Dr. Goldman's Blog

Doctors are finally helping stop superbugs

A new kind of thinking is helping curb the over-prescribing of antibiotics. @NightshiftMD explains why doctors are finally starting to get the message.
With antibiotic stewardship, doctors work with nurses, pharmacists, public health and other health professionals to make sure that the most appropriate antibiotic is prescribed at the right dose, for the right number of days, and only when necessary to fight a confirmed or suspected bacterial infection. (Shutterstock)

The World Health Organization says that superbugs, which are caused by antibiotic resistance, are among the greatest threats to global health. Doctors who over-prescribe antibiotics are a big part of the problem. The U.S. Centers for Disease Control (CDC) estimates that roughly 30 per cent of antibiotics (47 million prescriptions per year) are prescribed unnecessarily in doctors' offices and emergency departments in the United States. 

Much of them are prescribed inappropriately to treat viruses that cause colds and other viral illnesses, especially in infants and children. Doctors continue to prescribe unnecessary antibiotics for people with bladder infections that don't cause any symptoms, particularly in residents of nursing homes. A lot of antibiotic prescriptions are being written in the dentist's office. A 2016 study found that the prescribing of antibiotics by dentists in Canada and the U.S is up over 62 per cent, much of it unnecessary.

Now, the medical profession wants to be part of the solution through something called antibiotic stewardship. The idea behind antibiotic sterwardship is to preserve the effectiveness of antibiotics now and in the future. That means preventing or moderating antibiotic resistance. In the past, the prescribing of antibiotics was up to each individual physician. With antibiotic stewardship, doctors work with nurses, pharmacists, public health and other health professionals to make sure that the most appropriate antibiotic is prescribed at the right dose, for the right number of days, and only when necessary to fight a confirmed or suspected bacterial infection.  

Antibiotic stewardship programs have been started in hospitals and long-term care facilities and some outpatient surgery clinics and, to some extent, doctors' offices. Some are organized by public health departments, some are province-wide, and some are national in scope. In hospitals, antibiotic stewardship is often led by a physician and a pharmacist who are accountable for the program. Their job is to find and post the most appropriate antibiotics for everything from pneumonia to skin infections, and to inform their colleagues. They monitor and report all antibiotics prescribed, and track rates of resistance. Among other things, the program may call for a time-out after 48 hours of antibiotic use to evaluate whether the treatment is doing the trick.

Roughly 40 per cent of hospitals in the U.S. have antibiotic stewardship programs that do all the things recommended by the CDC. A study in the February issue of the Joint Commission Journal on Quality and Safety looked at four of the better hospital-based programs. All of them use electronic health records to remind doctors of the most appropriate antibiotics to prescribe in real time. One of the hospitals gives the pharmacist the power to authorize the dispensing of appropriate antibiotics and the right to block inappropriate ones. 

A 2016 study showed that stewardship programs improve antibiotic prescribing by doctors. One study found that an alert system cut dramatically the time needed to stop inappropriate antibiotic use in hospitalized patients.  But there are challenges. The study of four hospitals I talked about also found bottlenecks like lack of funding and electronic health records that don't share information.  

The emergence of superbugs is a major public health concern in Canada, particularly in hospitals and in vulnerable populations. Clostridium difficile, multi-drug-resistant Enterobacteriaceae and Carbapenem-resistant Enterobacteriaceae (CRE) and others are showing up in Canadian hospitals. They have caused outbreaks, and have put a strain on the healthcare system. Gonorrhea infections are also of particular concern. In Canada, gonorrhea infections have doubled since 1997. The use of antibiotics of last resort to treat serious infections is becoming more common in hospital intensive care units. 

The United Kingdom Review on Antimicrobial Resistance reported in 2014 that at least 10 million people per year by die of resistant germs by the year 2050. That is more than the number of people who currently die from cancer.

I hope that programs like these succeed.  

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