November 21, 2013
Stan Deresinski, MD, is a clinical professor in the Department of Infectious Diseases at the Stanford University School of Medicine and the medical director of the university’s Antimicrobial Stewardship Program.
We are in the midst of Get Smart About Antibiotics Week, an annual CDC-sponsored event that brings together various stakeholders to enhance recognition of antibiotic resistance as a massive global public health threat and to accentuate the importance of appropriate antibiotic use. This year s activities coincide with remarkably heightened awareness of the problem of antibiotic resistance by the media, policymakers, multiple professional organizations, and the general public.
The problem of antibiotic resistance is, as discussed by CDDEP Director Ramanan Laxminarayan and colleagues for the Lancet Infectious Diseases Commission, a global one, and is not limited to human medicine. It is, unfortunately, exploding at a time when much of the pharmaceutical industry is turning its back on antibiotic development. The huge and multifaceted nature of the problem requires an aggressive multipronged response, key elements of which include strong government action as has been promoted for a number of years by the Infectious Diseases Society of America (IDSA) and promoting greater public awareness of resistance issues.
In response to this problem and overlapping with Get Smart About Antibiotics Week, the Antimicrobial Stewardship Program at Stanford University is posting a comprehensive online course on appropriate antimicrobial use. The course consists of multiple concise lectures divided into two main content areas, with Part One considering the underlying clinical science of antimicrobial use and Part Two of the course dealing with the practical aspects of implementing an antimicrobial stewardship program, as well as the application of such programs to special circumstances and populations. Thus, the course not only lays out the nuts and bolts of a developing a program, but also covers the practical applications of stewardship principles in a broad array of clinical situations, ranging from transplant patients and pediatrics to long-term care and outpatient parenteral therapy.
While our course is primarily aimed at licensed professionals, portions of it are suitable for medical students, many of whom are lacking sufficient education regarding the appropriate use of antimicrobials. A recent study by Lillian Abbo and colleagues highlighted this knowledge deficit and the Wake Forest School of Medicine, working with CDC and the Association of American Medical Colleges has made available a slide-based curriculum on stewardship for medical students as an initial attempt to fill this knowledge gap. Medical schools will play a crucial role in developing additional educational resources aimed at this important group of future prescribers .
In its report presented at a congressional briefing on antibiotic resistance in September, the CDC recommended several core actions to curtail the spread of antibiotic resistance in both inpatient and outpatient health care settings. Chief among these is the overall improvement of antibiotic prescribing practices. Thus the CDC, the IDSA, and the Lancet Infectious Diseases Commission each strongly recommend the implementation of antimicrobial stewardship programs in all healthcare facilities.
The case of California is instructive in this regard. In 2006, then Governor Arnold Schwarzenegger signed legislation mandating all general acute care hospitals to develop processes for evaluating the judicious use of antibiotics and to monitor outcomes. As a result the California Department of Public Health created the Antimicrobial Stewardship Program in 2010 the first and currently only statewide initiative of its kind in the US.
The director of the program, Kavita Trivedi, recently published the results of a survey sent to California acute care hospitals in 2010-2011 and found that 50% of responding facilities had some form of a stewardship program, while another 30% were planning to initiate one. The most frequently reported barriers to developing a program were, as one would expect, staffing constraints and lack of funding. Lack of resources was an especially important problem for small and rural hospitals a problem that could potentially be overcome by telemedicine and other remote expert consultative services. The education of personnel using online resources such as our course is another potential solution.
The California experience buttresses an IDSA recommendation that all healthcare settings not just acute care hospitals be required to have stewardship programs as a condition of participation in federal Medicare and Medicaid programs or through other regulatory means. While stewardship programs are now in place in the majority of academic hospitals and many other major hospitals in the U.S., their administrative and financial support varies widely, as does their quality and intensity. It is clear that further legislative measures will be needed to encourage the implementation of such programs nationwide.
We should have heeded the warning of Alexander Fleming when, during his acceptance speech upon winning the Nobel Prize in Physiology and Medicine in 1945, he cautioned us about the potential for bacteria to develop resistance to penicillin as a result of misuse. This misuse has indeed become commonplace and we now find ourselves in a situation evoked by Laurel and Hardy films, in which Oliver Hardy often complains, Well, here’s another nice mess you ve gotten me into . We have indeed found ourselves in mess; but through a continued focus on stewardship education and awareness can we hope to work our way out of it.
Elizabeth Robilotti, MD, MPH, and Instructor in Medicine at Stanford University and Emily Mui, PharmD, and Infectious Disease Pharmacist at Stanford University contributed to this piece.
