Fewer than 2 years after penicillin was introduced in 1941, penicillin-resistant strains of Staphylococcus aureus appeared. After methicillin was introduced in 1961, it took less than 1 year for staph to learn to resist it, according to a 2001 paper in Emerging Infectious Diseases. The story is similar with many infection-causing bacteria in the world, according to CDC.
Antibiotic resistance is an inevitable result of natural selection, but resistance is promoted by inappropriate antibiotic use by prescribers and patients.
“Over 50% of [antibiotic] prescriptions in the outpatient setting are estimated to be unnecessary,” said Lauri Hicks, DO, Medical Director of CDC’s Get Smart: Know When Antibiotics Work Program, at the International Conference on Emerging Infectious Diseases in Atlanta in March. Up to 50% of antibiotic use in hospitals is estimated to be inappropriate as well, according to data released by the Get Smart campaign.
Hicks and three other physicians presented during a panel on antibiotic stewardship at the conference last month. They called for hospital and outpatient antibiotic stewardship programs. They also stressed the need for pharmacists to help lead inpatient stewardship programs and to educate patients in community pharmacies.
One of the panel presenters, Ruth Lynfield, MD, State Epidemiologist and Medical Director for the Minnesota Department of Health, told Pharmacy Today, “Pharmacists lend critical expertise to an antibiotic stewardship program because of their understanding of how antimicrobials work, the appropriate dosages and routes, and their toxicities and interactions. Pharmacists also know how antimicrobials are used in the health care system, what the available antimicrobials are, and how to fine tune the formulary.”
Why antibiotic stewardship?
Since their introduction in the last century, antibiotics have slashed the rates of death by bacterial infection. But already “antibiotic resistance threatens a return to the preantibiotic era,” Lynfield said.
CDC estimates that behind the 90,000 people who die yearly from hospital-acquired infections alone, 70% of the bacteria that caused these infections were resistant to at least one preferred antibiotic used to treat them. Where drug-resistant bacteria used to be found most readily in hospitals, many such infections are now found widely in communities, including methicillin-resistant S. aureus.
Viral infections, such as some ear infections, sore throats, and sinus infections, and the common cold account for the majority of unnecessary antibiotic use. To combat this misuse, the Infectious Diseases Society of America recently released new guidelines for the use of antibiotics in the treatment of sinus infections.
Guidelines include criteria to determine whether the infection is more likely bacterial or viral before prescribing an antibiotic. “Over 50% of antibiotics prescribed are prescribed for conditions often caused by viruses. What is really alarming is how often antibiotics are still prescribed for common colds,” Hicks said.
Changes in the practices of prescribers and patients can reduce antibiotic misuse. Misuse includes prescribing the wrong antibiotic, dosage, or duration; prescribing an antibiotic unnecessarily; and patients not taking antibiotics correctly. According to Hicks, unnecessary antibiotic prescriptions are a particular problem in outpatient care because of patient pressure. Patients often ask for antibiotics by name.
What can pharmacists do?
The Guidelines for Developing an Institutional Program To Enhance Antimicrobial Stewardship, published in Clinical Infectious Diseases in 2007, call for antibiotic stewardship programs to be co-led by a physician and a pharmacist with specialties in infectious disease.
Panelists at the conference emphasized the need for this collaboration, noting, however, that relatively few pharmacists in the United States have special expertise in infectious diseases. “You’re not going to find infectious disease pharmacists for most institutions currently. That being said, a pharmacist with an interest in antibiotic use, willingness to learn, and a comfort level advising physicians can implement stewardship,” said Sara Cosgrove, MD, MS, Director of the Antimicrobial Stewardship Program at Johns Hopkins Hospital, during her panel presentation.
“A pharmacist should work with the stewardship physician to get recommendations across and to make decisions about program priorities, as well as serve as a critical bridge to the pharmacy department,” Cosgrove continued. “There are many pharmacists who aren’t used to doing interventions and communicating directly with physicians, but the field needs to move in this direction,” she said.
The panelists identified great opportunity and need for community pharmacists to communicate with patients about antibiotics. CDC’s Get Smart program offers online continuing pharmacy education training modules on this topic for community pharmacists.
Because patients often get advice from their pharmacist before making physicians’ appointments, pharmacists should be familiar with treatment guidelines. If a patient wants an antibiotic for the common cold or a sore throat, pharmacists can educate patients on treating the symptoms of those conditions with OTC medicines instead.
According to CDC, most sore throats, except for strep, clear up on their own and do not require antibiotics. The common cold and runny nose also almost always clear up on their own, and pharmacists can counsel patients to first treat the symptoms with OTC products.
Pharmacists can educate patients on the importance of using antibiotics only when necessary and to follow instructions precisely in order to help prevent antibiotic-resistant infections. CDC recommends counseling patients that taking antibiotics when they are not necessary can do more harm than good and advise them not to press physicians for a prescription.
Community pharmacists can also alert patients to the possible adverse effects of antibiotics, including nausea, diarrhea, stomach pain, possible allergic reactions, and vaginal yeast infections. “The concept of adverse drug events has never really occurred to the general population,” Hicks said.