OP-ED

CDC: Together We Can Provide Safer Patient Care

There are many stories of patients who suffer when we make errors prescribing antibiotics. 75-year-old Bob Totsch from Coshocton, Ohio, went in for heart bypass surgery with every expectation of a good outcome.

Instead, he developed a surgical site infection caused by MRSA. Given a variety of antibiotics, he developed the deadly diarrheal infection C. difficile, went into septic shock, and died.

A tragic story and, probably, a preventable death.

Today, we’ve published a report about the need to improve antibiotic prescribing in hospitals.  Antibiotic resistance is one of the most urgent health threats facing us today. Antibiotics can save lives.

But when they’re not prescribed correctly, they put patients at risk for preventable allergic reactions, resistant infections, and deadly diarrhea. And they become less likely to work in the future.

About half of hospital patients receive an antibiotic during the course of their stay. But doctors in some hospitals prescribe three times more antibiotics than doctors in other hospitals, even though patients were receiving care in similar areas of each hospital.

Among 26 medical-surgical wards, there were 3-fold differences in prescribing rates of all antibiotics, including antibiotics that place patients at high risk for developing Clostridium difficile infections (CDI).

CDC has estimated that there are about 250,000 CDIs in hospitalized patients each year resulting in 14,000 deaths.

We estimate that a 30% reduction in use of broad-spectrum antibiotics could result in a 26% reduction in CDI.  High-risk antibiotics include fluoroquinolones, β-lactam antibiotics with β−lactamase inhibitors, and extended-spectrum cephalosporins.  CDI reductions of this magnitude would likely have additional positive ripple effects in reducing exposure and transmission of C. difficile between patients throughout the health care system and community.

Among the six most common patient-location types, critical care units reported higher rates of antibiotic prescribing than ward locations, although the difference in prescribing rates (between the top 10% and bottom 10% of reporters) within any one patient-location type was highest (3-fold) among combined medical/surgical wards.

When limiting the comparison to assessing prescribing within a similar patient-care location (e.g., 26 medical/surgical wards), rates of prescribing for specific antibiotic classes varied even more: 8-fold for fluoroquinolones, 6-fold for antipseudomonal agents, and 3-fold for both broad-spectrum agents (antibiotics considered high risk for subsequent CDI), and vancomycin.

CDC recommends that every hospital in the country have an effective antibiotic stewardship program, and has developed guidance to assist hospitals in starting or expanding stewardship programs to improve antibiotic prescribing practices. Central to this guidance are seven core elements that have been critical to the success of hospital antibiotic stewardship programs:

  • Leadership commitment: Dedicate necessary human, financial, and IT resources.
  • Accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
  • Drug expertise: Appoint a single pharmacist leader to support improved prescribing.
  • Act: Implement at least one prescribing improvement action, such as requiring reassessment within 48 hours to review drug choice, dose, and duration.
  • Track: Monitor prescribing and antibiotic resistance patterns.
  • Report: Regularly report to staff on these prescribing and resistance patterns, and recommend steps to improve.
  • Educate: Offer education about antibiotic resistance and improving prescribing practices.

In addition, hospitals should work with other health care facilities in the area to prevent infections, transmission, and resistance.

Given the proven benefit of these programs and the urgent need to address the growing problem of antibiotic resistance, CDC recommends that all hospitals make it a top priority to implement an antibiotic stewardship program.

Our new guide and checklist can help hospitals make a major step forward in protecting these endangered resources and providing better patient care.

Tom Frieden, MD, MPH (@DrFriedenCDC) is Director of the Centers for Disease Control and Prevention.

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Mighty CaseySentinel MedPhenelle Segal RN CICElizabeth Felter, DrPHMichael Millenson Recent comment authors
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Bill Riedel
Guest
Bill Riedel

There is an interesting article on phage therapy in the current issue of NEWSWEEK – Beyond Antibiotics – By Roger Highfield. Please note that this technology can be used under provisions such as: “WORLD MEDICAL ASSOCIATION DECLARATION OF HELSINKI Ethical Principles for Medical Research Involving Human Subjects 35. In the treatment of a patient, where proven interventions do not exist or have been ineffective, the physician, after seeking expert advice, with informed consent from the patient or a legally authorized representative, may use an unproven intervention if in the physician’s judgement it offers hope of saving life, re-establishing health or… Read more »

Phenelle Segal RN CIC
Guest

Bill, I’m sure Tom will provide a more articulate response but I will share some thoughts and experiences in the meantime. This is not as simple as thought. I was the clinical coordinator for an AMS Collaborative in Southeastern and Central PA last year and developed (with the help of key persons at CDC) process measures which included culturing before starting antimicrobial therapy. Empiric therapy is far more useful when a culture is taken prior to the start of the antibiotic(s), but depending on the situation, may not always be possible (the culture). Unfortunately, there are many instances whereby (particularly… Read more »

