32 replies »

1. 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 alleviating
   suffering. Where possible, this intervention should be made the object of research,
   designed to evaluate its safety and efficacy. In all cases, new information should be
   recorded and, where appropriate, made publicly available.”

   That provision is being used by Polish government – see – The Phage Therapy Center, Tbilisi, Georgia – http://www.phagetherapycenter.com/pii/PatientServlet?command=static_about&secnavpos=0&language=0

   Institute of Immunology and Experimental Therapy Polish Academy of Sciences, http://www.iitd.pan.wroc.pl/en/Phages

2. 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 tissue infections). In other instances, for example a first uncomplicated bladder infection in a college-aged woman, a urine culture, although it is predictive of the causative agent and resistance, does not usually impact management and therefore may not be cost effective to perform routinely.

   Thus one important way that we can improve antibiotic prescribing is to develop better, more rapid diagnostic tests. However, in hospitals, cultures are more frequently indicated. CDC recently published some tips to improve prescribing in hospitals. http://www.cdc.gov/vitalsigns/antibiotic-prescribing-practices/

3. 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 if it is not a critical situation such as an outpatient visit to the doctor) the physician will feel that from a cost savings standpoint (because let’s face it, healthcare today is driven by finances) it’s “unnecessary” to culture as he/she is “certain it is an xxxxxx infection”, when in fact, resistance and overuse/misuse of antimicrobials is not considered. There are also instances whereby the physician is 98% correct with the presumptive diagnosis and bases his/her therapy on that fact, once again, keeping cost of a C&S in mind. There are definitely other factors that play a role in culturing beforehand and the key in my opinion, is to continue spreading the word amongst our healthcare providers to take the time and become educated about the perils of antimicrobial abuse/misuse so that clearer decisions can be made when patients present in a non critical situation. However, on the other hand, even in the case of acute sepsis, we attempt to pan culture prior to initiating therapy if possible. Always best to learn what the organism(s) is/are so that A) the treatment is as effective as possible and B) there is less risk of having to switch antibiotics because the patient is not getting any better from the first one.

4. 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 at the beginning and switch to the effective antibiotic as soon as possible – any information or references are appreciated.

5. 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, or much in the way of mass-market dairy of any kind. I did have cause to remember that in ’07 when I was dx-ed with hormone positive breast cancer, but that’s different story (beef consumer).

   I did that story in ’89. It remained a story, bubbling below the fold, for all the years since. It was only in December of last year that the FDA announced a *voluntary* program for agricultural producers to cut back on antibiotic use.

   All the HAI prevention protocols in the world won’t amount to a hill of beans if patients arrive at the hospital’s doors with a lifetime of antibiotic resistance programmed into them by the food they eat.

   FDA “voluntary” program announcement: http://www.fda.gov/forconsumers/consumerupdates/ucm378100.htm

   BGH history: http://en.wikipedia.org/wiki/Bovine_somatotropin

   NYTimes piece from ’94 about Monsanto’s successful BST (new form of BGH) sales to 7% of dairy producers: http://www.nytimes.com/1994/10/30/us/despite-critics-dairy-farmers-increase-use-of-a-growth-hormone-in-cows.html

6. 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. 🙂

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

8. 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.

9. 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

10. 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

11. 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. You may want to consider working with other patient advocates as well. We appreciate the feedback on how we can continue to beat the drum on this issue.

    Please keep up the great work – even one hospital, one blog, one event at a time.

12. 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, but he’s adamant that it’s the required practice!
    I think the biggest issue for someone like myself is that I’m not an M.D. and although I have been practicing IP for 31 years, IPs are not heard nor taken notice of as we’re RNs and not medical doctors. The offenders are the physicians who are overprescribing. CDC, HHS, CMS and other organizations can do whatever it takes to produce and publicize data, literature, scientific based studies, Webinars, You Tube etc., but my experience is that until the “offender” experiences an adverse event him/herself, he/she will continue to violate best practices and CDI/MDRO issues will prevail. There is such resistance to even listening to others, let alone changing practices. I’d love to take a dog and pony show on the road and help our physicians/PAs/NPs to change the culture. The question is how to initiate this? Who will listen to an IP without feeling threatened?

13. 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 an inappropriate dose of IV Ancef post operatively and 4 days later I was admitted to the ED with profuse colitis. The medical congress that sets standards for the surgery I had, specifically states that post op antibiotics must not be given for this very reason. The surgeon violated those standards with his own theories for administering them. The pain, diarrhea, dehydration, electrolyte imbalance, chills, anemia and all else was awful and all I could think of was how the elderly and those with co-morbidities tolerate this awful illness. I am in my early 50’s, with a benign health history and had a negative screening colonoscopy 3 months prior. The hardest part for me was being told by my surgeon that “if he doesn’t give the additional dose post op, the hospital will be after him”. He told me that he has about 10 cases of C. diff a year after this type of surgery and he is sorry that this happened to me.
    Dr Frieden, do you know how I can become even more active in this battle as now, not only does my work involve AMS efforts, but I have a personal story to tell as a patient with the professional background experience too? I am a member of the HHS taskforce for the elimination of HAIs, but that is not “global enough” for me to spread my message as those that are in the room when we have a meeting once a year or once every other year are all healthcare professionals involved with HAI elimination and not the prescribers of medication. Look forward to your input.

14. 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 do you think this isn’t part of the larger discussion?

15. 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?

16. 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 that any hospital deliberately allows infections to occur. But when financial incentives align with “more is better,” and with the hassle factor of doing things differently, bad prescribing habits are allowed to persist and flourish.

