Last month, news from China provided a stark reminder that in an arms race between powerful antibiotics and rapidly-evolving bacteria, the germs usually win. Scientists reported that they had discovered a new strain of bacteria able to fight off colistin, a powerful antibiotic known as one of the drugs of last resort.
This is just the latest incident to raise the specter of a “post-antibiotic era.” As antibiotics are overused in hospitals, clinics, nursing homes, and—as in this latest example—the livestock in our food supply, bacteria evolve defenses so they become completely resistant to standard treatments, turning common infections and surgical procedures into potentially life-threatening situations.
While this is a global problem, doctors and pharmacists can limit the growth of antibiotic resistance on a smaller scale by carefully monitoring the use of antibiotics within a hospital. The University of Chicago Medicine has been placing controls on antibiotic use since the early 2000s, but the practice became formalized in 2010 when it formed its Antimicrobial Stewardship Program (ASP). Stewardship means finding the right balance between treating infections, but not overusing antibiotics in a way that promotes resistance.
“We focus on optimization of antimicrobial drug therapy, so using the right drug for the right patient at the right time, and for the right duration,” said Jennifer Pisano, MD, Adult Medical Director of the UChicago Medicine ASP.
One of the primary ways of doing this is by restricting the availability of the most powerful drugs. The ASP has put 38 adult and 42 pediatric medications on a restricted list, so if a doctor wants to prescribe one of them, the ASP team has to review the case first. If the restricted agent is approved, the ASP then consults with the physician to monitor the patient during treatment.
The ASP also works with the pharmacy and IT department to use features in the electronic medical record system to help providers choose the right antibiotics based the patient’s diagnosis or specific need. This further limits the overuse of certain agents, and saves providers a few steps in the process.
This review process has produced stunning results in both antibiotic usage and cost savings. UChicago Medicine has reduced the use of carbapenems, a powerful class of drugs whose overuse is known to promote resistance, by about 50 percent in the first four years of stewardship. In that same time period, UCM has also reduced spending on antimicrobial drugs by an average of over $420,000 per year.
Perhaps the most important—and challenging—part of the program has been education and getting buy-in from providers.
“Physicians like to use what they know, and they don’t like to feel restricted when a patient comes to the hospital,” Pisano said. Doctors may prescribe antibiotics just to be sure, or give in to patient pressure (especially with parents of children) to give the impression of doing something, even if a patient may not need it. Pisano said that the ASP helps physicians spot situations where antibiotics may not be needed or may need modification.
Getting physicians to buy-in to the idea of stewardship is key to the program’s success, as is driving home the point that it’s not just about saving money or limiting the use of a particular drug, but increasing patient safety. And it’s been working: Of the roughly 1,300 times the ASP team has intervened in a case since 2010, providers have accepted their advice 90-95 percent of the time.
“That’s the point of having an antimicrobial stewardship program. It’s safety,” said Natasha Pettit, PharmD, Adult Pharmacy Director of the ASP. “We want to make sure that patients are getting the antibiotics they need and not getting more than they need. By doing that, we ensure that we’re maintaining susceptibilities of the most dangerous organisms.”