Bill Riedel
Guest
Bill Riedel

I recently had a minor infection and was handed a prescription for an antibiotic and was given the usual instructions. As a microbiologist I asked whether it would not be advisable to take a sample for sensitivity testing before I started on the antibiotic and I was rebuked. My question is: What is the contribution to resistance development when doctors continue to do blind prescriptions – that is to say if I take an antibiotic which is not effective and a week later I am prescribed another antibiotic (again without sensitivity testing). Would it not be better to do sensitivity… Read more »

Tom Frieden, MD, MPH
Guest

Bill and Phenelle: Certainly, we must improve prescribing practices. Obtaining proper microbiologic samples, when they are indicated, before antibiotics are started is essential both to improving overall antibiotic use and to taking good care of patients. This is balanced, however, by the importance of starting antibiotics promptly when indicated (such as in the case of suspected sepsis). In addition, as Phenelle points out, in some instances there can be complexities in obtaining a microbiologic specimen that will yield meaningful results. For example, sometimes there is no readily available specimen to culture (e.g. middle ear infections and some skin and soft… Read more »

Mighty Casey
Guest

Terrific post, and an even more terrific comment thread. I’d like to point out something that hasn’t been mentioned yet: antibiotics used in food production. I remember like it was yesterday (it was 1989, actually) working on a story for NBC Nightly News about the rise of antibiotic resistant infections that focused on the massive amounts of BGH pumped into dairy cows to up milk production, which in turn required massive doses of antibiotics to fight the massive udder infections that resulted in the treated cows. At the time, I thought that I was really glad I didn’t drink milk,… Read more »

Sentinel Med
Guest
Sentinel Med

Yes. Prescribing with utmost care is most important of all. Together we can provide better care to the patients and needy people. I completely support your suggestion of implementing prescribing improvement action as this can bring upon a huge change. Great share. 🙂

Phenelle Segal RN CIC
Guest

I am an experienced Infection Preventionist and provide consulting services to various sectors of healthcare. My most recent Collaborative involvement was with the Commonwealth of Pennsylvania and The Health Care Improvement Council where I was responsible for the clinical tasks of an Antimicrobial Stewardship program. I was instrumental in developing process and outcome measures as well as engaging many wonderful, nationally renowned speakers and our facilities (hospitals and a few nursing homes) were very engaged. However, it was my own personal experience with elective surgery at the end of October 2013 that truly opened my eyes when I was given… Read more »

Tom Frieden, MD, MPH
Guest

Phenelle – Infection preventionists play a critical role in the prevention of healthcare-associated infections and antimicrobial stewardship is an important piece of that. You bring a unique perspective as a nurse, an IP, and a patient who has been impacted by the adverse effects of antibiotics. In our 7 core elements, we note the importance of including prescribers (usually physicians) in efforts – perhaps you could team up with a like-minded prescriber and combine your efforts and stories. At CDC, we work with a number of patient advocates and have seen the tremendous impact of their individual and collective work.… Read more »

Phenelle Segal RN CIC
Guest

Dr Frieden,
I have been thinking of reaching out to people like Arjun S and Cliff McDonald with whom I have a very close working relationship to find out how I can be more involved so thank you for your advice. I’d like to continue with your very insightful and helpful blog.

Do you have any information to share with me as a starting point to work with patient advocates? Any direction would be positive for me to begin this process. If I can see just one less patient go through this, I would be delighted.

Phenelle

Tom Frieden, MD, MPH
Guest

Phenelle – We have worked closely with Consumers Union, the advocacy arm of Consumer Reports.

Consumers Union has a network of patient advocates who work on the Safe Patient Project: http://safepatientproject.org/

Please feel free to email us at patientsafety@cdc.gov and one of our staff members will connect you with the appropriate individuals.

Phenelle Segal RN CIC
Guest

Thank you Dr. Frieden,
I have e-mailed patientsafety@cdc. Looking forward to working with the Safe Patient Project if possible.

