Antibiotic Stewardship Programs Need Infection Preventionists

Arjun Srinivasan, MD, recently sat down with Infection Control Today® to discuss the Centers for Disease Control and Prevention’s (CDC) effort¹ to decrease the inappropriate prescribing of antibiotics in hospitals for community-acquired pneumonia (CAP) and urinary tract infections (UTIs) by 90% and the overprescribing of fluoroquinolones and vancomycin by 95%. Srinivasan, the CDC’s associate director for Healthcare-Associated Infection Prevention Programs, told us that to reach these goals in the next 5 years, robust antibiotic stewardship programs are crucial, and must include infection preventionists (IPs). “The key is for the IPs to make sure they’re connected with their stewardship programs,” Srinivasan said. “And…in almost every instance where I interact with hospitals, that connection is already present, and it’s very strong.”

Infection Control Today®(ICT®): In broad strokes, can you explain what the problem is and what the CDC plans to do about it?

Arjun Srinivasan, MD: We know that antibiotics are overprescribed, overused in all health care settings in the United States, whether that’s hospitals, nursing homes, outpatient settings. But…to really improve prescribing… [we need to know] where antibiotics are being overprescribed. For what conditions and why…? This study…was really an attempt to answer those important questions, because that gives us data for action. If we know where they’re being overprescribed and why…, we can then take steps and the providing community can take steps to make improvements. …Two of the reasons why antibiotics are most commonly prescribed in hospitals are for respiratory tract infections, particularly CAP, and UTIs. There is considerable opportunity to improve prescribing for both of those conditions. What this study found is that in over 70% of prescriptions for both CAP and UTIs, the therapy was not prescribed and delivered in a way that is in accordance with best practice guidelines. And that’s really what’s being measured here. …When you say we want to improve prescribing by 90%, what we’re saying is that 90% of the time we should be following the best practice guidelines. That’s the goal you see set there. It’s to bring us in concordance with what the experts are telling us is the best way to prescribe.

ICT®: What’s fascinating is how much human nature comes into play here. Hand hygiene adherence has been dismal for decades. What about the overprescribing of antibiotics? Do doctors just give in and give the patients what they’re demanding?

Srinivasan: You’re right. Behavior is front and center of what we work on in health care, because so much of what we need to do…relies on human behavior. …We work very hard to help human behavior and, where we can, to even remove remembering and behavior from the equation…. But many of these actions—like hand hygiene, how you prescribe antibiotics—are actions that people have to do. And anytime you have an action that someone has to do over and over again, it’s a system that needs support. When we think about antibiotic prescribing in the hospital setting, I really don’t think that patient requests for antibiotics factor in significantly there. That is a big issue when you talk about outpatient settings, but much less so in hospitals. What we see in hospitals is some degree of inertia. This is the way we prescribed for a long time: People were taught, “Oh, give 10 days or 14 days of antibiotics.” And the new data say that’s overkill. You know, 5 to 7 days is really enough, 5 days in most cases of CAP. Some of this is education. It’s helping providers know. Then some of it is maybe building in systems. We’ve seen some places that have done things at the time of discharge. They have someone review the chart for the duration of prescription. A pharmacist takes a look and says, “This person is diagnosed with CAP. They’ve got 5 days of antibiotics, so they don’t need anything after they’ve been discharged.” And that’s a key gap that we saw in this study with most of the excess duration of therapy. In many cases the therapy is not in accordance with guidelines. The antibiotics are being given for too long. And in many cases, that excess therapy happens after the patient is gone. The patient’s been in the hospital, say, an average of 4 days. They need about 1 more day of antibiotics. But what happens is they oftentimes get a prescription for 10 more days or 7 more days. So some of it is building systems. You could think of alerts and prompts as when a patient has an admitting diagnosis of CAP. We’ve got electronic health records in many hospitals now. When the provider goes in to do the discharge paperwork, maybe a prompt could come up and say, “This person’s [received] 4 days of therapy for antibiotics. Guidelines recommend just 1 more day. Would you like to prescribe guideline concordant therapy?” I think there’s a lot we can do to help with human behavior and to build systems that will support the optimized therapy.

ICT®: You set some pretty high goals. What deadline is there?

Srinivasan: Yes, we do have a national action plan for combating antibiotic resistance by bacteria. And that’s being done in phases…. The first phase of that so-called CARB [combating antibiotic-resistant bacteria] action plan was from 2015 to 2020, and the second phase is 2020 to 2025. In my opinion, I know it’s ambitious, but I think we should line up with that. I would love to see that by 2025 we reach these targets of having 90% of prescribing be in accordance with best practice guidelines. I think our patients deserve that. These guidelines are written for a reason: They’re evidence based. This is the therapy that experts are telling us is the right therapy. It’s also important to note that the data in that study are older data…from 2015. They really predate a tremendous amount of work that’s been done on antibiotic stewardship and hospitals. If you go back to 2015, only about half the hospitals in the country had an antibiotic stewardship program that implemented all of what we call the CDC’s Core Elements of [Hospital] Antibiotic Stewardship Programs.² For 2019, the most recent year we have data for, that number was [85%]. So nearly a doubling [since 2014, in which it was 41%,] of the number of hospitals that had stewardship programs that incorporated all our core elements. I think we’re probably in a much better place than we were in 2015.³ Those goals remain ambitious, but like I said, every patient who comes into the hospital deserves to get the best therapy. And for these conditions [such as CAP and UTI], the best therapy is what’s put forward in the guidelines. And though there are situations where providers need to deviate from the guidelines, …those…should be rare—less than 10% of the time. That’s why we set that goal.

