U.S. Moves on Antibiotic Stewardship, but the Problem is Global

February 11th, 2015

The analogy between antibiotic resistance and climate change is an apt one in the sense that both require a global response and the actions of one country affect the welfare of others.

Even within our own health care system, hospitals cannot solve the problem alone no matter how rigorous their antibiotic stewardship programs. Some progress is being made in the hospital segment of the health care continuum, as regulatory requirements mandating antibiotic stewardship are now widely seen as a foregone conclusion. But the massive overuse and misuse of antibiotics in agriculture and outpatient settings also will have to be addressed if the tide of multidrug resistant bacteria is to be turned in the U.S.

Confirming an all too common theme, a recent study found that 45% of patients with respiratory tract infections were inappropriately prescribed antibiotics in an outpatient practice of general internal and family medicine.¹ “Most antibacterial drugs prescribed for humans are administered in outpatient settings rather than in hospitals,” a Presidential Advisory Committee on the issue noted in a recent report.² “In ambulatory care, the vast majority of antibiotics are used for acute respiratory tract infections. Yet most respiratory tract infections are caused by viruses, against which antibacterial drugs are useless. Such inappropriate use contributes directly and substantially to increased antibiotic resistance, increased adverse drug reactions, increased C. difficile infections, and increased cost of care.”

The advisory panel recommends that the Centers for Medicare & Medicaid Services address outpatient settings through quality measures that assess excessive or inappropriate antibiotic prescribing in the Physician Quality Reporting System (PQRS). “PQRS is a voluntary reporting program that helps providers assess and improve the quality of care they are giving so that patients receive the right care at the right time,” the committee concluded. “Inclusion of such quality measures will give physicians the opportunity to avoid the payment penalty for non?participation in PQRS by reporting on these measures. Where applicable, the antibiotic?reporting module should be mandatory.”

Yet even if we can muster the will and determination to get our own formulary in order, there is that aforementioned global problem. It is now abundantly clear that a pathogen that emerges anywhere can very quickly cause problems just about anywhere else. Michael Bell, MD, a veteran epidemiologist at the Centers for Disease Control and Prevention, recently wrote an editorial that cited a disturbing example of the problem, as evidenced by a study running in the same issue of JAMA Internal Medicine.³

Wang et al⁴ describe “a striking and widespread example of medical misuse that can rapidly drive the acquisition and spread of antibiotic resistance,” Bell wrote. “They assessed China’s primary care system, a network of mostly rural facilities that provide two-thirds of that country’s health care --- amounting to 3.7 billion outpatient encounters each year. More than 60% of antibiotic prescriptions were found to be inappropriate, with 78% to 93% of respiratory infections being treated with antibiotics. In addition, they describe a system supported by staff with little training and education; their ability to restrict antibiotic misuse is further hampered by an innate conflict of interest wherein the facility must sell antibiotics to maintain its operating budget. Unfortunately, China’s situation is not unique.”

References

1. Barlam T, Morgan J, Wetzler L. Antibiotics for Respiratory Tract Infections: A Comparison of Prescribing in an Outpatient Setting. Infect Control Hosp Epi 2015; 36(2):153-159 (Abstract)

2. President’s Council of Advisors on Science and Technology. Report to the President on Combating Antibiotic Resistance. September 2014. Available at: http://1.usa.gov/1qhDgF6

3. Bell, M. Antibiotic Misuse: A Global Crisis JAMA Intern Med 2014;174(12):1920-1921. (Excerpt)

4. Wang J, Wang P, Wang X. Use and Prescription of Antibiotics in Primary Health Care Settings in China. JAMA Intern Med 2014;174(12):1914-1920. (Abstract)