Antibiotic stewardship: convincing infectious disease physicians that less is more

Contributing lab leaders: Edward Septimus and Michael Broyles

While antibiotics can be life-saving for patients with deadly infections and are an effective means of treatment in a wide range of medical scenarios, they also tend to be over-prescribed. According to the U.S. Centers for Disease Control and Prevention (CDC), between 20 and 50 percent of the antibiotics prescribed in hospitals in the United States are “either unnecessary or inappropriate." It's a trend, the CDC notes, that has led to antibiotic resistance, “one of the most serious and growing threats to public health."1

To help combat over-prescribing, the CDC encourages hospitals to develop antibiotic stewardship (ABS) committees and recommends that laboratory staff and pharmacists be actively involved. Here's a look at how an ABS committee—and the lab and pharmacy in particular—can help physicians to better understand that “more antibiotics" isn't always the best answer.

Article highlights:
  • Over-prescribing of antibiotics has been a longstanding problem in U.S. hospitals.
  • Hospital laboratories and pharmacies can combat over-prescribing through better collaboration with infectious disease physicians.
  • The use of rapid-diagnostic testing via molecular studies and biomarkers can help determine when antibiotics are necessary.

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A difficult problem

Physicians who over-prescribe antibiotics, says Michael Broyles, director of pharmacy and laboratory services at Five Rivers Medical Center in Pocahontas, Arkansas, often do so because they believe not prescribing could be even worse. “When a patient is bad, you don't know what else to do, you give them antibiotics. The mentality is, 'Just to make sure.'" Doctors, he explains, are susceptible to remembering the patient who did poorly because of something they missed. “So we make decisions based on that one bad outcome, thinking we have to cover everybody."

Edward Septimus, MD, FIDSA, FACP, FSHEA, clinical professor at Texas A&M College of Medicine, agrees. “One of the things that drives unnecessary and prolonged care is diagnostic uncertainty." Infectious disease physicians who don't have the information they need to understand for sure what they're seeing in a patient may decide to prescribe right away rather than wait for test results to come in. “Sometimes that first dose of an antibiotic is being hung before the phlebotomist has come to do blood cultures," Dr. Septimus says.

On diagnostic stewardship

Edward Septimus, MD, FIDSA, FACP, FSHEA
Professor of Internal Medicine
Texas A&M Health Science Center

Several solutions

The key to change, Dr. Septimus notes, involves early laboratory and pharmacy participation on the patient-care team. Pharmacists and laboratorians should “leverage all the tools that we have available to us," he says, and work closely with nursing staff to ensure they're “collecting the right specimen at the right time—before antibiotics are started."

Once specimens are in the laboratory, Dr. Septimus continues, rapid-diagnostic tests, including molecular studies and biomarkers like procalcitonin (PCT), should be used to get results as quickly as possible. He points to the impact that such testing can have on patients with chronic obstructive pulmonary disease (COPD) as evidence of why they're so important to run. “Across the U.S., exacerbations of COPD demand 80 to 90 percent of antibiotic use, when we know that a lot of these exacerbations are either environmental or viral. By using the viral multiplex channels along with procalcitonin, we can determine on the front end that not all of these patients with exacerbations need antibiotics."

Education is critical

Above all else, Dr. Septimus recommends, laboratorians and pharmacists should do everything possible to educate physicians about the solutions they have to offer. In many hospitals, the majority of clinicians have no idea where the laboratory is located, he notes. Eliminating that “disconnect" should be a top priority in any organization focused on ABS.

Combine testing education with communication and collaboration and most hospitals should eventually see their physicians prescribing fewer antibiotics. And, Dr. Septimus says, that should help “improve patient outcomes and decrease some of the unintended consequences of over-treatment."

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  1. “Antibiotic Prescribing and Use in Hospitals and Long-Term Care: Core Elements of Hospital Stewardship Programs," U.S. Centers for Disease Control and Prevention. Available at: elements.html.