Nicole Le Saux is Associate Professor in the Division of Infectious Diseases at the University of Ottawa *
As physicians we should be concerned about the inappropriate use of antibiotics. Have you ever had a patient with an extended spectrum beta-lactamase (ESBL), E. coli or Klebsiella urinary tract infection, a Clostridium difficile infection (CDI) or a drug-resistant N. gonorrhoeae?
Whereas resistant bacteria and CDI were rare a decade ago, these clinical situations are now commonplace in hospitals, long term care facilities and emergency departments. According to the Canadian Antimicrobial Resistance Surveillance System Report 2016 the rate of CDI in hospitalized patients is 3.4 cases per 1000 patient admissions (approximately one in every 300 patients admitted). As of 2014, 18.2% of isolates of Neisseria gonorrhoeae were resistant to penicillin with worrisome decreased susceptibility to cefixime, ceftriaxone and azithromycin. ESBL producing Enterobacteriaceae are now common in Canadian hospitals and long term care facilities. These antibiotic-resistant organisms tend to be resistant to multiple classes of antibiotics and often necessitate treatment with broader spectrum agents such as meropenem or ertapenem. Of even more concern is the global spread of carbapenemases that confers resistance to meropenem which leaves little to no therapeutic options.
These now common scenarios are all related to overuse and/or inappropriate use of antibiotics (either unnecessary initiation, overly broad spectrum of an antibiotic that is not targeted to the pathogen or unnecessarily prolonged treatment duration) and in some instances related to acquisition from foreign travel or breaks in infection control. Unchecked antibiotic use and continued spread of antibiotic-resistant organisms in institutions will eventually severely compromise our ability to treat infections. If we continue without acting, our ability to treat successfully some infections may be compromised in the not too distant future.
Antibiotics are different from other drugs in that they have substantial unique potential adverse effects. These include disruption of patient’s microbiome and promotion of the emergence of antimicrobial resistance with the distinct possibility of transmission of resistant bacteria to other people who have never been personally exposed to the antibiotic, thus spreading the resistant organisms. Additionally, most antibiotics (even those with the broadest of spectrums) can be prescribed by all physicians, dentists, nurse practitioners and, in some jurisdictions, naturopaths & pharmacists. Given these issues, acute care facilities as well as long-term care facilities should have resources to measure and help optimize the use of antibiotics by all prescribers.
In fact, health care institutions are accountable to provide oversight and tools to help prescribers use antibiotics appropriately and responsibly. Did you know that antimicrobial stewardship programs (ASPs) are a required organizational practice of Accreditation Canada in all healthcare institutions? To date, specific requirements are not prescriptive and remain a poorly filled gap in many Canadian health care institutions. Patients with antibiotic-resistant organisms or CDI experience more morbidity and costly hospital stays contributing to the overcapacity we currently experience in many hospitals. Comprehensive antimicrobial stewardship programs have demonstrated significant benefits in clinical outcomes, cost savings and prevention of adverse events. However, such programs require both initial and ongoing financial investments.
Asking for additional resources in ever shrinking budgets requires making a strong business case to health administrators. Who will write this, how can the required personnel be quantified, and how will the cost be calculated?
The Antimicrobial Stewardship and Resistance Committee of the Association of Medical Microbiology and Infectious Disease (AMMI) Canada, has developed an adaptable business case for people to use to start and raise funding for local antimicrobial stewardship programs . The ultimate goal of a business case is to secure ongoing funding to support antimicrobial stewardship activities. The document, based on a scan of the literature, recommends 1.0 physician, 3.0 pharmacist, 0.5 administrative support and 0.4 data analyst full time equivalents per 1000 acute care beds for an antimicrobial stewardship program.
The template is modifiable based on institutional needs, written in language that is scientific and factual but is relevant and easily understood by hospital administrators (e.g. highlighting increased length of stay for patients who acquire a resistant infection or CDI). Apart from an executive summary, referenced sections describe the benefits and potential harms of antimicrobial therapy and the burden and cost of antimicrobial resistance and CDI. The fourth (stand-alone) section is essentially a business case analysis template in Microsoft Excel 2013 (Microsoft Corp, Redmond, Wa.) that permits the inclusion of costs and benefits of the proposed business case for the local institution.
Feel free to share this easily customizable tool with your hospital and pharmacy administrator colleagues, and work together towards establishment of a successful ASP at your institution. Antimicrobial stewardship is an ethical responsibility; we need to preserve antibiotics for our patients and future generations.
*Dr Le Saux writes on behalf of AMMI's business case Group, the members of which are,
Andrew Morris (Committee Chair)
Nicole Le Saux