Where Are The Hot Spots For Antibiotic Resistance?

Tom Frieden CDCIn July, CDC will roll out a new way every hospital in the country can track and control drug resistant bacteria.CDC already operates the National Healthcare Safety Network (NHSN), with more than 12,000 health care facilities participating.  Now we are implementing a breakthrough program that will take control of drug resistance to the next level – the Antibiotic Use and Resistance (AUR) reporting module.  The module is fully automated, capturing antibiotic prescriptions and drug susceptibility test results electronically.

With this module, we’ll be able to create the first antibiotic prescribing index. This index will help benchmark antibiotic use across health care facilities for the first time, allowing facilities to compare their data with similar facilities. It will help facilities and local and state health departments as well as CDC to  identify hot spots within a city or a region.

We’ll be able to answer the questions: Which facilities are prescribing more antibiotics? How many types of resistant bacteria and fungi are they seeing? Do prescribing practices predict the number of resistant infections and outbreaks a facility will face?  Ultimately with this information, we’ll be able to both improve prescribing practices and identify and stop outbreaks in a way we have never done before.

This will help deploy supportive and evidence-based interventions at each facility as well as at regional levels to help stop spread among various facilities.

The need for a comprehensive system to collect local, regional, and national data on antibiotic resistance is more critical than ever. The system now exists, and we need quick and widespread uptake.

Rapid and full implementation of this system is supported through the proposed increase of $14 million contained in CDC’s 2015 budget request to Congress.

With the requested funding increase in future years, CDC would look to develop web-based tools and provider apps so physicians will gain access to facility- and community-specific data via NHSN on the most effective empiric antibiotic for the patient in front of them. For example, a physician in a burn unit treating a patient with a possible staph infection will know what antibiotics that particular microbe is likely susceptible TO and which ones are likely to be most effective.

Instead of broad-spectrum antibiotics being the default choice, as is often the case now, doctors will see recommendations for targeted narrow-spectrum antibiotics that are more likely to be effective and less likely to lead to potentially deadly infections such as C. difficile.

In addition to improving patient care, this information has an economic impact. Health care facilities that have evaluated their prescribing and resistance patterns and instituted effective antibiotic stewardship programs have saved money by reducing the amount of antibiotics they need to purchase and reducing complications, thus reducing their facility-specific cost of treatment.

There’s a great deal of interest in the development of new antibiotics, and some discussion of fast-tracking development of new antibiotics for limited populations. With the new electronic module, we’ll be able to track the use of almost any antibiotic to improve prescribing and prolong the life of new antibiotics as well as those currently in use.  The new module can also contribute to research adverse events related to newly approved antibiotics.

These changes won’t happen overnight, and all of this data won’t be available immediately upon the launch of the module. But with expanded investment, within five years, we should be able to make a real difference and save thousands of lives.

16 replies »

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  2. To follow up from what I’ve seen as well, public misconception often expects (and demands) antibiotics for every little scratch, twinge, and discomfort. With that mentality often times people (in hospitals, private and community clinics) demand from their primary care providers antibiotics as the “magic pill.” Education to both the public and the providers at the community level would be a great first step in helping to prevent antibiotic overuse, and thus decreasing likelihood of antibiotic resistance.

  3. A big hole is being missed if not dismissed in the control over resistance and it seems that this is for political reasons. In the late 1970s the US EPA conducted a major study on how sewer plants across the nation generated and dispersed multi antibiotic resistant bacteria into the nation’s waterways. The US EPA then completely removed that study and all references of it from its data base. One must ask why? We are documenting dispersal of large loads of antibiotic of resistant genes from these systems and hence finding them in the drinking water. The CDC is aware of this and appears to have been in a non-action mode. The topic is and has been brought up to the CDC and seems to be consistently ignored. We have asked several times without adequate agency response to see efforts within CDC that would address this issue. There has been only the weakest response which we ascribe to a mode of non-action. The question is why? Unless and until this issue is faced, the expansion of the resistance issue into the community at large can not be controlled.

  4. Yes, the guidelines should also include capture/inform antibiotic prescribing practices in Govt. Hospitals, private nursing homes.

  5. The real hot spots are the developing countries. One god example is the spread of NDM-1 producers. My submission is to suggest some baseline activities in monitoring and controlling the MDR strains. I hope CDC may help this issue in developing countries.

  6. What, if anything, is being done to stop disease from spreading through the USA from those arriving through the borders. These borders have been opened to persons of all countries and they are carrying diseases that we have not been exposed to before. Look at Ebola from Africa, this could wipe out half our population. The immigrants are being distributed all over the country with no examinations or questions. This is disaster in the making..

  7. Thank you for the thoughtful comment.

    I agree that educating the public about antibiotic resistance is critical. This is one of the reasons that the CDC AR Threat Report was so visual last year, filled with plain language, infographics and images of pathogens. Publishing scientific papers is critical, but translating that information into content that is engaging and communicates how a problem impacts people’s lives is more important than ever – scientists are not our only audience.

