When It’s Time for an “Antibiotic Time Out”
Arjun Srinivasan, M.D.
Medical Director, Get Smart for Healthcare Program
Centers for Disease Control
Every few years there are reports of antibiotic resistant microbes that prompt a series of predictions about “the end of antibiotics.” It happened in the 1990s with multi-drug resistant tuberculosis and then again earlier this decade with methicillin-resistant Staphylococcus aureus or MRSA. It’s happening once more with carbapenem-resistant Enterobacteriaceae or CRE.
One of the reasons our current antibiotics are losing their effectiveness is because we don’t use them properly. Studies have shown, repeatedly, that up to 50% of antibiotic prescriptions are either unnecessary or inappropriate. Not only does this overuse reduce the effectiveness of our current antibiotics, it threatens the utility of any new antibiotics that come along in the future. In addition to reducing antibiotic overuse, it is important that we prevent the transmission of resistant organisms through the implementation of effective infection prevention measures, and that we continue to research new vaccines and diagnostics which can aide in their control.
While we work on new antibiotics for the future, there is much that must be done right now to both preserve the lifespan of the antibiotics we currently have and to pave the way to ensure prolonged usefulness of new antibiotics that are developed. The most important immediate need is to reduce the overuse of these drugs. Reducing antibiotic overuse is good for society as a whole, but it is also good for individual patients.
For healthcare providers, there are three simple things that can be done to ensure antibiotics are being prescribed wisely. First, all antibiotic orders should include three pieces of information – a dose, duration, and indication. Too often, antibiotics in hospitals are continued unnecessarily simply because clinicians caring for the patient do not have the information indicating why the antibiotics were started in the first place, or how long they were to be continued. It is certainly harder to stop therapy if it is unknown why it was started in the first place. This challenge is compounded in today’s healthcare system where the primary responsibility for patient care is transitioned frequently from one clinician to another. Ensuring that all antibiotic orders are accompanied by the dose, duration, and indication will certainly help other clinicians caring for the patient to change – or stop – therapy when appropriate.
Second, when an antibiotic order is placed, it should include microbiology cultures. Knowing the susceptibility of the infecting organism can allow clinicians to narrow a broad-spectrum therapy, change the therapy to better treat resistant pathogens, or stop antibiotics when the culture results suggest an infection is unlikely. Third, when culture results return in 24-48 hours, it’s time for an antibiotic “time-out”. This is the time to stop and reassess therapy. Antibiotics are generally started before a patient’s full clinical picture is known. After 24 to 48 hours, it is time to re-evaluate why the therapy was started in the first place and gather all of the evidence to determine whether there should be a change in the course of therapy or whether antibiotics should be stopped altogether (if an infection no longer appears likely). If data suggest an antibiotic is needed, this can be a good time to narrow therapy and specify a final duration of therapy.
As we look ahead, we should remember that antibiotics are a shared resource – and for some infections, they are a scarce resource. The solution is not just to identify new antibiotics. Experts agree that it will be years until we have new antibiotics available for use. Even then, if we don’t improve the way antibiotics are used, the new drugs will be lost, too. We must preserve the antibiotics that we have now by implementing effective strategies to use antibiotics wisely. But the benefits are not just societal or long-term. Improving antibiotic use can and will improve outcomes for individual patients right now. We must begin to view antibiotic stewardship as the important patient safety issue that it is.
It is time to take an “antibiotic time out.” It is time to take action and improve our use of antibiotics. These actions – often referred to as antibiotic stewardship – will preserve a precious resource and ultimately save lives.
For additional information: http://www.cdc.gov/getsmart/
For additional information on Diagnostics see APUA Newsletter Vol. 27 No. 1&2