    This, of course, is not something that someone like Dr. Frieden can say publicly, because then you are not perceived as being constructive and professional. But it is real, documented in, say, how oncologists who make money off of drugs have used them.

    Let’s help doctors and hospitals “do well” when they do the right thing by changing the financial incentives. That will help the “leadership” factor quite a bit.

17. 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.

18. 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 priorities at the facility level, this information will be included in aggregate NHSN reports and help us direct our resources and attention.

    Already, hospitals paid by CMS are required to report certain information to NHSN. That information is then publicly available on http://www.medicare.gov/hospitalcompare/search.html so patients can see the information and discuss it with their healthcare providers.

    Several states require and publicly report additional information, and CDC reports national and state-level information http://www.cdc.gov/HAI/surveillance/index.html using NHSN data. A new HAI progress report is due out later this month.

19. 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, which includes all federal government agencies with a stake in preventing antibiotic resistance: http://www.cdc.gov/drugresistance/actionplan/taskforce.html. Additionally, we have a collaboration with the EU through the Trans-Atlantic Task Force for Antibiotic Resistance (TATFAR). A new report is set to be released this month providing a progress update on these efforts.]

20. 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

21. 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 at a local book store.
    2. Michael Shnayerson & Mark J. Plotkin, 2002, The Killers Within – The deadly rise of drug-resistant bacteria, Little Brown and Company. Chapter 14, entitled Bacteria Busters, is already on phage therapy.

    Hope this helps answer some of you questions and I would also suggest you google some videos.

22. 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 signs of diarrhea, follow up to see if C. diff is the culprit, especially if the patient is on antibiotics or if there’s a C. diff problem at the facility.

23. 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, such as carbapenem-resistant Enterobacteriaceae or CRE ( “nightmare bacteria”) resistant to all or nearly all antibiotics.

24. 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!

25. 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 their patients and work together to assure that appropriate use is the norm.

26. 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 I think that this is tragic.

    Below is the 1st para. of a piece I wrote on the subject:
    : Monitoring and optimizing antibiotics, The Ottawa Citizen, June 19, 2013, A10.
    THE PROBLEM OF SUPERBUGS AND ANTIBIOTIC-RESISTANCE HAS BEEN ADEQUATELY DESCRIBED – WHAT WE NEED NOW ARE SOME SOLUTIONS. ONE SOLUTION IS USE PHAGE THERAPY WHEN ANTIBIOTICS FAIL. THIS COULD CURE PATIENTS, REDUCE COST AND FREE HOSPITAL BEDS!
    When it comes to antibiotic-resistant superbugs I think it is fair to note that we are dealing with a case of collective wilful blindness since a cure for many such infections has existed longer than antibiotics have been used. In the book ‘Beyond Bullsh*t: Straight-Talk at Work’ (available at Ottawa public libraries) author and professor of management at the University of California, Samuel A. Culbert, introduces the concept of mokita meaning “the truth everyone knows but no one speaks. The mokita or paradox of the antibiotic-resistant superbug problem is that we have known how to treat some, perhaps even most, antibiotic-resistant superbug infections since before antibiotics have been used to treat bacterial infections. A recent BBC interview on phage therapy, as this medical treatment is known as, can be found at: http://www.bbc.co.uk/iplayer/episode/p015cdyn/Health_Check_Bacteriophages/ – . For Canadians it should be of interest that it was the French-Canadian microbiologist, Felix d’Herelle, working at the Pasteur Institute, in 1917 who coined the name bacteriophage and experimented with the possibility of phage therapy – he subsequently worked all over world, including Russia, Tbilisi, Georgia, where his efforts survive to this day in the form of a Phage Therapy Center (http://www.phagetherapycenter.com ) that treats patients from all over the world. D’Herelle was elected as a laureate of the Canadian Medical Hall of Fame in 2007 (http://www.cdnmedhall.org/dr-f%C3%A9lix-d%E2%80%99h%C3%A9relle ) and it would seem like the height of hypocrisy that we reject one of his most important discoveries by not using phage therapy when antibiotics fail. The Canadian film: Killer Cure: The Amazing Adventures of Bacteriophage and the book by Thomas Haeusler entitled, Viruses vs. Superbugs, a Solution to the Antibiotics Crisis? attest to d’Herelle’s work and both references are available at Ottawa libraries. Another video on phage therapy from Australia can be found at http://www.youtube.com/watch?v=JG6dnOligeM .

27. 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 or admitting privileges? If it isn’t publicly available, what does it matter?

    Personally, I am ambivalent about another government agency gathering more data on the promise of it’s all for the good.

28. 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?

29. 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 at specific distances?

    I have also found the federal bureaucracy’s fractured approach to use of antibiotics throughout the culture to be more harmful than helpful. FDA approves. USDA affects use in farming and veterinary services. CDC advises on issues like the ones raised in this post. Would it not make more sense to advocate to Congress that this issue is a sufficiently challenging public health risk that federal oversight of antibiotics should be consolidated under one agency? If it is a public health crisis, then it seems that the federal voice requires unification and less of a la-di-da songsheet.

    Part of what promotes medical care industry’s desultory approach to making changes is the play-nice mentality that emanates from agencies that should be pushing more forcefully. It’s not enough to “encourage, recommend, offer, and hope (for change).” It is well past time to tell hospitals and physicians that their “we’ll get to it” mentality is a vestige of a time gone by.

30. 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?

31. @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?

32. 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?