Studies show that up to half of all antibiotics prescribed in U.S. hospitals are inappropriate, which has contributed to the spread of antibiotic-resistant microbes. Dr. Arjun Srinivasan is associate director for health care-associated infection prevention programs at the Centers for Disease Control and Prevention’s National Center for Emerging and Zoonotic Infectious Disease. For much of his career, Srinivasan ran the unit that investigated infectious disease outbreaks in hospitals and other health care facilities. Today, he leads CDC’s effort to improve the use of antibiotics in hospitals.
CDC estimates that more than 2 million people each year are infected with antibiotic-resistant organisms, resulting in approximately 23,000 deaths annually. In 2014, CDC recommended that all acute care hospitals implement “antibiotic stewardship programs.” Srinivasan, who will be speaking at the upcoming U.S. News Hospital of Tomorrow conference, talked with U.S. News about the risks of resistant infections and the role antibiotic stewardship programs play in preventing them. (The interview has been edited for length and clarity.)
What is antibiotic stewardship?
We can’t control the way bacteria develop resistance. And, as a physician, I can’t control how fast new antibiotics come on the market. What I can do is improve how I use antibiotics. That’s where antibiotic stewardship comes in. These programs can both optimize the treatment of infections and reduce adverse events associated with antibiotic use.
We are at a crisis moment with respect to antibiotic resistance. For some patients, we’ve completely run out of antibiotics that work. We have patients in hospitals in the United States who have infections that their doctors can’t treat. This is something that fundamentally threatens our ability to deliver modern medicine. So much of modern medicine has become very dependent on treating infections. For example, [consider] cancer chemotherapy, when we weaken someone’s immune system with powerful chemotherapy … To continue to do [these treatments], we need to manage infections. Improving the use of antibiotics is one of the most fundamental things we can do.
Dr. Arjun Srinivasan leads the Centers for Disease Control and Prevention’s effort to improve the use of antibiotics in hospitals.Courtesy CDC
What’s required for antibiotic stewardship?
CDC has developed seven core elements needed for antibiotic stewardship programs. … The elements are: Hospital leaders must be committed and willing to supply resources; an effective program leader who is accountable for getting results; a pharmacist with antibiotic expertise; a recommended action, such as re-evaluating patients’ need for antibiotics after a set period of initial treatment; monitoring of antibiotic prescribing and resistance patterns; regular reporting of information on antibiotic use and microbial resistance to doctors, nurses and relevant staff; and education for clinicians to convey critical information about optimal prescribing and antibiotic resistance.
How many hospitals in the U.S. have antibiotic stewardship programs?
About 40 percent of hospitals in the U.S. say they have implemented all seven of the CDC’s core elements, based on responses to questions we added to the National Healthcare Safety Network Annual Facility Survey, which involves about 4,000 acute care hospitals in the U.S. that voluntarily submit patient-safety data to CDC.
How difficult is it for hospitals to monitor antibiotic use?
Obviously, [approaches] that are built into the system are much, much more likely to get done than things that busy providers have to remember every day. We’ve seen a lot of success at hospitals working through their pharmacy, laboratory or electronic health records, putting into place systems to alert providers to issues [involving] antibiotic prescribing. For instance, a provider might get an alert indicating that someone is getting an antibiotic intravenously but other medications orally. It prompts the provider to see whether this person might be a candidate for a switch. … The balance [to strike] is to make sure you have just the right number of alerts; if you have too many, people ignore them.
How effective is antibiotic stewardship?
It’s effective on a number of different fronts. There’s a nice study showing that patients in antibiotic stewardship programs have higher infection cure rates and lower treatment failure rates, indicating that providers do a better job of treating patients. We know that hospitals that have implemented these programs achieved decreases in Clostridium difficile rates – that’s one of the huge impacts of antibiotic stewardship programs.
These benefits seem so obvious, yet more than 60 percent of hospitals haven’t adopted antibiotic stewardship programs. Why?
That’s the key question. That’s something we’re working to try to understand. For the folks who haven’t done all seven core elements, which ones haven’t you implemented? Are there ones that are particularly challenging? Are there areas where people are really struggling? We’re looking at the results of the [NHSN] survey to try to figure this out.
Do you see higher adoption rates in certain kinds of hospitals?
Yes we do. We see much higher adoption rates in larger hospitals than we do in smaller hospitals, and we see slightly higher adoption rates in teaching hospitals than in non-teaching hospitals, although that probably reflects the size issue. I think the real gap we’re seeing right now is that larger hospitals are more successful in implementing all these elements than smaller hospitals are. We’re trying to figure out what’s causing that gap and trying to bridge it. … The key is to work with the small hospitals that have done it, get the lessons learned and hold them up as a model for the smaller hospitals that might not have done it yet.
Are hospital leaders on board?
The American Hospital Association [whose members are hospital executives] has been on board for quite some time now. Last year when CDC released the core elements, AHA released a tool-kit and identified antibiotic stewardship as one of the top five things that hospitals can do to use resources efficiently.
What about patients? What role do they play?
We’ve got some experience from our work in infection control that helps us understand that patients actually do play an important role in what goes on behind the curtains in a hospital. Historically, all of the infection control work that happened at a hospital was invisible to patients. They didn’t see a lot of [it] or know to ask questions about it. That’s changed; now people are much more engaged about asking providers to wash their hands. … We want to see that same culture with antibiotics. We want people to know when they’re in the hospital: What antibiotics am I taking? What are they being used for? What infection is being treated? Are the bacteria causing that infection being killed by that antibiotic? How long do I need that antibiotic? Do I need it intravenously or can I take it orally?
We expect our report on the [antibiotic stewardship] survey to come out in coming months. Another huge thing that will be developing over the course of the next year revolves around measurement of antibiotic use in hospitals. This has long been a big gap. We don’t have good information about antibiotic use within the walls of hospitals. … What we want to do – and it’s something hospitals have asked us for – is [develop] the kind of benchmarking [standards] we’ve been able to do with infection control. [Hospitals] want to compare their antibiotic use with hospitals that look like them and see where they fit. Are they doing a really good job? We’ve proposed the first-ever antibiotic benchmarking measure on antibiotic use for the National Quality Forum [a group that evaluates new health care performance measures]. It’s cleared its first hurdle. We hope by early 2016 that measure will be endorsed and approved by the NQF.