I was recently asked to evaluate a young child with a urinary tract infection caused by an extended spectrum beta-lactamase (ESBL)–producing Escherichia coli.
I’d just broken the bad news to the mother: There was no oral medication available to treat the baby, so she’d have to stay in the hospital for a full intravenous course.
“Has your child been treated with antibiotics recently?” I asked the mother, wondering how the baby had come to have such a resistant infection.
Dr. Kristina Bryant
“She had a couple days of runny nose and a low-grade fever a couple of weeks ago,” she told me. “Her doctor treated her for a sinus infection.”
In 2011, doctors in outpatient settings across the United States wrote 262.5 million prescriptions for antibiotics – 73.7 million for children – and according to the Centers for Disease Control and Prevention, about 50% of these were completely unnecessary because they were prescribed for viral respiratory tract infections (Clin Infect Dis. 2015 May 1;60[9]:1308-16).
Prescribing practices varied by region, with the highest rates in the South. Don’t think I’m judging. I live in Kentucky, the state with the highest rate of antibiotic prescribing at 1,281 prescriptions per 1,000 persons. Is it any wonder that we’re seeing kids with very resistant infections?
The CDC estimates that at least two million people in the United States are infected annually with antibiotic-resistant bacteria and at least 23,000 of them die as a result of these infections. It is estimated that prevention strategies that include better antibiotic prescribing could prevent as many as 619,000 infections and 37,000 deaths over 5 years. Fortunately, my little patient recovered fully, but it has made me think about antimicrobial stewardship, especially its role in the outpatient setting.
According the American Academy of Pediatrics, the goal of antimicrobial stewardship is “to optimize antimicrobial use, with the aim of decreasing inappropriate use that leads to unwarranted toxicity and to selection and spread of resistant organisms.”
Antimicrobial stewardship programs (ASPs) are increasingly common in inpatient settings and have been shown to reduce antibiotic use. These programs can take many forms. The hospital where I work relies primarily on clinical guidelines emphasizing appropriate empiric therapy for a variety of common conditions. Other hospitals employ prospective audit and feedback, as well as a restricted formulary. Medicare and Medicaid Conditions of Participation will soon require hospitals that receive funds from the Centers for Medicare and Medicaid Services have an ASP.
Comparatively little has been published about ASPs in the outpatient setting. The American Academy of Pediatrics suggests that effective strategies include patient education, provider education, provider audit and feedback, and clinical decision support. We have at least some data that these work, at least in a research setting.
From 2000 to 2003, a controlled, cluster-randomized trial in 16 Massachusetts communities demonstrated that a 3-year, multifaceted, community-level intervention was “modestly successful” in reducing antibiotic use (Pediatrics. 2008 Jan;121[1]:e15-23). As a part of this intervention, parents received education via direct mail and in primary care settings, pharmacies, and child care centers while physicians received small-group education, frequent updates and educational materials, and prescribing feedback. Antibiotic prescribing was measured via health insurance claims data from all children who were 6 years of age or younger and resided in study communities, and were insured by one of four participating health plans. Coincident with the intervention, there was 4.2% decrease in antibiotic prescribing among children aged 24 to <48 months and a 6.7% decrease among those aged 48-72 months. The effect was greatest among Medicaid-insured children.
More recently, 18 primary care practices in Pennsylvania and New Jersey were randomized to an intervention that consisted of a 1-hour, on-site education session followed by 1 year of personalized, quarterly audit and feedback of prescribing for bacterial and viral acute respiratory tract infections (ARTIs), or usual practice (JAMA. 2013 Jun 12;309[22]:2345-52). The prescribing practices of 162 clinicians were included in the analysis.
Broad spectrum–antibiotic prescribing decreased in intervention practices, compared with controls (26.8% to 14.3% among intervention practices vs. 28.4% to 22.6% in controls), as did “off-guideline” prescribing for pneumonia and acute sinusitis. Antibiotic prescribing for viral infections was relatively low at baseline and did not change. The authors concluded that “extending antimicrobial stewardship to the ambulatory setting, where such programs have generally not been implemented, may have important health benefits.” Unfortunately, the positive effect in these practices was not sustained after the audit and feedback stopped (JAMA. 2014 Dec 17;312[23]:2569-70).
Not all antimicrobial stewardship interventions need to be time- and resource-intensive. Investigators in California found that providers who publicly pledged to reducing inappropriate antibiotic use for ARTIs by signing and posting a commitment letter in exam rooms actually prescribed fewer inappropriate antibiotic courses for their adult patients (JAMA Intern Med. 2014 Mar;174[3]:425-31).