ICT®: As you know, a good portion of our readership comprises IPs, many of whom have a nursing background. Do you envision them participating in stewardship programs in any way?

Srinivasan: Yes, very much. What we really envision is a kind of stewardship program and the infection prevention program; they’re kind of equal partners in efforts to address antibiotic resistance. There’s a lot of…codependencies between these programs, …a lot of potential for synergy between the infection prevention program and the antibiotic stewardship program. So absolutely, our vision is that those programs are working very, very closely together on all these issues.

ICT®: How has antibiotic prescribing been during the COVID-19 pandemic?

Srinivasan: We have some data that are being presented, and I believe have been posted. [These were] presented to the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria—the PACCARB committee. And we at the CDC have done some analysis of antibiotic prescribing during the COVID-19 pandemic, and those data were shared. I believe those slides are available on the PACCARB website. What we found is exactly what you’re saying: In the hospital setting, [regarding] antibiotics that are commonly used for CAP, [such as azithromycin, their] use…did rise a bit as COVID-19 rates went up in the country. But they did go back down as COVID-19 activity began to decrease. So there definitely was an increase in the prescribing of agents that…are probably being used for CAP. I think a lot of that represents the fact that you had a lot more patients presenting to the hospital with signs and symptoms consistent with pneumonia. They had cough, they had fever, they had chest x-ray infiltrates. And in some of those instances, it was likely difficult to distinguish who had a true respiratory tract bacterial infection and whose symptoms were only due to COVID-19. So, it’s not very surprising that we did see a rise in prescribing of those agents.

ICT®: How much of this do you attribute to defensive medicine?

Srinivasan: I don’t know. I think more of it is attributable to either a lack of awareness of the guidelines or people who are practicing medicine as they maybe learned it and not as the experts are recommending it today. I don’t think a lot of it is, “Oh, I need to treat this patient for 14 days because otherwise something bad is going to happen.” I think it’s largely people who aren’t aware that there are many, many studies that have been done. There’s a lot of evidence to say 5 days is sufficient. I am optimistic that we can really make great strides in improving prescribing by, 1, educating people and letting them know…these are the best practices that need to be in place. And 2, as we were talking about earlier, by building better systems. How can we take advantage of electronic health records of these new stewardship programs and of the expanded role of pharmacists in stewardship practices? How can we take advantage of all of that to fix the system so the system is built to deliver optimized prescribing?

ICT®: When you say guidelines, are you talking about CDC guidelines?

Srinivasan: The treatment guidelines are the Infectious Diseases Society of America guidelines.⁴ Those were the guidelines we used as the benchmark comparison for appropriate antibiotic prescribing, [which] are updated on a regular basis. The updates, of course, are intended to bring in the latest and greatest information. And that’s why we really want people to be prescribing in accordance with those guidelines.

ICT®: In the study, the median age of the people from whom data were collected was 67. Is overprescribing a problem for older people or does it cut across all demographics?

Srinivasan: It does cut across all age groups. The age bias in the data is because those are the people who tend to get hospitalized. What we see for overprescribing in younger people is that it’s more reflected in outpatient settings, because younger people, when they develop CAP, more often can be [treated] as outpatients. And we know there’s a lot of opportunity to improve outpatient prescribing for respiratory tract infections as well.

ICT®: What do you suggest IPs do with this data? How do they fit in?

Srinivasan: I think the key is for the IPs to make sure they’re connected with their stewardship programs. …In almost every instance where I interact with hospitals, that connection is already present, and it’s very strong. But I think these data do help us understand that there are some great opportunities here. You know, when you think about it from an infection prevention standpoint, Clostridioides difficile is a big target. That’s an infection where antibiotic prescribing is a huge driver. This is a great opportunity to say, ‘Let’s take a look at our prescribing for CAP or for UTIs. Let’s see if we can improve that prescribing.’ And if we do that, it may have a big impact on our C difficile rates. So, here’s a target that is very much a focus for the IP and an intervention that is very much a focus for the antibiotic stewardship programs. Both of them can come together to make progress on that outcome.

This interview has been edited for clarity and length.

REFERENCES:

1. Diamond F. CDC wants to improve antibiotic overprescribing by over 90%. Infection Control Today®. March 18, 2021. Accessed April 22, 2021. https://www.infectioncontroltoday.com/view/cdc-wants-to-improve-antibiotic-overprescribing-by-over-90-
2. Core Elements of Antibiotic Stewardship. CDC. Updated August 15, 2019. Accessed April 25, 2021. https://www.cdc.gov/antibiotic-use/core-elements/index.html
3. The Core Elements of Hospital Antibiotic Stewardship Programs: 2019. CDC. Accessed April 23, 2021. https://www.cdc.gov/antibiotic-use/healthcare/pdfs/hospital-core-elements-H.pdf
4. COVID-19 real-time learning network. Infectious Diseases Society of America. Accessed April 25, 2021. https://www.idsociety.org/