The misuse of opioids has captured the media spotlight recently, but inappropriate antibiotic use could have much more significant long-term implications for the practice of medicine.
That is the rationale underlying the work of the Duke University Hospital Antimicrobial Stewardship and Evaluation Team (ASET), a core program of the Duke Center for Antimicrobial Stewardship and Infection Prevention. The work has culminated in the hospital’s designation as an Antimicrobial Stewardship Center of Excellence by the Infectious Diseases Society of America.
The team is focused on ensuring that all practitioners select the right antibiotic to treat a condition and prescribe the correct dosage for the fewest number of days, according to team co-chair and infectious disease specialist Rebekah Moehring, MD, MPH. Appropriate antibiotic use benefits patients and limits the development of antibiotic resistance by bacteria.
One target of the stewardship program has been to help prevent devastating iatrogenic diseases like Clostridium difficile. “Our hospital leadership has put a lot of resources into addressing C. difficile as a high institutional priority,” Moehring says.
One step was to address a primary risk factor for contracting C. difficile. “We have made a lot of progress in avoiding the use of fluoroquinolones, the class of drugs associated with C. difficile,” Moehring says.
There are often better alternatives than broad spectrum antibiotics such as fluoroquinolones, which are known as a primary risk factor for C. difficile, along with age, complex medical care, extended stays in healthcare settings, and a weakened immune system. Replacing fluoroquinolones with narrower spectrum antibiotics is a key aspect of the multidisciplinary infection prevention team’s commitment to antibiotic stewardship.
As a core element of the Duke Center for Antimicrobial Stewardship and Infection Prevention, which unifies education, research, consulting and hospital services under the leadership of director Deverick J. Anderson, MD, MPH, ASET’s work extends beyond monitoring antibiotic use to spearheading research. One recent study demonstrated that enhanced techniques incorporating ultraviolet light in terminal room disinfection can reduce the risk of patients contracting multidrug resistant organisms such as C. difficile.
These programs have succeeded in driving down the incidence of C. difficile at Duke University Hospital. Moehring credits many multidisciplinary efforts for the decrease in the standardized infection rate over the past two years, including stewardship, improved diagnostic testing criteria, and environmental cleaning.
Stewardship is not only aimed at avoiding problematic antibiotics, but also at ensuring that patients receive the most appropriate antibiotics for their condition. “Penicillin-related antibiotics are the mainstay of treatment for a lot of bacterial infections,” Moehring says. “But folks get told they are allergic to penicillin when they are a kid because they had a rash, and they don’t realize that you can grow out of reactions you had in the past. But if you have that label on your chart we can’t use the best medicines to treat you.”
“Duke University Hospital was the first hospital in North Carolina to implement pharmacist-administered penicillin skin testing to address this issue,” says Christina Sarubbi, PharmD, co-chair of ASET.
The first step is an allergy assessment to identify people who believe they are allergic but actually have low-risk histories. Of the more than 150 such patients tested, only two or three have had positive skin tests. “We work really hard to diagnose people, but it is even more satisfying to be able to take [a misdiagnosis] off of somebody’s chart,” Moehring says.
“This program has allowed us to use more first-line antibiotics,” Sarubbi says. Patients with penicillin allergies are often given fluoroquinolones as an alternative, so knowing these patients can actually take penicillin safely has also helped in the effort to limit their use.
The team monitors the literature carefully to learn of opportunities to minimize the number of days a patient receives an antibiotic. “More data are emerging from clinical trials comparing short courses vs. longer courses of treatment, with data showing that many infections are treated as well with short courses. The cure rates are often the same whether you use five days or ten days or more,” Moehring says.
“For a urinary tract infection in a young female who has no comorbidities or other disease states, you can sometimes get away with three or five days of an antibiotic,” Sarubbi says.
“We know that each day of antibiotic use is associated with some risk, so we try to give the narrowest antibiotic for the fewest number of days,” Moehring says.
“Antibiotic use has trended down hospital-wide,” Sarubbi concludes. “We have one of the most advanced systems in the nation to monitor antibiotic use, and other medical centers look to us for best practices.”