Hello. Welcome to the Nebraska Health Network outpatient antimicrobial
stewardship education module presented by the Nebraska Medicine and Nebraska
Antimicrobial Stewardship Assessment and Promotion Program, ASAP.
I am Jasmine Marcelin, an infectious diseases physician at the University of
Nebraska Medical Center and Associate Medical Director of the Nebraska
Medicine Antimicrobial Stewardship Program. This education module is a
two-part series. In this presentation we are going to talk briefly about why
antimicrobial stewardship in the outpatient setting matters. In the second
presentation we will discuss diagnosis and management strategies for select
upper respiratory tract infections commonly encountered in the ambulatory clinic.
Let's start with a little background on antibiotics.
Antibiotics were an amazing discovery and have led to a tremendous impact on medicine.
In the pre-antibiotic era mortality from simple skin and soft-tissue infections was significant.
The introduction of sulfa antibiotics followed by penicillin
led to a substantial reduction in mortality due to these infections.
Antibiotics are unique drugs a shared natural resource that must be preserved
for future generations. Compared to a drug like an antihypertensive for
example they are the only drugs that lose efficacy over time and need to be
used sparingly to preserve efficacy. And they are the only drugs where my
prescribing practices effects whether or not the drug will be efficacious for
your patient when you prescribe them. In modern medicine the use of antibiotics
have allowed us to successfully perform organ transplants, complex surgical procedures
and care for extremely preterm infants. These interventions have
been successful because antibiotics have allowed us to prevent and/or treat
infections in these critically ill patients. Unfortunately we now live in an
era where the utility of these amazing agents is threatened by the emergence
and spread of antimicrobial resistance.
So what is the significance of antimicrobial resistance. In 2013, the CDC tried to quantify the
effect of antimicrobial resistance in the United States with its Antibiotic
Resistance Threat Report. In this report, they try to estimate the impact in terms
of tangible outcomes such as deaths and Clostridium difficile infections.
About two million people per year develop illnesses due to resistant organisms and
from that population about 23,000 people die per year due to infections with
antibiotic resistant organisms. Similarly bout 250,000 people per year develop
C difficile infections with about fourteen thousand deaths per year arising from these infections.
So this is a significant contribution by
antimicrobial resistance to both annual morbidity and mortality.
Antibiotic use is the key driver of antimicrobial resistance and we know
that even after just four days of using antibiotics our patients throat flora
can be changed to become resistant to commonly use antibiotics. But how much do
we prescribe in the outpatient setting anyway. A 2016 study demonstrated that
almost 13% of patient clinic visits resulted in antibiotics with almost half
of these prescriptions designated for respiratory conditions. Additionally it
has been estimated that up to 30% of outpatient antibiotic prescriptions are unnecessary.
This graphic of 2015 data from the CDC compares ambulatory visit
antibiotic prescriptions by state. The deepest red indicates the highest
antibiotic use. Zooming into our own state Nebraska we are above the national
average in outpatient antibiotic prescriptions with 1045 antibiotic
prescriptions dispensed per 1000 population. These statistics are
terrifying but how do we deal with it. The first response would be to create
new drugs. However, this is not as straightforward as it seems in the past
six years only seven new antibiotics have been
approved by the FDA. In 2017 there were only 24 new or repurposed antibiotics in
late-stage clinical development and no single antibiotic candidate claims to
have activity against those bacteria resistant to all currently available drugs.
If we can't make new drugs easily we can combat resistance by controlling
the spread of resistant organisms which is the principle of infection control
and out of the scope of this video. However if we truly want to get to the
heart of the matter. We must change the way we use antibiotics and this is the
premise of antimicrobial stewardship.
Antimicrobial stewardship describes the processes to optimize the use of
antimicrobials through interventions to guide clinicians on appropriate
antibiotic selection, timing, dosing and duration. Antimicrobial stewardship
focuses on both patients and public health goals to cure or prevent
infection, minimize adverse events and antimicrobial resistance and ultimately
reduce treatment costs. Recall that as a state Nebraska has one of the highest
rates of outpatient antibiotics prescribed. This figure shows antibiotics
prescribed by a primary care clinics in Nebraska over a one year period for the
diagnosis of acute bronchitis. This is a diagnosis where most major specialty
organizations recommend no antibiotic use at all. However there is a seasonal
trend showing high numbers of prescriptions for macrolides followed by
fluoroquinolones and amino penicillins for the diagnosis of bronchitis.
The previous figure demonstrated that we have a lot of room for improvement and
this is where empowering prescribers and patients to avoid unnecessary antibiotic
prescriptions will be essential. As clinicians we have many reasons to care
about antibiotic stewardship. Due to the ongoing issue of antibiotic resistance
in 2014 the president called for a 50% reduction in inappropriate
outpatient antibiotic use in his National Action Plan for Combating
Antibiotic-Resistant Bacteria. The Joint Commission wants us to care. They have
required antimicrobial stewardship in hospitals and hospital based ambulatory
clinics and soon the Centers for Medicare and Medicaid Services will too.
Our patients want us to care to avoid medication side effects toxicities and
to preserve antibiotics so when they are really needed. Finally we should care
because we pledge to do no harm. This is a problem that we as humans created.
Therefore, as clinicians pledge to take care of our patients, we should be eager
to reduce or reverse any potential harms that are within our power to do so.
So as we close this part of the presentation remember that we can all play a part in
preserving the antibiotics we have for future use by being conscious
prescribers and offering alternatives when appropriate. Citations for
guidelines or data quoted in this presentation are listed on individual
slides referencing the information. For any questions regarding antimicrobial
stewardship initiatives in the outpatient setting feel free to contact
any of our team members listed here. Thank you for your attention.