A Southwest Memorial Hospital pharmacist is part of a national group setting the standard for antibiotic stewardship in hospitals.
Marc J. Meyer, a registered pharmacist, is collaborating with the Centers for Disease Control, large health systems, patient health foundations and consumer watchdog agencies to address the growing problem of antibiotic resistance.
Antibiotic misuse and overuse cause more than 2 million illnesses and 23,000 deaths globally every year. The CDC estimates that nearly half of all antibiotic prescriptions are unnecessary or prescribed for an incorrect dose or duration.
“Resistance to antibiotics means that individuals could contract bacterial infections for which no effective antibiotic therapy is available,” Meyer said. “Those infections potentially are fatal.”
In December, Meyer attended the National Quality Forum in Washington, D.C., to write a “playbook” to guide hospitals and physicians toward appropriate antibiotic use, in order to minimize antibiotic resistance and other antibiotic-related medical problems.
Meyer explained that because of overuse and misuse of antibiotics, bacteria have evolved into resistant forms that no longer are killed by certain drugs. For example, when penicillin was invented, it was effective against nearly all disease-causing bacteria. The first case of resistance to penicillin occurred less than six months after the drug became available in 1928, and now, only a handful of bacterial illnesses respond to penicillin.
Diseases such as tuberculosis have developed multi-drug resistant and extremely resistant forms. Epidemiologists currently are most concerned about carbapenem-resistant klebsiella species and E. coli, which in some cases may not respond to any antibiotic.
In China, a strain of E. coli has developed plasma-mediated resistance to the drug that is currently the antibiotic of last resort in human patients. No new therapeutic classes of antibiotics have been approved for use in the past decade, which means that medical practitioners are limited to existing drugs and must steward them in ways that ensure their continued efficacy.
“If the health-care profession does not act decisively to deal with antibiotic resistance, we could start to see patients dying from bacterial illnesses that right now are easily treated with antibiotics,” Meyer said. “Essentially we would return to a pre-antibiotic era.”
Misuse a problem
Antibiotics are not effective against viruses, yet it is commonly prescribed for that. For example, although most upper respiratory infections are viral, many patients demand antibiotics for such conditions. The CDC estimates that as many as 60 percent of antibiotic prescriptions for upper respiratory symptoms do not target the cause of the infection and may contribute to antibiotic resistance and other problems.
Other problems also result from overprescribing antibiotics, which destroy the normal bacteria present in the body. In the United States each year, more than $3 billion is spent treating Clostridium difficile, an opportunistic pathogen that causes severe diarrhea and results in death in approximately 5-10 percent of patients who develop a C. difficile infection. Between 1999 and 2011, the mortality rate of C. difficile has increased tenfold.
A key component of the playbook are the five Ds of effective antibiotic use: diagnosis, drug, dose, duration of therapy, and de-escalation.
“One lesson I learned was that as a small hospital, Southwest Memorial can move more rapidly than larger organizations when it comes to effectively choosing the best medication for each individual patient,” Meyer said.
In conjunction with the hospital lab, Meyer monitors culture reports for bacteria resistant to more than three classes of antibiotics, as well as bacteria resistant to specific frequently prescribed antibiotics. Patients who have resistant bacteria, such as MRSA (methicillin-resistant staph), ESBL (that produce an enzyme that makes them resistant to penicillin and cephalosporins), CRE (carbapenem-resistant enterobacteriaceae such as klebsiella and E.coli) and others, may face different treatment protocols, including isolation, in the hospital and as outpatients.
Nursing homes
Southwest Memorial is in the process of launching a nursing home antibiotic stewardship project with CG Health targeting homes across southern Colorado. On March 23, there will be a education day in Cortez for about 100 health-care providers on the topic of proper use of antibiotics. An expert from the CDC will be attending.
Meyer has been a clinical pharmacist at Southwest Memorial Hospital since 1990 and has served as Southwest Health System’s infection preventionist since 1999. He is board certified in infection control and epidemiology, and also has served on the Colorado Hospital Association’s Antibiotic Stewardship Collaborative.
Journal reporter Jim Mimiaga contributed to this report.
Q&A on antibiotics
Marc Meyer, pharmacist and infection preventionist at Southwest Memorial Hospital, discusses antibiotic stewardship with The Journal. He is part of a national task force addressing the dangerous problem of mismanaging antibiotics.
Question: What is antibiotic stewardship?
Answer: In brief, antibiotic stewardship is appropriate and effective use of antibiotics, while avoiding misuse and overuse.
Question: What should the public know about prescribing and use of antibiotics?
Answer: They are not effective against viruses, including colds, influenza, and most upper respiratory infections, and most intestinal infections. Also, there is a misconception that every antibiotic is effective against every bacterial infection. In order to be effective, antibiotics must be very specifically targeted to the infection.
Question: Are rural hospitals at risk for so-called super-bugs that are resistant to antibiotics?
Answer: The U.S. population is very mobile, so patients in rural areas can come from anywhere and have been in contact with other individuals from anywhere. Their risk is no greater or less than patients in metropolitan areas. Rural hospitals do monitor for multi-drug resistant bacteria, do have programs to try to prevent antibiotic resistance.
Question: What is SWMH doing to prevent antibiotic resistance?
Answer: Southwest Memorial Hospital is at the forefront of antibiotic management for our patients, and we pay a great deal of attention to this issue. We minimize unneeded antibiotic exposure by using the narrowest-spectrum antibiotic appropriate for each patient, at the correct dose, for the shortest effective duration.
Question: What can people to do to help solve the problem?
Answer: Don’t demand antibiotics from your health-care provider; let the provider decide whether antibiotic therapy is warranted. Be aware that they do not kill viruses, and clinicians can distinguish between viral and bacterial infections. Follow the instructions on your antibiotic prescription. Don’t take “leftover” medication. An example is a patient who receives a prescription for antibiotics, starts to feel better and discontinues taking the medication; then another family develops symptoms and begins to take the leftover pills. That helps breed resistance by exposing bacteria to an antibiotic without eliminating that bacteria from the body. Observe basic prevention practices, including handwashing and immunizations.
