Bacteria and other pathogens have increasingly developed resistance to antimicrobials. Dr Lauri Hicks from the US Centers for Disease Control and Prevention has dedicated her career to improving antibiotic use. She explains why stewardship is so critical.
Imagine a place where exotic infections are standard, rather than the exception. This is what Dr Lauri Hicks expected during her fellowship in Department of Infectious Diseases at Brown University. Indeed, she encountered lots of patients with “interesting infections”, such as those caused by ticks and mosquitoes, despite the university’s location in a mid-sized city in Rhode Island on the US east coast. However, it was not the exotic diseases, but the lack of cure that deeply unsettled her. “What really left an impression on me was the patients for which treatment didn’t seem to be working.” In many cases, standard antibiotics were powerless against antibiotic-resistant bacteria. “We had to resort to toxic antibiotics that hadn’t been pulled off the shelf in years,” Hicks says.
Antibiotics and antimicrobials save lives. They are critical for treatment of common infections such as pneumonia, and are essential for medical procedures such as surgeries. However, through decades of overprescribing antibiotics, bacteria and other pathogens have increasingly developed resistance to these potent drugs. Some hospital-acquired infections (HAIs), such as with Methicillin-resistant Staphylococcus aureus (MRSA) bacterium, Clostridium difficile and surgical site infections (SSI) may be life-threatening.1
The growing threat of resistance prompted Dr Hicks to dedicate her career to improving how people use antibiotics. Today, she heads the Office of Antibiotic Stewardship for the US Centers for Disease Control and Prevention (CDC).
She wants to ensure that each patient gets the best treatment, including antibiotics when necessary.
At the same time, she works to make sure that healthcare professionals optimise how they prescribe this medication, and that every hospital, healthcare and senior-care facility has an antimicrobial stewardship programme.
Antibiotics are medicines used to prevent and treat bacterial infections. Antibiotic resistance occurs when bacteria change in response to the use of these medicines. Bacteria, not humans, become antibiotic resistant. Antimicrobial resistance is a broader term, encompassing resistance to drugs to treat infections caused by other microbes as well, such as parasites (for example, malaria), viruses (for example, HIV) and fungi (for example, Candida).2
Antimicrobial stewardship is a set of strategies, practices and policies that aim to optimise antibiotic use to achieve better clinical outcomes. This rests on the so-called “5 Ds “ of antimicrobial prescribing: optimal diagnosis, drug selection, dosage, duration, along with de-escalation. In other words, use the right drug in the right amount at the right time, but only when needed, only as long as needed, and reduce when possible.3
Stewardship programmes also focus on behaviour change – for example, physicians choose rapid diagnostic tests, so they can quickly target specific pathogens, rather than prescribing broad-spectrum antibiotics.4 Pharmacists educate staff on the wise use of antimicrobial agents, and provide feedback to prescribers5. Nurses monitor patients closely who are on antibiotics.6 And, through good hygiene practices everyone works to avoid transmission of bacteria and pathogens, and lower the rate of nosocomial infections. As Hicks says, “We all have a role to play in preventing antibiotic resistance.”
Dr Lauri Hicks, Director of CDC’s Office of Antibiotic Stewardship
Through stewardship programmes, hospitals and other healthcare facilities aim to reach the important goals of improving patient outcomes (reduced surgical infection rates, better infection cure rates), increasing patient safety (fewer unintended consequences of antimicrobials), slowing the spread of resistance, and lowering healthcare costs through fewer infections and reduced use of antibiotics.
In response to the threat of antimicrobial resistance, the medical community is uniting to provide education and assistance. The CDC has developed a framework for implementing antibiotic stewardship for hospitals, nursing homes, and outpatient clinics called the Core Elements. It suggests seven key strategies and specific guidelines on who should do what to ensure successful take-up of stewardship programmes:
“Absolutely the most essential element of any stewardship programme is a dedicated leader or champion,” emphasises Hicks.
In addition, hospitals, medical associations, and health bodies from the local to international levels offer education on how to set up stewardship programmes. The material is often tailored to the relevant subgroups, such as clinicians and pharmacists as primary advisors on antibiotics, to nurses who are on the front line of hygiene efforts. Most resources are easy to access, and often free (see box below). These include university-level massive open online courses (MOOCS), but also continuing-education training offered by medical organisations. “Installing ‘programmes’ may not be feasible in outpatient settings such as in doctor’s offices,” says Hicks, “But I believe it’s important that all healthcare providers demonstrate commitment to improving antibiotic use.”
Finally, stewardship also involves informing visitors and the public on their role in preventing infections, and educating patients how to take antibiotics properly. This concern came close to home for Hicks recently, when her father had an infection that did not respond well to antibiotics. Here, too, clinicians had to resort to very strong intravenous antibiotics. She couldn’t help but think about what could have happened if they hadn’t worked for him. “I also think of the patients I have cared for who are running out of antibiotic options,” she says, “This scares me, because it is even more common today than it was when I was in fellowship.”
When commonplace infections become more threatening than exotic ones, it’s time to recognise that antibiotics are like limited natural resources, adds Hicks, that we must preserve through prudent use – so that patients including her son, his children, and his children’s children will also have access to the life-saving power of antibiotics.
Diseases and Organisms in Healthcare Settings, Centers for Disease Control and Prevention
National Quality Partners Playbook™: Antibiotic Stewardship in Acute Care, National Quality Forum
The role of rapid diagnostics in antimicrobial stewardship, Cottam J, Infectious Disease News
The role of the pharmacist in antimicrobial stewardship, Ashiru-Oredope D et al., Hospital Pharmacy Europe