Phenelle Segal RN CIC
Guest

Thank you too for suggesting working with a prescriber. I have done a lot of IP related work with key ID doctors for the past 3 years across the nation and a few of them were very helpful to me when I was sick as I didn’t trust anyone other than CDC’s experts and private physicians who know how to treat CDI. I will reach out to them and see if I could collaborate.
Much appreciated!
Phenelle

Elizabeth Felter, DrPH
Guest
Elizabeth Felter, DrPH

So glad this issue is finally getting some attention! My son suffered two rounds of C. diff before the age of 2 because of antibiotic (in his case, Augmentin) use 4 years ago. I am religious about using Florastor now when my kids get antibiotics. While encouraging appropriate antibiotic use is critical, it is unlikely that we are going to stop prescribing antibiotics in children under the age of 2 who have AOM or sinusitis. Shouldn’t more be done to co-prescribe probiotics like Florastor to mitigate the harm that is done to intestinal flora with the (sadly necessary) antibiotics? Why… Read more »

Perry
Guest
Perry

There is currently an article in Medscape regarding patient satisfaction.
Unfortunately, hospitals are using patient satisfaction surveys tied to the prescribing of both antibiotics and narcotics. The concern is, are doctors willing to get a bad rating on a survey to do what is most medically appropriate? If doctors consistently get bad reviews what is the consequence, and shouldn’t sound medical judgement trump an ill-thought out survey?

Michael Millenson
Guest

When I first started researching patient safety in 1993, an epidemiologist who had succeeded in reducing his hospital’s infection rate told me how an administrator had privately taken him to task for upsetting the hospital’s budget. Though he didn’t use these words, the gist was that drugs are to a hospital’s profit margin what dessert and drinks are to the profit margin of a restaurant: it’s not the entree and it’s not the room rate that keep the doors open. No antibiotics to stop infection, no profit from prescribing drugs. The epidemiologist continued his work. And I am not saying… Read more »

Bill Riedel
Guest
Bill Riedel

I find it interesting that we keep recycling the same ideas when it comes to antibiotic-resistance. I still have a couple of copies of “Proceedings of the International Conference on Nosocomial Infections held at CDC Aug. 3-6. 1970.” Yet hardly ever mentioned in these discussions is phage therapy which has been used in the former USSR almost 100 years. We appear to pretend that we are the friends of Georgia, where the most significant knowledge on phage therapy now exists; but at the same time we don’t trust their science. As a speaker, meeting organizer and author on phage therapy… Read more »

Don't Go Back to Rockville
Guest
Don't Go Back to Rockville

Isn’t this a situation where the promise of big data can be realized?

Shouldn’t CDC be able to track and identify problematic antibiotic prescribing patterns in real time? Why aren’t we doing this? Or are we? And if we are – why aren’t we doing more with it?

Vik Khanna
Guest

Oh, the lure of the mysterious and all powerful big data (or so big data acolytes tell us): Does CDC have statutory authority to gather this data? Is antibiotic misuse a (mandatory or voluntarily) reportable public health problem? Who’s going to report it? How? Who’ll have access to it? Should it be a public database that a consumer such as me can access before my son or wife is admitted to the hospital? How will providers identified as bad actors be allowed to appeal or modify how their data is displayed? Can the data be used to modify compensation, credentialing… Read more »

Tom Frieden, MD, MPH
Guest

Vik, please see below response to Don’t Go Back to Rockville for information about the growing amount of publicly available information related to healthcare safety. We think patients have a right to know key information about the facilities they are cared for in – especially if the funding of those facilities is with taxpayer money.

Tom Frieden, MD, MPH
Guest

We believe that tracking antibiotic prescribing and antibiotic resistance patterns is a critical step toward slowing resistance and saving lives. CDC’s National Healthcare Safety Network (NHSN) is used by 12,000 hospitals and healthcare facilities nationwide to track and compare rates of healthcare-associated infections and other information. This allows facilities, quality improvement groups, and public health organizations to quickly identify areas of progress and areas where improvement is needed. Recently, NHSN launched its Antibiotic Use and Resistance module to help facilities track antibiotic prescribing information. The module will include the capability to track resistance information, too. In addition to helping direct… Read more »

Phenelle Segal RN CIC
Guest

Dr Frieden, having been the unlucky “recipient” of unnecessary antibiotics after an elective gyn surgery and subsequent CDI a few months ago, which took me out of work for over a month and other consequences, how do we get our medical community to understand the concept of stewardship? Being that I am so heavily involved with AMS programs and CDI Collaboratives, I have tried to talk to my surgeon about the ACOG guidelines where they specifically state that post operative antibiotics are not only not indicated, but are discouraged due to the threat of MDRO acquisition as well as CDI,… Read more »

Vik Khanna
Guest

I think that Perry makes a crucial point: why aren’t we concentrating more on simpler more accessible solutions? Press reports emphasize repeatedly that hospitals and health systems fail to get employees to clean their hands. Where is CDC guidance on how organizations should handle the logistical challenge of ensuring that hand cleaning tools are readily accessible? Is there a metric for that? Does it have to be hand washing? Do hand sanitzers work as well? Are visitors taught to clean their hands? Should there be a hand sanitizer station every x feet, just the way that neighborhoods have fire hydrants… Read more »

