Local physicians know the unremitting struggle associated with combating antibiotic resistance.
“It’s just every day a constant day-to-day battle to come up with the best possible treatments,” says Dr. William McKenna, an Asheville physician specializing in infectious diseases.
It’s an issue that challenges members of the medical community everywhere across the U.S., and it isn’t going away anytime soon.
“It is ongoing and growing,” says Elizabeth Dodds-Ashley, a clinical pharmacist with the Duke Antimicrobial Stewardship Outreach Network based at Duke University in Durham. “[It’s] faster than we are able to get new therapies to address it.”
One solution that has presented itself is a practice called antibiotic stewardship, which — in simple terms — involves creating strategies for the appropriate use of antibiotics while decreasing the chance of bacteria becoming resistant to them.
Dodds-Ashley says only two states in the U.S. — Missouri and California — require hospitals to have antibiotic stewardship programs, which act as a formal way of establishing and refining safe guidelines for antibiotic use. However, the Centers for Medicare & Medicaid Services has indicated that it would like to see more hospitals adopt antibiotic stewardship practices in the future, going so far as to propose a rule in 2016 that promoted the use of antibiotic stewardship in hospitals.
The Centers for Disease Control and Prevention recommends that all hospitals have an antibiotic stewardship program and in 2014 released a list of seven core guidelines that it recommends hospitals follow. The guidelines include appointing a single leader to be responsible for program outcomes, tracking antibiotic prescribing and resistance patterns, and reporting information on antibiotic use to doctors, nurses and other staff.
In a study published by Oxford University Press in 2017, the CDC found that 48.1 percent of the 4,569 U.S. hospitals evaluated had adopted all seven core principles in 2015, an increase from 40.9 percent in 2014.
According to CDC data reported by The Pew Charitable Trusts, North Carolina’s hospitals are on the cutting edge of this push, with 60 to 80 percent of hospitals in the state adopting all seven core principles, making it one of only eight states on that range of compliance.
Invasive bacteria can find their way into the human body through a startlingly diverse number of pathways. An animal bite, a poorly aimed sneeze or a raw slab of chicken are all ideal modes of transportation.
Since the discovery of penicillin in the early 20th century, doctors and scientists have had a go-to tool for combating bacterial infections — antibiotics.
But this advance in medical science comes at a cost. According to the CDC, antibiotic-resistant bacteria become a problem when an antibiotic kills off all bacteria except for the ones that are drug-resistant. Those drug-resistant bacteria are then capable of multiplying and spreading. Some bacteria can even pass their resistance on to other bacteria through the exchange of genetic material.
Dodds-Ashley says that misuse and overuse of antibiotics mean that many commonly prescribed antibiotics are becoming ineffective without adequate replacements.
According to a report by the CDC in 2013, antibiotic resistance accounts for infections in 2 million people and approximately 23,000 deaths each year.
Getting with the program
In Western North Carolina, many of the major hospital systems have their own antibiotic stewardship programs.
McKenna chairs Mission Health’s antibiotic stewardship committee, a group made up of representatives from hospitals in the health system. The committee reviews prescribing practices and guides the actions of the antibiotic stewardship program.
Mission’s program got started in the 1990s and has been part of a snowballing effort in the health care industry to establish better controls for antibiotic use, he says.
In the past 10 or 15 years, McKenna says, the World Health Organization, the CDC and the Joint Commission, a not-for-profit organization that certifies and accredits hospitals, all began advocating antibiotic stewardship programs. “So it’s been a progressively expanding movement,” he adds.
Mission’s program has a dedicated pharmacist who reviews patients’ bacterial cultures and gives advice to clinicians on how appropriate a certain antibiotic is for patients’ treatments.
“Every day, the pharmacist and I discuss individual cases about antibiotics and make decisions about what would be the most appropriate treatment and make recommendations,” McKenna says.
Pardee UNC Health Care also has its own antibiotic stewardship program.
Dr. Chris Parsons, medical director for the Pardee Center for Infectious Diseases, says, “These programs have demonstrated their utility in larger centers for improving patient outcomes and reducing complications of inappropriate antibiotic use, including development of antibiotic resistance, Clostridium difficile infection and other toxicities encountered with antibiotics.”
The goals of Pardee’s effort, Parsons says, include limiting antibiotic use in accordance with evidence-based recommendations, assisting medical personnel in the treatment of infectious diseases, establishing guidelines in connection with a stewardship committee and creating written materials for educating staff.
Al Newkirk, director of pharmacy at Harris Regional Hospital in Sylva, sees antibiotic resistance as a critical threat to public health in the U.S.
Harris doesn’t have an infectious disease physician on staff, but the facility does have a certified infectious disease pharmacist — Dustin Clark. Newkirk says staff members try to use antibiotics efficiently in the hope of achieving the best clinical outcomes while minimizing harm.
“It’s making sure that I get the right antibiotic on board up front to where we get you better and out of the hospital,” Newkirk says.
Expanding the network
Dodds-Ashley’s organization, the Duke Antimicrobial Stewardship Outreach Network, helps community hospitals establish measured ways to use antibiotics.
“Patients don’t come in with their diagnoses written on their foreheads,” she says. “Someone could come in looking very sick, and so antibiotics are certainly warranted to be started, but then the question becomes, ‘What do we do next?’”
DASON sends a team of pharmacists to member hospitals in the U.S. on a monthly or quarterly basis to consult with hospital staff and customize their suggestions to the needs of the specific institution.
“We do this by carefully obtaining, validating and then analyzing data on antibiotic use at the facility to look at trends where we may see opportunities for improvement, and then once those are identified, we go in and work very closely with the local sites to develop interventions that are specific and targeted to the needs of the facility,” she says.
In North Carolina, 15 hospitals are part of the network, including Frye Regional Medical Center in Hickory. Dodds-Ashley says members of the network vary in terms of their available resources, which means each institution might need different suggestions for how to improve its use of antibiotics.
So far, 29 community hospitals in North Carolina, South Carolina, Virginia, Florida, Georgia and West Virginia have joined the university’s antimicrobial stewardship network, but Dodds-Ashley says she hopes to see more health systems adopt the practice in the future.
“I think that it’s something everybody realizes is best practice,” she says. “Isolated places started doing this, and it has been growing, but we need to take the next step and get it more universal and in all of our facilities to really drive change.”
Dodds-Ashley says she sees antibiotic stewardship as a long-term solution to the problem created by antibiotic resistance.
“There will always be a need to be sure that we’re doing appropriate antibiotic therapy,” Dodds-Ashley says. “Our targets might change based on resistance patterns … and what common infections we’re seeing, but antibiotic stewardship as a concept is here to stay.”