Antibiotic stewardship: An approach to preserving our miracle drugs

Antibiotics were the miracle drugs of the 20th century, making once-fatal diseases curable with a simple pill. However, over the years an unanticipated problem has developed: bacteria have grown resistant to one antibiotic after another, faster than we can develop new ones.

It’s become a major health concern, with over two million illnesses each year and 23,000 deaths attributed to bacteria that are resistant to antibiotics. This number is expected to continue to rise, possibly as high as 10 million by 2050—especially if these precious resources continue to be misused and over-prescribed. In some parts of the world, they may be easily obtainable without a prescription, and even in the United States, they may be prescribed for infections that antibiotics can’t treat.

“As a result, the infectious disease community has promoted antibiotic stewardship as a way to preserve our antimicrobials and slow the rate at which our antibiotics become futile,” said Andrea Luce, PharmD, an infectious disease clinical pharmacist and assistant professor of pharmacy practice at the Texas A&M Irma Lerma Rangel College of Pharmacy. “Antibiotic stewardship aims to optimize antibiotic use and patient outcomes, minimize consequences of antibiotic use, optimize patient safety and reduce health care costs.”

The United States federal government is taking this approach seriously. The Obama Administration created a National Action Plan for Combating Antibiotic-Resistant Bacteria with five goals: slow emergence of resistant bacteria, strengthen surveillance efforts, advance new diagnostic tests, accelerate development of new antibiotics and vaccines and increase international collaboration. At the same time, the Center for Medicare and Medicaid Service will use reimbursement incentives to drive antibiotic stewardship. By 2017, all hospitals must have stewardship programs to be reimbursed under these federal programs. Future phases include similar requirements for outpatient surgeries and dialysis centers.

The core strategies of these stewardship programs are a prospective audit with intervention and feedback, formulary restrictions and preauthorization. The audit would require a second health care provider to review the chart of each patient prescribed antibiotics. This person would provide feedback to the prescriber about whether—in their second opinion—the prescription was warranted. A more aggressive approach would be formulary restriction and preauthorization in which a second pharmacist or physician must approve before the antibiotic could be administered to the patient.

“An organized, multi-disciplinary team to review antibiotic use within health systems could make a huge difference in responsible prescribing practices,” Luce said. “We already see that simply reviewing patient’s charts can decrease antibiotic use.”

The expanded use of electronic health records should make such reviews easier, because the charts can be searched for key terms. This technology also makes it possible to input a variety of data about each patient—including laboratory findings, vital signs, symptoms, and history—and assign a point value to each. As the point values go up, the higher patients’ ‘scores’ and the more attention—and potentially antibiotics—they will likely need. Such a system might help allocate antibiotic resources where they can do the most good.

Texas A&M public health researchers are also creating their own guides to antibiotic stewardship, particularly in nursing homes, where antibiotic-resistant infections can be devastating to already frail residents.

“With the increasing support from the United States government, antibiotic stewardship will soon be a required element in acute care institutions and will impact an increasing number of Americans moving forward,” Luce said. “In the meantime, we must use older antibiotics in new and creative ways to achieve positive outcomes.”