronts. To this end, the Centers for Disease Control and Prevention (CDC) launched a broad educational program called Get Smart: Know When Antibiotics Work in 2003. The program provides resources for providers to support appropriate prescribing in the outpatient setting and complementary educational materials for the general public. Each year, this program links professional societies and state-based appropriate antibiotic use campaigns during its Get Smart About Antibiotics Week (November 15-21, 2010), now in its third year. Five new message fact sheets were unveiled for this year's observance. Now, CDC has introduced Get Smart for Healthcare, a new campaign focused on improving antimicrobial use in inpatient healthcare settings (such as acute-care and long-term care facilities) through the implementation of antimicrobial stewardship programs and interventions. These interventions are designed to ensure that hospitalized patients receive the right antibiotic, at the right dose, at the right time, and for the right duration. Antimicrobial stewardship interventions have been proven to improve individual patient outcomes, reduce the overall burden of antibiotic resistance, and save healthcare dollars. Dr. Arjun Srinivasan and Dr. Lauri Hicks of CDC spoke with Medscape about antimicrobial overuse and antimicrobial stewardship. Dr. Srinivasan is the Associate Director for Healthcare-Associated Infection Prevention, Division of Healthcare Quality Promotion, and Medical Director for Get Smart for Healthcare. Dr. Hicks is a Medical Epidemiologist and Medical Director for the Get Smart: Know When Antibiotics Work program with the Respiratory Diseases Branch, National Center for Immunization and Respiratory Diseases. Medscape: How effective are antimicrobial stewardship interventions? CDC: Antimicrobial stewardship interventions have been shown to improve individual patient outcomes, reduce the risk for Clostridium difficile infection, reduce the overall burden of antibiotic resistance, and save healthcare dollars. Implementation of an antimicrobial stewardship program in a healthcare facility -- regardless of the setting -- will help ensure that hospitalized patients receive

the right antibiotic, at the right dose, at the right time, and for the right duration. As a result, there is reduced mortality, reduced risk for C difficile-associated diarrhea, shorter hospital stays, reduced overall antimicrobial resistance within the facility, and cost savings. [1] Medscape: It would be interesting to learn what leads to the most prescribing and most inappropriate prescribing by clinicians. Can you talk a bit about the key issues in both the outpatient and inpatient settings? CDC: It is estimated that roughly 50% of antibiotics are unnecessarily prescribed in both inpatient and office settings. This is especially true for upper respiratory infections (URIs) like cough and cold illness, most of which are caused by viruses. Prescribing antibiotics for viral URIs is the most common misuse of these drugs. These infections will resolve on their own without antibiotics. In children, antibiotics are the most common cause of emergency department visits for adverse drug events. Children may have up to 9 colds each year. Four out of 10 children who present to an outpatient provider with the common cold receive an antibiotic, even though antibiotics are never indicated for a common cold. Clinicians cite lack of time, perceived patient expectations, and diagnostic uncertainty as reasons that antibiotics may be prescribed when not needed. For example, prescribing an antibiotic can be quicker than taking the time to counsel a patient on appropriate use and about why antibiotics are not needed for viral illnesses. In addition, physicians are trained to be wary of missing serious treatable diseases and may prescribe an antibiotic when uncertain of the diagnosis because they are concerned about liability. In inpatient settings, clinicians often point to pneumonia and urinary tract infections as being important areas needing improvement with respect to antibiotic use. Antibiotics are sometimes given when they are not needed to patients with syndromes that might look like pneumonia or in patients with indwelling urinary catheters who have bacteria in the urine but no evidence of infections. Another important area for improvement in inpatient settings is unnecessary duplication of therapy. For example, clinicians will sometimes prescribe 2 intravenous agents to treat a suspected anaerobic infection, when this is almost never necessary. Medscape: What interventions actually work to change prescriber behavior and decrease the public's demand for antibiotics? CDC: The good news is that a variety of different interventions have proven successful. Several demonstration projects have been conducted to determine which interventions are most effective at decreasing the public's demand for antibiotics. We have learned that a multifaceted approach -- where we target healthcare providers and the general public -- is most effective. For example, Gonzales and colleagues [2] conducted a study in Colorado to identify how to reduce antibiotic use for uncomplicated acute bronchitis. There was a full intervention site, a limited intervention site, and 2 usual care control sites. Household- and office-based patient educational materials and a clinician educational intervention were provided at the full intervention site. At the limited intervention site, only office-based educational materials were offered. The full intervention showed a decline in antibiotic prescribing for bronchitis (from 74% to 48%), whereas no significant changes were seen at the control and limited intervention sites (from 78% to 76% and 82% to 77%, respectively). Simultaneous clinician and patient education is the most effective approach to reduce inappropriate antibiotic use in outpatient settings. Clinician and patient

