December 16, 2016
Recently, my community was visited by pan-resistant Klebsiella, a Gram-negative bacterium, by way of India. Only by virtue of a single, sharp hospitalist asking the right questions did we avoid the crisis of colonization of an entire intensive care unit with this pathogen, and a public relations nightmare for the medical facility. Reno, Nevada may be 7,600 miles from the source of this Klebsiella, but resistant pathogens do not have to buy a seat to get here on a plane. And although this one case is an interesting story, it’s one among the sea of resistant bacteria swarming our hospitals. Antimicrobial resistance has evolved to the point that we need to shift our attention to both a higher plane of observation and a broader context.
Although identifying a foreign invader is a rare event, homegrown antibiotic resistance is not. We have documented evidence of the rapidly increasing resistance of Escherichia coli in every acute- and long-term care center in our region. This is E. coli, the bacterium that lives in our gut, helps us digest food and defends us from other disease-causing bacteria. Also found on our toilets and bathroom sinks, E.coli can cause urinary tract infections that occasionally lead to sepsis. In our community, as in many across the country, E. coli has developed resistance to nearly every class of antibiotic once used to treat it. We are forecasting that the newest generations of certain antibiotics will be largely ineffective against E.coli within 15 years. We can hope that the pharmaceutical industry will make something new. However, there is a limit to what the pharmaceutical industry can do and even if they do, we have a responsibility to preserve the effectiveness of the antibiotics we have now.
In Western medical practice, prescribing drugs in response to public demand rather than to medical need is too often the norm. Here’s a common scenario: a mom walks into an urgent care clinic with a crying baby. She’s been up all night because the child was uncomfortable and running a low-grade fever. She’s had to take the day off from work and is now one of a dozen people in a busy waiting room. She wants an antibiotic and wants to go home. After the examination, the healthcare provider tells her the child does not need an antibiotic because there is no evidence of a bacterial infection. Frustrated, the mother posts a negative online review and a negative customer satisfaction survey with the clinic. Soon, the healthcare provider receives a phone call from his clinic administrator, who asks him to find a way to improve his customer satisfaction scores. Ultimately, the healthcare provider, not wanting to be penalized, gives an antibiotic to the next child with the same non-bacterial symptoms. This is the reality for healthcare providers who want to do the right thing but are not backed up by management.
I talk to Infection control experts, pharmacists, and even some hospital administrators who want to be good antibiotic stewards who tell me they are tired of fighting physicians on appropriate antimicrobial use. It’s understandable why many prescribing clinicians, faced with possible customer disapproval and lawsuits, and conditioned by habit, choose to ignore the guidelines.
Enter Antimicrobial Stewardship
Nearly 25 years ago, alarmed by global increases in drug-resistant malaria, tuberculosis, and HIV, the World Health Organization and the CDC began encouraging the pursuit of “antimicrobial stewardship” (AMS): the coordinated effort to improve the appropriate use of antimicrobials, achieve optimal health outcomes, reduce the costs of health care for infections, and slow the development of antimicrobial resistance. Despite these early warnings, while AMS is often given lip service, it is rarely acted upon or consigned to “paper compliance” by hospital committees or undertrained employees. However, we cannot close our eyes and expect bad diseases and their carriers to go away. We can no longer ignore the warnings and assume that our current practices are good enough.
The Centers for Medicaid and Medicare Services (CMS), in partnership with the CDC, have recently proposed guidelines for AMS programs. But the indicators that CMS has chosen to focus on have been roundly criticized for not being specific enough to hold medical facilities accountable. Many have chosen to create “paper committees” that conform to the letter of the guidelines, but fall short of the intent.
To be fair, medical center executives are besieged with a mind-numbing array of CMS requirements, backed by the threat of losing federal funding. Some CEOs have told me, “This issue is not our fault. We do not see how we are responsible.” This would be true if the healthcare facility operated in isolation from all other outpatient, urgent care, long term or other facilities where inappropriate prescribing occurs. For better or for worse, the current healthcare economy is increasingly moving toward a mass acquisition of all modes of healthcare by a few corporate entities, creating an opportunity to address stewardship from primary care all the way to the intensive care unit. This underscores the fact that healthcare is not an “island” but a highly interconnected ecosystem with other care providers in the community and region. To be effective, AMS requires the undivided attention of all outpatient healthcare facilities, urgent care centers, and emergency departments, along with the inpatient wards and intensive care units. It requires absolute attention by specialized nursing and long-term care facilities. All of these facilities must communicate and share data with each other openly.
A Bright Spot Amid the Darkness
Despite evidence of persistent ignorance of the problem and continual deterioration of drug efficacy, there is an occasional bright spot. When Dr. Mitchell Rubinstein, a cardiothoracic surgeon, took the helm of AMS at his New Jersey hospital, he successfully turned the tide of healthcare provider- and antimicrobial resistance. Together with Dr. Neil Gaffin, infectious disease specialist, Dr. Rubenstein found that expensive antibiotics were prescribed when cheaper ones would have been effective, and saw the high rate of hospital-acquired infections as a liability that was driving away patients. And the fact that CMS refused to reimburse the hospital for these avoidable infections didn’t hurt his credibility with management.
When mere persuasion failed to move his fellow physicians to follow prescribing guidelines, Dr. Rubinstein opted for a mandatory AMS program, for which he had the all-important unequivocal support of his CEO. Compliance was monitored and reported. The most common infections were targeted. Prescriber guidelines were hardwired into the electronic medical record. If an inappropriate antibiotic was prescribed, the pharmacist alerted the physician. On the infection control side, all patient rooms were decontaminated with ultraviolet light.
The outcome? A greater than 30 percent reduction in antibiotic utilization. The initial $600,000 investment in equipment and staff was repaid within three years, with a positive return on investment. The incidence of the notorious hospital-acquired Clostridium difficile was reduced by 40 percent.
What was accomplished by Dr. Rubinstein and colleagues is a first step, but it’s just one hospital in a complex healthcare ecosystem, where patients cycle through a variety of inpatient and outpatient sites of care, carrying their microbiomes with them and leaving their drug resistance signatures as they go.
A plea to CEOs
Without hesitation, antimicrobial resistance is more concerning to me than any other issue I have encountered in my career as both a pediatrician and as a national security professional. It is more frustrating than lacking an effective treatment for a serious disease because we have the tools to address it, but we are unwilling to use them. A critical factor—a necessary though not sufficient ingredient—in producing a successful AMS program in a healthcare facility is for the CEO to make it a high priority with mandatory compliance. Unfortunately, I have yet to meet the CEO in Nevada who is willing to establish this level of stewardship in his or her medical facility and this must be true around the country. The CEOs must also step up and develop a coordinated response throughout the local healthcare ecosystem (more on that in a future post).
My plea to every healthcare executive, Nevadan or otherwise, is to stop procrastinating and lead now, engage rather than resist, and champion active antimicrobial stewardship at every level within your professional reach.
James M Wilson V, MD
Fellow, American Academy of Pediatrics
Director, Nevada State Infectious Disease Forecast Station and the International Center for Medical Intelligence, University of Nevada-Reno
Image via Sheep Purple