Bill Riedel
Guest
Bill Riedel

I think Vik raises a lot of questions for which answers exist in the scientific/medical literature and even some of the literature directed more at the general public. I would suggest two references as, both information sources and sources for additional references: !. Maryyn McKenna, 2010, The Fatal Menace of MRSA – SUPERBUG, Medicine disregarded it. Antibiotics can’t control it. MRSA—drug resistant staph—may be the most frightening epidemic since AIDS, Free Press. Besides being an informative read, it has an extensive listing of references. It is available in paper bag and I was able to buy it of the shelf… Read more »

Tom Frieden, MD, MPH
Guest

Vik – yes, hand sanitizers are effective against most microbes and have been an important tool to increase compliance to hand hygiene and reduce infections. Unfortunately, hand sanitizers do not work effectively against the most common healthcare-associated infection – C. diff – and I suspect many clinicians do not yet realize this. Regarding federal government collaboration – there are systematic efforts across the federal government around antibiotic use, prescribing, and resistance. Certainly, there are several settings where more responsible use and prescribing is needed, and we work to balance those needs. CDC leads the Interagency Task Force on Antimicrobial Resistance,… Read more »

Perry
Guest
Perry

As an adjunct to this posting, what is the research on simple strategies such as hand-washing procedures on the reduction of hospital infections, which should alleviate the need for antibiotics in the first place?

Tom Frieden, MD, MPH
Guest

Handwashing can make a big difference. Unfortunately, hand hygiene studies show that most clinicians do not clean their hands every time they should. These are critical patient safety misses and continued work is needed. That said, even our best hand hygiene efforts would not completely alleviate the need for antibiotics. Patients who are going through chemotherapy, complex surgery, organ transplants, etc., all require antibiotics. Here are concrete examples of people at especially high risk for infection who need antibiotics: http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=24%5D

m25
Guest
m25

@Bill-Maybe due to the scant resources for solid primary care in this country? It seems to me that everything begins there. And without good understanding (from the patient and the provider), well-coordinated care, room for error only becomes greater…

Dr. Frieden: What can nurses do to be of support?

Kathleen Potempa, PhD, UMSN Dean
Guest

Nurses can be very helpful in reducing the use of broad -spectrum antibiotics that can lead to microbial resistance. They should understand the antibiotic drugs and effects and question all orders that are not following CDC guidelines. Nurses in leadership at the unit and hospital levels should also initiate and support hospital policies that curb the use of antibiotics that are not necessary. Such protocols can be very useful guides to both nurse and prescribing physicians who may not be aware of the latest CDC guidelines. Nurses should also partner with pharmacists and physician leaders to review antibiotic use in… Read more »

Bill Riedel
Guest
Bill Riedel

I think nurses can do a lot by going beyond professionalism! What I am trying to say is when we say something like: “Antibiotic-resistant superbugs don’t discriminate!!! I may be the next person infected with such an infection or it may be a close relative. The infection may or may not be related to my work; however, no matter who gets such an infection or where it originates from, I want to know that the best prevention protocols and\or treatment protocols are available FOR ALL OF US” then we may succeed!

Tom Frieden, MD, MPH
Guest

A nurse, Ms. Pearl Branch, helped me learn how to treat tuberculosis. Nurses are generally better than doctors at adhering to protocols. Nurses can play many critical roles including following up to be certain that the dose, duration and indication is included in the patient record. In addition, nurses can be key to ensuring that prescriptions are reassessed at about the 48-hour mark to double check the Rx against test results and patient status. At that point, the drug should be continued, adjusted, changed, or stopped. Nurses are also critical to monitoring patients’ status – if the patient is showing… Read more »

Bill Koslosky, MD
Guest
Bill Koslosky, MD

This problem has been simmering since Joshua Lederberg shared the 1958 Nobel Prize in Physiology or Medicine for discovering the mechanism of bacterial gene exchange. He warned of the dangers of antibiotic resistance.

Why was this problem never seriously addressed until now?

Tom Frieden, MD, MPH
Guest

As a medical student, my father saw the first patients cured of endocarditis – with 50,000 units, as opposed to the tens of millions of units we use now. (See our timeline in our Antibiotic Resistance Threat Report: http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=28). Periodically, there have been reports of antibiotic-resistant microbes that prompt a series of predictions about “the end of antibiotics.” It happened in the 90s with multi-drug resistant tuberculosis and then again earlier this decade with methicillin-resistant Staphylococcus aureus or MRSA. The difference is – in the past we always had another drug to turn to. Now we are literally seeing bacteria,… Read more »