Curbing Antibiotic Use

Hospitals are turning to a new breed of antibiotic SWAT team to win the war against "superbugs" -- the bacteria that are outmaneuvering nearly every weapon in the arsenal of drugs long used to fight them.

The efforts, known as antimicrobial stewardship programs, team top pharmacists, infectious-disease specialists and microbiologists. The groups monitor the use of a hospital's antibiotics and restrict prescriptions of specific drugs when they become less effective at fighting infections. The heightened vigilance comes as the federal Medicare program plans to begin refusing to pay hospitals to treat preventable infections that patients contract while under the facilities' care.

Some two million people acquire bacterial infections in U.S. hospitals each year, and 90,000 of those patients die as a result. Although antibiotics generally kill or inhibit the growth of susceptible bacteria, they also allow some bugs to survive and become resistant to the drugs. The current epidemic of MRSA -- a form of drug-resistant staph found in hospitals and places such as school locker rooms -- is just one example of the growing number of bacteria that have developed resistance to common drugs.

Now, two of the leading hospital purchasing groups are mounting new campaigns to reduce the use of antibiotics. VHA Inc., an alliance of more than 1,400 nonprofit hospitals, has launched a "Bugs and Drugs" program to help member institutions identify and manage resistance to antibiotics. Premier Inc., which represents more than 2,000 hospitals, is urging members to adopt antimicrobial stewardship programs and offering an electronic data-tracking system to help monitor the use of certain drugs.

At the University of Wisconsin Hospital and Clinics in Madison, Sarah Bland, senior clinical pharmacist, calls herself the "antibiotic police." Working with an infectious-disease specialist, she uses Premier's software program, called SafetySurveillor, to track the antibiotics prescribed in the 450-bed hospital. The aim is to get doctors to use the narrowest-spectrum antibiotic possible -- a drug that is designed to attack only the bacteria causing a specific infection.

Ms. Bland says patients admitted to the hospital or the ER are often prescribed a powerful, broad-spectrum antibiotic such as ciprofloxacin to cover any possible infection. Once lab tests come back with a specific diagnosis, such as a urinary-tract infection that can be treated with a narrow-spectrum drug like amoxicillin, the best course may be to substitute the new drug, she says. Instead, she says, doctors may simply leave the patient on ciprofloxacin or add the second drug.

"Cipro is incredibly potent and active against many different kind of bacteria, but it is something we should have kept in reserve for the most serious infections, and we don't do that," says Ms. Bland. "Every unnecessary dose I avert preserves that drug a little more for the next patient down the line."

Some hospitals have measured tangible benefits. Hunterdon Medical Center in Flemington, N.J., a 178-bed community hospital affiliated with VHA, joined the Bugs and Drugs program in 2006. The hospital developed guidelines for the most commonly overused antibiotics, and routinely tests bacteria from its facility to determine their susceptibility to drugs in its formulary. In a 2007 test, Hunterdon found that 51% of cultures of Klebsiella pneumoniae, which causes pneumonia, urinary tract and wound infections, were susceptible to ciprofloxacin, up from 27% a year earlier. Over the period the susceptibility to antibiotics of another infection-causing bacteria, Pseudomonas aeruginosa, rose to 79% from 54%.

Pending Legislation

The recent hospital programs come as legislation is pending in Congress to create a federal office of antimicrobial resistance and a public-health network to help detect emerging resistant strains of bacteria before they become a national threat. The National Quality Forum, the leading government advisory body on health-care quality standards, plans to issue revised safety standards for hospitals this fall including a new requirement that hospitals implement antimicrobial stewardship programs, according to Charles Denham, co-chairman of its Safe Practices group.

Hospitals also are under new cost pressures to better manage their antibiotic prescriptions, which account for 30% to 50% of many hospitals' total drug budgets. Medicare announced last summer that starting next month it will no longer pay the extra cost of treating some preventable injuries and infections that occur while a patient is in a hospital. The following year, it will add to the list hospital-acquired blood infections and pneumonia acquired on a ventilator. Private insurers including Aetna Inc. and WellPoint Inc. are evaluating their own policies on the issue.

"There is finally recognition by physicians that this is their problem, not just everyone else's," says Neil Fishman, director of the antimicrobial management program at the University of Pennsylvania Medical Center, which other hospitals have used to model their own programs.

Still, for doctors, it's a new role that can run counter to traditional practices. The programs can pit the desire of doctors to use the most powerful antibiotic for their own patient against medical evidence about the use of such drugs in the general population. The programs also can override doctors' own decisions and force them to answer to pharmacists, who previously merely filled their orders.

At Maine Medical Center in Portland, clinical pharmacist Rob Owens, co-director of the antimicrobial stewardship program, says the program uses a computerized system that requires doctors to answer five questions about the patient before they can order an antibiotic. The system rejects inappropriate antibiotics and automatically orders the correct one, though doctors can override the system under certain circumstances. Dr. Owens says the program helped reverse a trend of rising bacterial resistance at the hospital over a five-year period ended in 2003. Tests showed bacterial susceptibility to certain antibiotics improved by between 20% and 47%, and the hospital has been able to maintain those trends since that time, he says.

Dr. Owens says he examines a list of about 135 patients daily and may find 20 to 40 whose antibiotic therapy he needs to review with physicians. "It takes a little human touch to just tap a doctor on the shoulder and say hey, guys, you may not have seen this lab result, but you happen to have the patient on two drugs that cover the same infection. Maybe two aren't necessary."

"Infectious-disease doctors may only see their individual patient and don't see that in six months you might as well try Holy Water to cure this bug," says Vivien Ng, director of performance improvement at VHA. Once they see data showing that a pattern of resistance is emerging in their hospital to a common antibiotic, "their jaws drop" she says.

The University of Pennsylvania's antibiotic-management team includes infectious-disease doctors, pharmacists and staff from the microbiology lab. The group regularly updates guidelines for antibiotic use at the hospital's Web site. The use of certain antibiotics requires prior approval, and an infectious-disease doctor is on call to arbitrate disagreements.

Studies at the hospital have shown that when the program was used to prescribe antibiotics, use of the drugs was more appropriate. There also was an increased cure rate for infections, and a reduction in the rate of infections that weren't cured. Over a one-year period, the hospital saved $302,400 on antibiotic costs, $533,000 on infection-related costs and $4.2 million in costs measured from start of intervention in antibiotic therapy to hospital discharge from shorter ICU stays, the hospital says. The program also showed a trend toward decreased emergence of resistance.

Analyzing Patterns

Some VHA member hospitals are working with the University of Florida in Gainesville, which offers a free program to analyze a hospital's patterns of drug resistance and compares these with regional, state or national benchmarks. The program has been used by about 400 hospitals, according to its developer, John Gums, a professor of pharmacy and medicine, who has financed the program with grants from pharmaceutical companies.

But hospital efforts may not be enough, says Robert Pickoff, chief medical officer at New Jersey's Hunterdon Medical Center. He says hospitals still need to work with doctors from the community and local health officials to get the word out about over-prescribing antibiotics. "We interchange patients with doctors in the community all the time, so the expert use of antibiotics has to be followed by everyone," Dr. Pickoff says. "Anyone who doesn't has the potential of breaking the system down and reversing all the progress we've made."

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