Antibiotic Resistance
Maria G. Tanzi, PharmD
More than 2.8 million antibiotic-resistant infections occur in the United States each year, with an estimated 35,000 Americans dying of these infections annually, according to CDC’s 2019 report on antibiotic resistance threats. “Dedicated prevention and infection control efforts in the U.S. are working to reduce the number of infections and deaths caused by antibiotic-resistant germs, but the number of people facing antibiotic resistance is still too high. More action is needed to fully protect people,” the agency wrote.
The CDC report, the second published since 2013, includes updated national death and infection estimates that highlight the ongoing issues associated with antibiotic resistance in the United States. Nearly 223,900 people in the United States required hospital care for Clostridium difficile in 2017, and at least 12,800 people died from the disease, the agency noted.
The report lists 18 antibiotic-resistant bacteria and fungi and places them into three threat categories—urgent, serious, and concerning—based on clinical impact, economic impact (when available), incidence, 10-year projection of incidence, transmissibility, availability of effective antibiotics, and barriers to prevention. The urgent threats include carbapenem-resistant Acinetobacter, Candida auris, C. difficile, carbapenem-resistant Enterobacteriaceae, and drug-resistant Neisseria gonorrhoeae.
The report also includes information on actions aimed at combating antibiotic resistance.
FDA priority approvals
FDA is also addressing antibiotic-resistant infections by focusing on timely approval of new antibacterial drugs. Qualified antibacterial and antifungal products are given priority review, with the goal of taking action on the application within an expedited time frame.
For example, cefiderocol (Fetroja—Shionogi), was approved in November 2019 for treatment of adult patients with complicated UTIs (including pyelonephritis) caused by susceptible gram-negative pathogens when they have no alternative treatment options. Cefiderocol is given as an I.V. infusion and should be used in those with complicated UTIs caused by Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, or Enterobacter cloacae complex.
Pharmacist involvement
Pharmacists practicing in both outpatient and inpatient settings can help reduce antibiotic-resistant infections. In the inpatient setting, education on antimicrobial resistance and stewardship practices for clinicians who prescribe antibiotics is essential, along with education of patients and their families about appropriate use of antibiotics.
In the outpatient setting, pharmacists can assess all antibiotic prescriptions for appropriate indications to ensure they are concordant with current practice guidelines and are being used for appropriate durations. Also, accessibility to patients allows pharmacists to thoroughly educate them and their families on proper use of antibiotics.
New requirements
As of January 1, 2020, new antimicrobial stewardship requirements are applicable to all Joint Commission–accredited ambulatory health care organizations that routinely prescribe antimicrobial medications.
The new medication management standard focuses on five elements: identifying an antimicrobial stewardship leader; establishing an annual antimicrobial stewardship goal; implementing evidence-based practice guidelines; providing clinical staff with educational resources; and collecting, analyzing, and reporting data related to the goal.
The Joint Commission, the Infectious Diseases Society of America (IDSA), and the Society for Healthcare Epidemiology of America (SHEA) have also released guidance on antibiotic stewardship programs focused on the inpatient setting.
The Joint Commission’s standard for hospitals and nursing care centers recommends forming a multidisciplinary antimicrobial stewardship team that includes an infectious disease physician, infection preventionist(s), pharmacist(s), and other practitioners, as well as appointing a single pharmacist leader responsible for improving antibiotic use.
The IDSA/SHEA guidance on antibiotic stewardship has a list of recommendations that includes
- Use of antibiotic time-outs or stop orders
- Incorporation of computerized clinical decision support tools at the time of prescribing
- Implementation of pharmacokinetic monitoring for aminoglycosides and vancomycin
- Increased use of oral antibiotics as a priority
IDSA/SHEA also offer guidance on the shortest effective durations of antibiotic therapies.
Pharmacists are well positioned to lead antibiotic stewardship programs across practice settings and to work with other health care providers to implement recommended strategies to reduce the morbidity and mortality associated with antibiotic-resistant infections.