FirstHealth's Processes on Antibiotics Use Preceded CDC Advisory

Gretchen Arnoczy, M.D.

PINEHURST – Antibiotics save lives, but their overuse has put patients at unnecessary risk for preventable allergic reactions, super-resistant infections and a potentially deadly form of diarrhea, according to the federal Centers for Disease Control and Prevention (CDC).

In response to the situation, the CDC has called upon American hospitals to develop their own “antibiotic stewardship” program to improve practices for prescribing antibiotics.

FirstHealth of the Carolinas has had most of these processes in place at Moore Regional Hospital for more than three years.

“We've kept a close watch on our broad spectrum antibiotic use and launched multiple initiatives to streamline and decrease unnecessary use,” says Gretchen Arnoczy, M.D., an infectious diseases specialist with FirstHealth. “I have reviewed the CDC checklist, and we hit all of the main recommendations.”

The CDC recommends that every hospital develop an antibiotic use program that includes seven core elements: leadership commitment, accountability, drug expertise, at least one prescribing improvement action, tracking of prescribing and resistance patterns, regular reports to physicians, and education about antibiotic resistance and ways to improve prescribing patterns.

According to Drew Kessell, Pharm.D., the pharmacist spearheading the local stewardship program, the FirstHealth efforts are patient-specific and hospital-wide and are intended to assure that each patient gets the “right antibiotic, at the right dose, at the right time, and for the right duration.”

FirstHealth currently has more than 30 potential medication therapies on its list of available antibiotic treatments – some of them better suited than others for specific medical diagnoses. The goal is to save the so-called “big guns” antibiotics for the sickest patients.

“We need to make sure we are not overusing antibiotics that kill everything and reserve them for the most appropriate patients,” Kessell says.

According to the CDC, more than half of all hospitalized patients in the U.S. will get an antibiotic at some point during their hospital stay and physicians in some hospitals are prescribing three times as many antibiotics as physicians at other hospitals.

The most common types of conditions for which these prescriptions are written are urinary tract infections, pneumonia and suspected infections caused by drug-resistant bacteria such as MRSA, the report indicated.

According to Kessell, FirstHealth's stewardship program includes a regular review of antibiotic use; a drug strategies plan to address more efficient treatments; and a series of processes used to determine the most appropriate dosage based on the patient's age, weight, renal function and other criteria.

FirstHealth pharmacists also use a software system that has been in place since 2012 to monitor patients who have tested positive for a bacterial infection (those for which an antibiotic is appropriate) to ensure that the best medication has been prescribed and to suggest alternative treatments if they are more appropriate.

“The software allows us to query the patient list so we use antibiotics as appropriately as possible,” Kessell says.

Richmond Memorial Hospital uses the same system to identify positive lab cultures, and Moore Regional Hospital-Hoke Campus will eventually incorporate the process. Program oversight belongs to an Antimicrobial Stewardship Committee (ASC) with membership that includes FirstHealth pharmacists, infectious disease specialists, and the directors of Moore Regional's microbiology lab and Infection Control and Patient Safety office.

FirstHealth's hospitalists (physicians who practice only inside the hospital) and two infectious diseases physicians are central to the success of the program, which covers antibiotics that are prescribed for hospitalized patients only. Prescriptions that are written for patients seeking care in an outpatient clinic or nursing facility are not covered.

“But this is an area of interest for the ASC,” Dr. Arnoczy says.

ASC member Jayne Lee, R.N., the Infection Control and Patient Safety director, says patients can take a role in controlling antibiotic use by not insisting that their provider prescribe one for such common ailments as cold, stomach bug or even the flu. These illnesses are caused by viruses, not bacteria, so antibiotics have no effect on them, she says, and it's best simply to let problems like these run their course.

If an antibiotic is necessary, however, it should be taken when and as often as prescribed and completed, Lee says. Although many people will stop taking their medication when they start to feel better, antibiotics are prescribed to be taken in a certain number of dosages over a certain number of days.

Stopping before the medication is gone increases the likelihood that the infection will recur and the patient will have to start over with the same or a stronger antibiotic.

According to Lee, another “huge issue” in the antibiotic overuse problem involves Clostridium difficile (C difficile), a serious form of diarrhea that develops when antibiotics kill the “good bacteria” that live in the colon and are necessary for normal digestion.

“It's very difficult to treat and very difficult to get over, and that's how we get it – from antibiotic use,” she says. “That's been a big focus of our (stewardship) program, to decrease the number of C difficile cases.”

Lee agrees with Kessell that the antibiotic “big guns,” which include those known to kill most infectious bacteria, should be saved for the sickest patients.

“They should be saved for the critically ill,” she says.

Kessell, who presented information about the FirstHealth processes during a national pharmacy meeting in December 2012, says the CDC stewardship program isn't “the first shot across the bow” in the ongoing attempt to curb antibiotic use and misuse. Because many once-reliable antibiotics are no longer effective in treating infections and have actually contributed to the development and spread of so-called “super bugs,” health care agencies throughout the country – from the CDC to individual hospitals – are intent on addressing the issue, he points out.

 “Microbes are good about developing resistance,” Kessell says. “What we use today won't be good tomorrow unless we take action. It's better to stem the tide now.”