educational materials are available for download at the CDC site (Get Smart: Know When Antibiotics Work). Medscape: How should clinicians respond when a patient asks for an inappropriate antibiotic? CDC: Here are 4 communication strategies that clinicians can use to help prevent patient requests for an inappropriate antibiotic or to respond to such requests: 1. Provide a specific diagnosis to help patients feel validated. For example, say "viral bronchitis" instead of referring to an illness as "just a virus." 2. Recommend symptomatic relief and share normal findings as you go through your examination. 3. Discuss potential side effects of antibiotic use, including adverse effects and resistance. Many patients don't realize that antibiotics can be harmful. 4. Lastly, explain to the patient or parent what to expect over the next few days -- including that you will reevaluate their situation and prescribe antibiotics if it becomes medically appropriate. More information about appropriate antibiotic use and tools, including a symptomatic prescription pad can be found on CDC's Website. Medscape: What else is available to help clinicians prescribe more effectively and reduce inappropriate antibiotic usage? CDC: Clinicians are urged to stay aware of the most recent treatment guidelines developed by CDC and professional societies. Summaries of the guidelines and courses emphasizing these guidelines are available, some offering educational credits. In addition, CDC offers resources for communicating with patients. Recent studies on some infections such as pneumonia and urinary tract infections suggest that shorter courses of treatment are just as effective, and less toxic, than longer courses. [3,4] It is important for clinicians to be aware of evidence that can help guide the optimal duration of therapy. Medscape: Your campaign reinforces the importance of clinician awareness of resistance trends in a specific practice area. What is the best way for a clinician to stay up-to-date on geographic resistance? CDC: Local antibiogram data can provide useful information about resistance patterns and can guide treatment and management decisions related to certain infections. Antibiogram data may be available from hospital microbiology laboratories or from other laboratories that perform antimicrobial susceptibility testing. State and national surveillance data can provide insight into the resistance patterns for certain bacteria. For example, Active Bacterial Core surveillance (ABCs) is a collaboration between CDC, state health departments, and universities. ABCs is an active laboratory- and population-based surveillance system that collects information about invasive bacterial pathogens of public health importance. Medscape: Are data on antibiotic usage collected routinely? Are they publicly available?

CDC: The National Ambulatory Medical Care Survey (NAMCS) is a CDC survey designed to meet the need for objective, reliable information about the provision and use of ambulatory medical care services in the United States. Findings are based on a sample of visits to non-federal-employed office-based physicians who are primarily engaged in direct patient care. Survey questions include several related to antibiotic prescribing for different diagnoses in outpatient settings and can be tracked over time. These data are publicly available and can be accessed through the NAMCS Website Large data warehousing companies also routinely collect proprietary antibiotic sales and utilization data. The National Healthcare Surveillance Network (NHSN) is a Web-based surveillance tool for hospitals and state health departments that monitors healthcare-associated infections. Currently, more than 2500 United States hospitals (approximately half) are enrolled in NHSN. Additionally, NHSN has recently revised its Antimicrobial Use and Resistance (AUR) Module. [5] The initial release of the module provided a mechanism for facilities to electronically report and analyze antimicrobial use and/or resistance as part of antimicrobial stewardship efforts at their facility. Medscape: Could antibiotic usage be used as a performance indicator? CDC: Yes, antibiotic use has and is being used as a performance indicator. Several state health departments across the country have partnered with local health plans to use prescribing data to identify high antibiotic prescribers to target them for education and messaging. The National Committee for Quality Assurance (NCQA) manages the Healthcare Effectiveness Data and Information Set (HEDIS), which health plans and employers can use to track provider practices. In 2011, HEDIS relevant indicators include: Antibiotic utilization; Appropriate testing for children with pharyngitis; Appropriate treatment for children with upper respiratory infection; and Avoidance of antibiotic treatment in adults with acute bronchitis. Where We Go From Here If you ask people who they believe is responsible for the problem of antimicrobial overuse, you will get many different answers. Some will blame patients who demand antibiotics when they aren't indicated, some will blame healthcare providers who are in a hurry to get patients out of the office, and others will blame the lack of rapid diagnostics to inform prescribing decisions. Clearly, this is a problem with many contributing factors and will require multifaceted solutions. The Get Smarteducational programs aim to do just that, and all that remains is for health professionals and the public to take responsibility, become educated, change behavior, and reap the benefits of still having effective antibiotics to treat bacterial illnesses in this and future generations. Related Resources Hicks L. CDC Commentary: Don't Give In and Give Those Antibiotics! Available at:http://www.medscape.com/viewarticle/730224 Accessed November 23, 2010.

Srinivasan A. CDC Commentary: Three Steps to Antibiotic Stewardship. Available at:http://www.medscape.com/viewarticle/731784 Accessed November 23, 2010.