    To your point on engaging academies – you’re right. Medicine is complicated and we need recommendations that are practical in practice. Just last year, the American Academy of Pediatrics collaborated with CDC to publish Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics.

    We need everyone’s help to turn the tide on antibiotic resistance. At last year’s Get Smart About Antibiotics Week, an annual effort to coordinate a one week observance of the work of CDC’s Get Smart Programs, state-based programs, non-profit partners, and for-profit partners work to combat antibiotic resistance and promote the importance of appropriate antibiotic use, we had tremendous engagement [http://www.cdc.gov/getsmart/campaign-materials/week/partners.html]. I hope this year is even better.

  8. To second Vik’s comments, parents, and patients in general often want antibiotics and come with an expectation and plan of receiving them. There is a feeling of taking action and it often helps. If there is going to be a whole series of guidelines to curtail and direct prescriber patterns, I hope that there is also an active public opinion and education campaign towards the public trying to inform them about the significance of antibiotic resistance (like the drug companies do with their direct to consumer marketing). There should also be an effort to join with the various academies to establish realistic and practical guidelines (unlike some recent ones from cardiology and psychiatry and others where totally impractical recommendations are made) that providers can stand behind. Otherwise, you leave practitioners open to both liability concerns and the court of public opinion.

  9. You’re right, Vik. Many parents do mistakenly believe that antibiotics are warranted every time their child has a sniffle or sneeze. Fortunately, recent CDC research demonstrates that attitudes are starting to change and parents are becoming more familiar with the growing threat of antibiotic resistance and that antibiotics aren’t always the answer.

    We constantly look for new and innovative strategies to change public perception around antibiotic use and an app is a great idea.

    Until something like that can be developed, another great resource that schools can put into place is the Antibiotics & You Curriculum (http://www.mi-marr.org/programs.php) developed by the Michigan Antibiotic Resistance Reduction Coalition.

    And for healthcare professionals, Imperial College London has developed a game (http://www1.imperial.ac.uk/departmentofmedicine/divisions/infectiousdiseases/cipm/cipm_apps/abxgame/). We welcome more ideas!

  10. Interesting idea, Argo. There are apps that help you track your food intake and exercise, other apps may be helpful. I agree that patients appreciate easy to use tools that educate them on how to best protect themselves and their loved ones.

    CDC has an information campaign called “Get Smart: Know When Antibiotics Work” that aims to reduce the rising rate of antimicrobial resistance by promoting adherence to appropriate prescribing guidelines among providers, decreasing demand for antibiotics for viral upper respiratory infections among healthy adults and parents of young children, and increasing adherence to prescribed antibiotics for upper respiratory infections (caused by bacteria).

    Explore our patient education materials at: http://www.cdc.gov/getsmart/campaign-materials/print-materials.html

    CDC’s “Get Smart for Healthcare” is focused on improving antibiotic use in inpatient healthcare settings such as acute-care facilities through the implementation of antibiotic stewardship programs designed to ensure that hospitalized patients receive the right antibiotic, at the right dose, at the right time, and for the right duration.

    Healthcare providers appreciate easy to use tools as well and some of the items we have created for them to help improve prescribing practices, can be found at: http://www.cdc.gov/getsmart/healthcare/

  11. When we refer to an “electronic module,” we mean that the National Healthcare Safety Network will be able to capture this data electronically, so no one has to hand enter it manually into NHSN via a keyboard.

    Data can then be received directly from healthcare facilities to CDC via electronic transfer.

  12. Tom, this is indeed a great idea. I want to expand on Argo’s note, which has in it a very important theme: the casual indifference people have to antibiotic use in their health lives. In my neighborhood of educated, affluent families, there is an expectation that when parents take a sick child to the doctor, typically for a URI, they will get an antibiotic. There is clearly a misunderstanding of the fact that many childhood URIs are viral and that not only is the antiobiotic useless (these kids are not immunocompromised), but that antibiotic overuse is broadly harmful.

    One tool that might prove helpful at point of care is perhaps an app that parents and kids can access together while waiting that walks them through some of the issues related to dispensing antibiotics for viral ailments. It could even be a game, trivia questions or some other user-friendly tool that will help them embrace the information in a memorable and actionable way and then discuss it with the clinician during that visit.

  13. Dr. Frieden, great to hear about this development. This is an idea that’s time has come. I applaud CDC on the innovative use of technology. Have you given any thought to giving patients tools that will help fight the problem on the consumer’s end? I am thinking of two ideas. 1). It should be possible to monitor prescriptions to be sure patients finish a prescription. There should be a non-intrusive way to do this, such as creating tools that passively track adherence and issue reminders to complete a prescription. 2). A CDC warning label and informational campaign designed to discourage antibiotic seeking. I am not talking about putting information on a web site, or creating a pamphlet, but rather requiring patients complete a form and look at a list of alternatives.

  14. For the benefit of those of us who don’t work in HIT, can you explain what an electronic module is?